atopic dermatitis eczem.pdf · chronic scalp scaling,pityriasis alba,cataract uk diagnostic...
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Dr.F.Shariati
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Diagnosis of eczema Incidence Aggravators History and assessment Treatments Clinical Cases Contact details and clinics
Atopic DermatitisTopics discussed
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TERMINOLOGY
Eczema =
Greek term “To boil over”
Usually refers to severely inflamed dermatitis, and the signs and symptoms associated with such an acute process (itching, sting, burning of the skin with
drainage from lesions)
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Types of common eczemas• Atopic eczema (infantile e., flexural e., atopic dermatitis). • Contact dermatitis: is of two types(Allergic contact dermatitis,
` Irritant contact dermatitis)• Xerotic eczema (asteatotic e., e. craquele or craquelatum,
winter itch, pruritus hiemalis)• Seborrhoeic dermatitis: or ("cradle cap“in infants)Less common eczemas • Dyshidrosis (dyshidrotic e., pompholyx, vesicular e,)
palmoplantar dermatitis,)• Discoid eczema: (nummular e., exudative e., microbial e.)• Venous eczema: (gravitational e., stasis dermatitis, varicose e.)• Dermatitis herpetiformis: (Duhring’s Disease)• Neurodermatitis: (lichen simplex chronicus, localized scratch
dermatitis)• Autoeczematization (id reaction, autosensitization)
Types of common eczemas
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(Charlesworth, Am J Med, 2002)
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CHILDHOOD ECZEMA
Atopic Eczema
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• The most common skin disorder seen in infants and children
• 80% present in first year of life• “Atopic March”: atopic dermatitis→food
allergies→asthma→allegic rhinitis• Characterized by exacerbations and remissions• Interruption of atopic dermatitis may↓incidence
of asthma and allergic rhinitis
ATOPIC DERMATITIS
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CLINICAL PRESENTATION
• Objective diagnosis• Pruritic, erythematous, dry patches• Scale and linear excoriations• Thickened skin with well-defined skin
markings (lichenification)• Crusting and oozing common in infants• Diffuse borders
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Infantile stage: ( 0-2 years ) tends to start around 3-6 months.Usually affects the face,wrists,nappy area and when severe every part of the body.Often gets infected.Childhood stage:( 2-12 years )the skin startsto become dry cracked and thickened.Usually affects the elbows,back of knees,ankles and back of ears.Severe thickening of the skin is very common in Afro-Caribbeans and Asians.Adolescent and adult phase:(puberty onwards) lichenification of the skin is veryprominent now.Affects the elbows,knees, neck and bottom of the eyes.
STAGES of Atopic EczemaPHASES
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Distribution
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Morphology
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Hand Eczema
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Foot Eczema
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Atopic Derm Adults
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Must have:Major Features
itchy skin
family history of atopy
typical picture, facial, flexures, lichenification
Plus three or more of the following:Minor Features
Xerosis/ichthyosis/hyper linear palms, keratosis pilaris
periaricular fissures,dennie-morgan lines
chronic scalp scaling,pityriasis alba,cataract
UK Diagnostic criteria Sampson et al
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Associated Findings Pityriasis alba
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Associated Findings Xerosis
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Associated Findings Keratosis Pilaris
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Associated Findings Ichthyosis
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Hyperlinear Palmar Creases
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VERY! 10-20% of children in developed countries (Harper et al,2000)
Incidence has trebled over the last 30 years (Harper et al , 2000)
Positive correlations of eczema with higher social classes and airpollution has been confirmed (Simpson, Hanifin, 2005)
80% of children will develop eczema in 1st year 50% of children will clear by 2 years of age 85% of children will clear by 5 years of age About 5% of children with eczema will continue into
adulthood
How common is Atopic Eczema ?
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Onset after 2 years of age (Vickers) Severe eczema in infancy Atypical location for age of the patient
(Eczema to extensors, wrists and hands to be more prone to persistence of eczema)
Severity and duration of eczema are correlated to the incidence of asthma
Biparental history of atopy have shown to be unfavourable
Factors influencing poor prognosisAtopic Eczema
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Intractable itch Sleep depravation Disruption to family life School/work absenteeism Parental marriage problems Teasing Chronic disease Low self esteem
Effects on LifeAtopic Eczema
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Heat Dry skin and environment Prickle Allergies Irritants Infection Saliva Water
What aggravates Atopic Eczema?
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Too many clothesHot baths >29 degreesToo many blanketsHot carsSport/running aroundHeatersHot school classrooms
What makes eczema hot and itchy?
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Soap, use bath oils or washesAir blowing heatersSwimming poolsAustralia!!!!Therefore apply moisturiser from
top to toe regularly andmore often when flaring
What makes eczema dry and itchy?
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Animal hair/danderWoolen clothesSharp seamsTags dust mites,molds rough fabrics
What prickles eczema and makes it itchy?
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Diagnosis?
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First appointment is important in managing the eczema effectively and gain the trust of the patient and family
Family historyCoexisting atopic disease ImmunizationAllergies, tests, diet manipulation and adequacyGrowth Previous treatments used and outcomesMost distressing element Sleep disturbanceEnvironmental aggravators, assess heat/prickle/drynessEffect on family life, school Parents expectations from treatment YOUR expectation from treatment
Taking a good history
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• Serum IgE levels
• Skin prick tests(Allergy test)
• RAST(checks to see if the body isproducing antibodies against commonthings like house dustmite,pollens,cat anddog hair and food substances)
• Skin biopsy
INVESTIGATIONS
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Patch Test
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PATHOPHYSIOLOGY
• Elevated serum IgE levels• Altered cell mediated immunity• Correlation of elevated IgE levels and
the severity of atopic dermatitis– Unclear if high IgE levels are primary or
secondary• Not all patients with elevated IgE levels
have atopic dermatitis
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IMMUNOLOGIC ABNORMALITIES
• Proliferation of T-helper 2(Th-2) • Cytokines are produced by Th-2 cells• Release of calcineurin activates cytokines• Cytokines irritate tissue and increase IgE synthesis,
therefore maintaining inflammatory response• Decreased numbers of IFN-gamma-secreting Th 1-
like cells• Specific IgE to multiple antigens• Cytokines are central to the pathogenesis of skin
inflammation in AD
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Differential Diagnosis
• Seborrheic dermatitis
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Differential Diagnosis
• Seborrheic dermatitis• Scabies
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Differential Diagnosis
• Seborrheic dermatitis• Scabies• Drugs
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Differential Diagnosis
• Seborrheic dermatitis• Scabies• Drugs• Psoriasis
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Differential Diagnosis
• Seborrheic dermatitis
• Scabies• Drugs• Psoriasis• Allergic contact
dermatitis
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Differential Diagnosis • Seborrheic dermatitis• Scabies• Drugs• Psoriasis• Allergic contact
dermatitis• Cutaneous T-cell
lymphoma
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Completely undress child Look for (SCORAD
http://adserver.sante.univ-nantes.fr/Scorad.html )
Extent % (1-10) Infection (1-3) Broken skin 1 /3 Erythema 1/3 Lichenification 1/3 Xerosis 1/3 Sleep pattern 1/10 Itch 1/10
Assessment of severity
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Assessment of severity
Clear – normal skin no evidence of active atopic eczema Mild – areas of dry skin, frequent itching +- small
areas of redness Moderate - areas of dry skin, frequent itching,
redness, +- excoriation and localised thickening. Severe – widespread areas of dry skin, incessant
itching, redness (+- excoriation, extensive skin thickening, bleeding, oozing, cracking.
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Selection of treatment
This depends on• Disease severity• Age• Compliance• Efficacy• Safety data• Treatment costs
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Every day avoid aggravators moisturiser bath oil
Eczema Treatments- 2 types
Flaring Treatments every day treatments +
steroid ointments wet dressings cool compresses antibiotics
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First line treatment: Emollients- use often every day Body- Elocon or Advantan fatty ointment,
Dermeze, hydraderm, aqueous cream, Contains squalane, a natural ingredient found in the skin's own oils.
Steroids use aggressively when flaring Face- hydrocortisone 1% or Elidel, bd Bath oils (cont’)
Topical Treatments
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• Antibiotics(for infected eczema)• Antiviral agents(for eczema herpeticum).• Steroids are better avoided at this stage.
• Antihistamines(for itching)• Pimecrolimus(thought to work by modifying the
immune system).• Patient may require admission as they
tend to be very unwell.
treatment (cont’)
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Within 24 hours if cortisone ointments are not clearing the eczema
Child is waking at night Itchy Skin is thickened If there is blood on the sheets
When to use a wet dressing
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Reduce itch Treat Infection Moisturise the skin Protect the skin Promote sleep
Why apply wet dressings?
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• Phototherapy(using ultraviolet rays UVA,nUVB)
• Immunity suppressing drugs(e.g.oral
steroids,azathioprine,ciclosporin,tacrolimus)
• Diet and nutrition (food allergy)
• Alternative therapies (Chinese medicine herbalism)
Second line treatment(severe cases):All these require specialist treatment in the
Hospital.
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• Viral infections like eczema herpeticum,warts and molluscum contagiosum
• Bacterial infections like impetigo(caused by staph aureus)
• Cataracts• Growth retardation(10% of children are affected
but not thought to be related to steroid use)
COMPLICATIONS
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NO TOPICAL STEROIDS remove crusts +/- oral/IV acylovir most often oral keflex admission prn
Eczema Herpeticum
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REMOVE CRUSTS Oral keflex/ 10 days if well IV flucloxacillin ONLY if unwell or febrile General Eczema Care Admission prn
Bacterial infected eczema
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Education and information Explain cause and course of disease Demonstrate quantities and frequency of
treatments Inform symptoms and signs of bacterial
infections How to recognise eczema herpeticum Ask about use of complementary therapies
explain have not be assessed for safety. Should continue to use emollients as well as complimentary therapies
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11 month old 2 month past history of eczema Erythema itchy waking every 1-2 hours overnight weeping general flare
Case One,History
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Infected atopic eczema admission remove crusts/weeping oral keflex cool compressing 1 hourly , apply
dermeze post wet dressings to limbs bd baby soap 2 layers of clothing to bed heater in the bedroom Diet; breast fed, full diet
Case one,What is the diagnosis?What is the plan?
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bath oil dermeze to face dermeze to limbs qid hydraderm to trunk qid wet t-shirt when red or itchy sigmacort 1% or elidel bd, prn
Case one,plan continued
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Sigmacort 1% bd to face, dermeze(50% soft, 50% liquid paraffin) face, qid
Elocon nocte to limbs and trunk, prn hydraderm to body qid keflex for 10days total cool compress prn bath oil follow up 1 -2 weeks
Case one,Discharge plan
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Thank you.