Joanna Lange

Atopic Dermatitis

Atopic Dermatitis: Definition Atopic dermatitis = eczema = itchy skin

  Starts in first 6 months of life in 45%

  60% start before 1 year old

  85% start before 5 years old

  40 - 60% clear by puberty

Atopic Dermatitis: Cause  The exact cause is unknown.

Scratching itching

Allergen Infection

mastocyte

eosinophils

Atopic Dermatitis: Cause

• Inborn skin defect that tends to run in families, e.g. asthma or hay fever • 85% with high serum IgE and + skin tests food & inhalant

defect of fillagrin

Morphology

Distribution

  In infants, the face is often affected first, then the hands and feet; dry red patches may appear all over the body.

  In older children, the skin folds are most often affected, especially the elbow creases and behind the knees.

  In adults, the face and hands are more likely to be involved.

Distribution

infants adolescents

Distribution

 In infants, the face is often affected first, then the hands and feet; dry red patches may appear all over the body.

 In older children, the skin folds are most often affected, especially the elbow creases and behind the knees.

 In adults, the face and hands are more likely to be involved.

Foot Eczema

Atopic Dermatitis: Associated features

 The skin is usually dry, itchy & easily irritated by:  soap  detergents  wool clothing

 May worsen:   in hot weather & emotional stress.  with exposure to dust & cats

Diagnosis (criteria of Hanifin and Rajka)

  Major characteristics   Pruritus with or without excoriation  Typical morphology and distribution  Chronic relapsing dermatitis   Personal or family history of atopy (asthma, allergy, atopic derm,

contact urticaria)   Other characteristics

 Dry skin/Xerosis/Ichthyosis/palmar hyper/keratosis pilaris   Pityriasis alba   Early age of onset  Cutaneous colonization and/or overt infections  Hand/foot/nipple/contact dermatitis, cheilitis, conjunctivitis,

Erythroderma, subcapsular cataracts (Drake, JAAD, 1992)

 Seborrheic dermatitis   Discoid eczema   Varicose eczema  Contact eczema   Pompholyx eczema   Irritant eczema   Lick eczema  Keratosis pilaris   Lichen simplex   Otitis externa   Juvenile Plantar Dermatosis   Pityriasis alba   scabies

Xerial capillaire (Xerial ciemieniucha)

Cardle cap

Localised eczema. Need to take a good history. Confirmed by patch testing

nickel allergy

Needs potent topical steroids as soon as itch starts

Felt to due to abnormal sweating

Can be due to nickel

Very common. No need for topical steroids. Moisturisers and exfoliate with nylon buffer. Should improve as gets older. Worse in the winter.

Scabies

InfectoScab 5% (permethrinum)

Ung. Wilkinsoni 100% adults

50% adolescents 25% infants and young

children

Sarcoptes scabiei

Differential Diagnosis

psoriasis allergic contact dermatitis

Differential Diagnosis

Cutaneous T-cell lymphoma

Atopic Dermatitis: Treatment

1. Reduce contact with irritants (soap substitutes) 2. Reduce exposure to allergens 3. Emollients 4. Topical Steroids 5. Antihistamines 6. Antibiotics 7. Steroid sparing 8. Other (herbals, soaps)

1. Reduce contact with irritants!

 Avoid  overheating: lukewarm baths, 100% cotton clothes, &

keep bedding to minimum  direct skin contact with rough fibers, particularly wool, &

limit/eliminate detergents  dusty conditions & low humidity   cosmetics (make-ups, perfumes) as all can irritate   soap- use soap substitute

 Use gloves to handle chemicals and detergents

2. Reduce exposure to allergens

 Keep home, especially bedroom, free of dust.  Allergic reactions include house dust mite, molds,

grass pollens & animal dander.  Special diets will not help most individuals – little

evidence that food is major culprit.   If food allergies exists, most likely dairy products,

eggs, wheat, nuts, shellfish, fruits or food additives.

3. Emollients

  Emollients soften the skin soft and reduce itching.   Moisture Trapping effectiveness

  Best: Oils (e.g. Petroleum Jelly)   Moderate: Creams   Least: Lotions

  Apply emollients after bathing and times when the skin is unusually dry (e.g. winter months) - sometimes severals daily.

  Large variety (e.g. Eucerin, Neutrogena)   Inexpensive emollients include petroleum jelly (Vaseline)   Urea creams   Oils

Emollients: Oils

 Consider using bath oil or mineral oil-based lotions in lukewarm bath water

 Bath oil preparations  Colloidal oatmeal - reduces itching (Aveeno

100% pure natural oatmeal) www.aveeno.com

4. Corticosteroids!  Topical steroids very effective

 Ointments for dry or lichenified skin

 Creams for weeping skin or body folds

 Lotions or scalp applications for hair-areas.

Corticosteroids

  Hydrocortisone 1-2.5% applied to all skin.   Quite safe used even for months   Use intermittently thin areas- (eg-face & genitals)   Stronger potency topical steroids for nonfacial/genital regions.   Avoid potent/ultrapotent topical steroid preparations on face, armpits,

groins & bottom.

Corticosteroids

Hydrocortisoni 1,0 Aq.dest.

Ung. cholesteroli aa ad 100,0 M f ung

Aq.dest. Ung.cholesteroli aa ad 100,0

Corticosteroids

  intermittent use of topical corticosteroid may prevent relapse

  Systemic steroids may bring under rapid control, but may precipitate rebound

 Once daily probably most cost effective

Topical steroids - summary

5. Antibiotics!  Atopic eczema frequently secondarily colonized with a bacteria

(up to 30%).  Use oral antibiotics in recalcitrant or widespread cases.

Impetigo can be mild or severe. It is usually caused by Staphylococcus but less commonly can be caused by Streptococcus

Bullous Impetigo is caused by

Staphylococcus

Crystacide – hydrogen

peroxide 1% Eczema sufferers are more prone to molluscum and tend to have more lesions

Solphadermol Molutrex

curettage

Regular polygonal often crusted lesions. If mild topical aciclovir.

Severe herpes infections in children with eczema – acyclovir i.v.

6. Antihistamines!

 Oral antihistamines can reduce urticaria & itch

 Non-sedating antihistamines less side effects but more expensive

  Sedative effect of hydroxyzine & diphenhydramine (first generation) helpful

7. Steroid Sparing!

  Topical calcineurin inhibitors

 Tacrolimus ointment & pimecrolimus cream

 Oral Cyclosporine  Ultraviolet light therapy (phototherapy) with PUVA

(psoralens plus ultraviolet A radiation) or combinations of UVA & UVB

 dicovered by japanese in 1987 y –from Streptomyces tsukubaensis;

 name - Tsukuba makrolide immunosupresant = TACROLIMUS;

  Side efects:   pruritus;

  redness of skin.

Proactive therapy

side effects

effe

citiv

enes

s

Group VI-VII

Group IV-V

Group I-III TA

GKS and inhibitors of calcineurin

PI

Tar preparations:   antiiflamatory properties;   used with steroids may reduce more potent steroid preparations;

  tar shampoos – beneficial for scalp involvement;

  use for actually inflamed skin should be avoided because this may result skin irritation

  side effects – dryness, irritation, photosensitivity reactions nad pustular folliculits;

Coventional therapy

Wet dressing (usually in hospitals, erytrodermia):   used with hydration and steroids therapy;  wet pajamas;   hands and feet – wet tube socks under dry tube socks;   face, trunk, extremities – wet gauze with dry gauze over it;   best tolerated ad bedtime;

  side effects – chilling, maceration of the skin, secondary infections

Coventional therapy

Dry bandages and medicated dressings (including wet wrap therapy)

Oral Cyclosporine and PUVA!

Treatment options - summary

Mild atopic eczema Moderate atopic eczema Severe atopic eczema Emollients

Mild potency steroids

Emollients

Moderate potency steroids

Topical calcineurin inhibitors

Bandages

Emollients

Potent topical steroids

Topical calcineurin inhibitors

Bandages

Phototherapy

Systemic therapy (e.g. systemic steroids, cyclosporine)

(Charman, Arch Dermatol, 2004)

The patient-oriented eczema

measure

Self Monitoring

Other! Psychological support  Alternative treatments  Chinese herbal tea

  Variably effectiveness   Liver toxicity possible

Evidenced-based

  Positive evidence that:  topical corticosteroids relieve symptoms and are safe  emollients & steroids better than steroids alone  excellent control of house dust mite reduces symptoms if

positive mite RAST scores & children  bedding covers most effective

  Little to no evidence that:  dietary change reduces symptoms  breast feeding or mother's diet prevents infant eczema