Nia Kurniati

Pediatrician encounter 1 out of 10-15 patient with skin problems in OPD

Generally they understand how to diagnose and deliver basic management

There are many things that is not direct

Related to “Atopic March”:

As first step

Around 75-80% will develop allergic rhinitis in later life

Around 50% will develop asthma

Leung, JACI 2003 (Suppl): S117

Bieber T. Atopic dermatitis. N Engl J Med 2008;358:1491.

ADULT

> 12 y.o - adult

CHILDHOOD

2-12 y.o

INFANTILE

baby- 2 y.o.

First 6 months of life (> 3 months) • Itch erythema macula , papules,

vesicles / plaque infiltrate oozing crusts

• early lesion face, forehead & scalp

• more acute, recurrent

• symmetric distribution

• spread to all over body area (rarely in diaper area)

Age > 6 months wrist, hand, flexor of arm & leg

• more dry lesion • more chronic itch scratch lichenification • Recurrence acute erythema, plaque

infiltrate, papules dan erosion • Location in hand, feet, wrist & ankle • Lesion in flexural antecubital & popliteal main sign

William Criteria

Basic feature (obligatory)

• Itchy skin

Diagnosis : Itchy skin + minimal 3 of the additional features

Additional features

• Skin symptoms in flexural regions & neck (cheeks in children < 10 years)

• Asthma / allergic rhinitis (or atopic diseases in close relatives in children < 4 years)

• Dry skin during the last years

• Visible eczema in flexural areas (or on cheeks and/or forehead in chlidren < 4 years)

• Eczema starting before age 2

ASSESING DISEASE

SEVERITY

• Developed by ETFAD on 1993

• Maximum score is 103

• 0-34 MILD

• 35-69 MODERATE

• 70-103 SEVERE

Pediatrician do not practice this

Modified Qualitative Scoring for AD – Developed by

Prof. Thiru THIRUMOORTHY

Classification of Severity in the Clinic to guide the Intensity of Treatment required Episodic Localised Flexural (2 or less flexures) Episodic Extensive Flexural Persistent Extensive Flexural Persistent Extensive Flexural & Non-flexural Generalised Atopic dermatitis – childhood Generalised Atopic dermatitis – adulthood ■Redness – None, Mild, Moderate, Severe ■Swelling(edema) – None, Mild, Moderate, Severe ■Oozing / crusting – None, Mild, Moderate, Severe ■Scratch marks(excoriation) – None, Scattered, Disseminated, Severe ■Skin thickening (lichenification) None, Mild, Moderate, Severe

Asses the most dominant sign found None=0; Mild=1; Moderate=2; Severe=3

Clinical impression of the extend of the lesion

Recurrent and persistent lesion

Standard Treatment: skin hydration, emollient, avoid irritant, identify and

avoid aggravating factor

Systemic Therapy (e.g: Cyclosporin A) or UV therapy

TCS moderate-super potent and/or TCI

TCS mild-moderate and/or TCI

DA severe, recalsitran

DA moderate-severe

DA mild - moderate

Dry Skin Only

TCS: topical corticosteroid ; TCI: topical calcineurin inhibitor

4

3

2

1

1. Education and empowerment of patients and caregiver(s)

1. Eczema school/eczema camps 2. Avoidance and modification of environmental

trigger factors 1. Lifestyle modification 2. Avoidance of skin injury

3. Rebuilding and maintenance of optimal barrier function

4. Clearance of inflammatory skin disorders 5. Control and elimination of the itch–scratch

cycle Rubel D, et al. Consensu guideline for the management of Atopic Dermatitis: An Asia-Pacific perspectives. J Dermatol 2013;40:161-70

Recognize trigger factors

Use of standardize lists ( house dust mite, chemical substance, 5 food)

Clearance of inflammatory skin disorders

Use of Topical Corticosteroid (TCS)

Control and elimination of the itch–scratch cycle

Oral antihistamine

1. Education and empowerment of patients and caregiver(s)

2. Avoidance and modification of environmental trigger factors

1. Lifestyle modification 2. Avoidance of skin injury

3. Rebuilding and maintenance of optimal barrier function

4. Clearance of inflammatory skin disorders 5. Control and elimination of the itch–scratch

cycle

It could be an easy or hardest part

History taking---taking time

Allergy tests --- are not in straight causal relationship (positive result doesn’t translate as the cause of AD, negative result is often misleading)

The patient (and family) should have discipline to avoid trigger factors

Develop a relationship with the family

Severity of

AD

Inhalant

and/or food

allergen

Food allergen

only

Mild 15% 20%

Moderate 18% 26%

Severe 20% 45%

Patrizi A, et al. The natural history of sensitizations to food and aeroallergens in atopic dermatitis: a 4-year follow up, Pediatr Dermatol 2000;17:261-5

Severity of AD Inhalant

and/or

food

allergen

Food

allergen

only

Asthma

and/ or

allergic

rhinitis

Mild 31% 6% 15%

Moderate 52% 6% 32%

Severe 100% 0% 75% Patrizi A, et al. The natural history of sensitizations to food and aeroallergens in atopic dermatitis: a 4-year follow up, Pediatr Dermatol 2000;17:261-5

• Personal/family history of atopy

• FLG Gen mutation

• Filagrin and Ceramid <<

Predisposing Factor

• Climate change : Low Humidity (travel). Air-conditioning or Heat Humidity Sweat

• Irritants: Soap, detergents, solvents, wool, dust, grass, sand,

• Swimming pool, hot showers, medicaments, cosmetics

Precipitating Factor

• Itch-Scratch Cycle : Damaged keratinocytes –release of cytokines

• Psychogenic pruritus

• Skin picking syndrome

• Medication

• Excess washing

Perpetuating Factor

Topical Corticosteroid, Topical Calcineurin, systemic

The wise ways to choose corticosteroid

Correct indication and know the contraindication

Choose the appropriate potency

Minimal side effects

Acceptability

Cost and benefit

Diprosone OV

27

HO

CH2Cl O

OCO

Cl

O

C27H30Cl2O6

CH3

CH3

CH3

9,21-dichloro-11β, 17 -dihydroxy-16 -methylpregna-

1,4 diene-3,20 dione 17-(2- furoate) 1

http://www.chemspider.com/ImageView.aspx?mode=3d&id=390091

Substitusi atom Fl menjadi Cl Menurunkan efek samping

Gugus furoate Meningkatkan antiinflamasi

Need to address concerns regarding steroid phobia If used correctly, AEs such as suppression of adrenal

function, diabetes mellitus, and moon face Low potential for skin atrophy with mometasone and

fluticasone in children/adults

1 Hanifin J, et al. Br J Dermatol 2002;147:528-537; 2Berth-Jones J, et al. BMJ 2003;326:1367.3Hong E, et al.

Pediatr Dermatol 2011;28:393-396; 4Saeki H, et al. J Dermatol 2009;36:563-577.

Acute Chronic (maintenance): intermittent, week

end, hot spot, has proven to control inflammation in recalcitrant cases

A number of defects in innate cutaneous immunology may explain the high rate of cutaneous colonization with

Staphylococcus aureus in AD

Improving eczema with anti-inflammatory regimen decreases staphyloccocal colonization.

This led to the clinical concept that patients with high numbers of colonizing S. aureus can benefit from combination treatment with corticosteroids and

antimicrobial treatment (Diprogenta®)

TCIs=topical calcineurin inhibitors; TCS=topical corticosteroids

Journal of Dermatology 2013; 40: 160–171

Atopic Dermatitis is an important step in allergic march in children

Stepwise management also apply in children, with emphasis on triggering factors management