atopic eczema sharon wong suzy tinker. classification endogenousvsexogenous acute vschronic
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Atopic Eczema
Sharon Wong
Suzy Tinker
Classification
• Endogenous vs Exogenous
• Acute vs Chronic
Acute eczema
• Acute: pruritus, erythema, vesiculationAcute: pruritus, erythema, vesiculation
Chronic eczema
• Chronic: pruritus, xerosis, lichenification, Chronic: pruritus, xerosis, lichenification, hyperkeratosis, +/- fissuringhyperkeratosis, +/- fissuring
Chronic eczema
Eczema – clinical subtypes
• Irritant contact dermatitis• Allergic contact dermatitis
• Atopic• Discoid• Seborrhoeic• Venous• Pompholyx• Asteatotic• Follicular/papular
Exogenous
Endogenous
Atopic dermatitisAtopic dermatitis
• Chronic relapsing skin disorder (prevalence Chronic relapsing skin disorder (prevalence 20%)20%)
• Onset <5 years in 80%Onset <5 years in 80%
• 40-60% remain symptomatic as adult40-60% remain symptomatic as adult
• 85% ↑ IgE, 80% associated with asthma/allergy85% ↑ IgE, 80% associated with asthma/allergy
• Family Hx of atopyFamily Hx of atopy
Pathogenesis of ADPathogenesis of AD
• Interaction of skin barrier, genetic, Interaction of skin barrier, genetic, environmental, pharmacologic, and environmental, pharmacologic, and immunologic factorsimmunologic factors
• Release of vasoactive substances from Release of vasoactive substances from mast cells and basophils, that have been mast cells and basophils, that have been sentitized by the interaction of the antigen sentitized by the interaction of the antigen with IgE.with IgE.
Exacerbating factors– Inhalants (dust mites, pollens)Inhalants (dust mites, pollens)
– Infections Infections
– Autoallergens (IgE)Autoallergens (IgE)
– Foods (eggs, milk, peanuts, soy-beans, fish, wheat)Foods (eggs, milk, peanuts, soy-beans, fish, wheat)
– Contact irritants (wools)Contact irritants (wools)
– Season (improves in summer, flares in winter)Season (improves in summer, flares in winter)
– Emotional stressEmotional stress
Clinical features
Atopic eczema
The Itch-Scratch cycle
• Pruritus usually begins and causes itch sensation
• Scratch causes skin trauma and precipitates skin inflammation
• Chronic inflammation leads to lichenification
Clinical variants
Discoid eczema
Seborrhoeic
Seborrhoeic eczema
Lichen simplex
Pompholyx
Follicular
Contact dermatitis (exogenous)
Allergic vs irritant
• Immunological• Type IV
hypersensitivity• Lifelong
• Positive patch test
• Non-immunological• Can affect anyone• More common atopics
Complications of Atopic Dermatitis
Impact of Atopic Dermatitis
• Hinders social interactions
• Disrupts sleep
• Disturbs schooling
• Failure to thrive
• Affects entire family
Treatment
Aim
• To get the eczema under control
• Keep the eczema under control
Basic stuff
• Avoid provoking factors (wool, bubble baths, soaps, perfumes)
• Avoid dryness:Bath oils (Oilatum, Hydromol, Aveeno, Dermol)Soap substitutes (Aqueous cream, Dermol)Emollients (500g in 2 weeks)
• Treat any infection
• Antihistamines
• Reduce inflammation
Reduce inflammation
• Topical steroids
• Topical immunomodulators
• Oral prednisolone
• Oral immunosuppressives
• Phototherapy
Topical steroids
• Ointments better than creams
• Learn 3 topical steroids
I) Hydrocortisone
ii) Eumovate
iii) Betnovate/Elocon
Common topical steroid myths
• Can’t apply to infected or broken skin
• Can’t use topical steroids for more than 1 week non stop
• Hydrocortisone topically can thin the skin
• Cannot use potent topical steroids on the face
To get the eczema under control
• Apply steroid daily until skin is back to normal
• Then stop or wean down
• Continue emollients
To keep the eczema under control
• Apply topical steroid immediately the eczema flares
• Consider maintenance Rx (eg Protopic)
• Eumovate >30g per month- baby- refer
• Betnovate>60g per month –child-refer
Tacrolimus ointment
• Inhibits T cell activation & suppresses cytokine gene transcription
• Inhibits IgE-induced histamine release from mast cells and basophils
• Down-regulates high affinity IgE receptor on Langerhans cells
Important instructions to patients
• Burning/stinging sensation following application which will spontaneously resolve
• Avoid application after a hot bath or shower
• Recommend adequate application of tacrolimus ointment, it is NOT a topical steroid
• Care in sun - long term immunosuppression???
Particular indications for topical tacrolimus ointment
• Peri-ocular involvement
• Flexural involvement
• Facial involvement
• Requirement for maintenance treatment with moderately potent or potent topical steroids
• Presence of topical steroid-induced cutaneous atrophy or striae
• Pigmented skin
Not winning?
• Compliance?• Infected?• Contact dermatitis• Difficult eczema?
Dressings & bandaging
• Dressings
• Wet wraps
• Comfifast, tubifast, dermasilk garments
– Over emollient / weak steroids
Quality Nursing Quality Nursing CareCare
Phototherapy
• UVB/TLO1
• Psoralen + UVA = PUVA– Methoxypsoralen– Topical or systemic
• Whole body or regional
Systemic treatments
• Short courses prednisolone
• Ciclosporin
• Azathioprine
• Methotrexate
• Mycophenolate mofetil
Steroid side effects- local
• Skin atrophy
• Telangiectasiae
• Acne
• Pigmentaion change
ALL MORE MARKED IN FLEXURAL SITES!
Steroid Side EffectsSteroid Side Effects
Atrophy, telangiectasia
Steroid side effects- systemic
• suppression HPA axis• cataracts• growth suppression• loss bone density• diabetes• cushings
Take home messages
• Bath oils, soap substitutes and emollients - all stages/severity of eczema
• Use the most appropriate strength of steroid for the severity and site
• Steroids can be used for longer than a week – arrange follow-up to review and step down when skin improved
• Check compliance – ask how long a tube of steroid/pot of emollient lasts
• Prompt treatment of coexistent infection• Assess severity by asking about sleep/school
disturbance, weight/height gain (red book), mood, family dynamics
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