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ATOPIC DERMATITISATOPIC DERMATITIS
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M. Sjabaroeddin Loebis, Lily Irsa, Rita Evalina
Allergy Immunology Division
Pediatrics Departement
Medical Faculty Sumatera Utara University
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Atopic dermatitisAtopic dermatitis
DefinitionDefinition
An inflammatory skin disorderAn inflammatory skin disorder
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An inflammatory skin disorderAn inflammatory skin disorder
characterized with : characterized with : erythema, edema,erythema, edema,
intense pruritus, exudation, crusting, intense pruritus, exudation, crusting, andand
scalingscaling..
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Mechanisms of Eczema in
Children
1. ALLERGY
2. SKIN BARRIER DYSFUNCTIONS
3. CHRONIC INFECTION
4. AUTO-IMMUNITY (?)
= complex interplay according to pt. and age
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Atopic dermatitis
1. SKIN DISORDER
2. ALLERGIC DISEASE2. ALLERGIC DISEASE
3. Combination ?
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Pathophysiology of atopic dermatitis
Components of the skin immune system
- The static component
- The dynamic component
- Lessons from the genes
Mechanisms inducing the inflammation in skinMechanisms inducing the inflammation in skin
- The role of antigen presenting cells
Putative mechanisms underlying chronicity (AD at
the frontier between allergy and autoimmunity)
- Staph. aureus and IgE response
- Epidermal antigens or autoallergens ?
- Evidence for a lack of tolerance: the IDO-story
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Onset of dermatities frequently coincidesOnset of dermatities frequently coincides
with the introduction of certain foods into thewith the introduction of certain foods into the
infant’s diet (especially:cow’s milk, wheat,infant’s diet (especially:cow’s milk, wheat,
soy, peanuts fish or eggs)soy, peanuts fish or eggs)
Diagnosis • Intense pruritus • Eosinophilia
• White dermographism
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• Intense pruritus• Family history of asthma, hay fever, atopic dermatitis
• elevated IgE• elevated antibodies to variety of foods & inhalants
• White dermographism
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Clinical manifestations
� Affect: 2-10%
children
�Most begin in infancy
• Early lessions: erythematous, weepy patches on cheek, �Most begin in infancy
(the first 2-3 mo of life)
� 60% affected by 1 yr of age, 90% by 5 yr of age
patches on cheek, extend to : face, neck, wrists, hands, abdomen, extensor aspect of the extremities
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Clinical Manifestation
Infantil form :begins at 2-3 month of age
face, sclap, extensor, surface of limb,
hand and sucked thumb, flexure folds
after 1 yr
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Children form: > 2 yr
Flexure folds, hand, food and periorbital
Adult form: > 20 yr
Lichenification, scaling.
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DIAGNOSTIC CRITERIA DIAGNOSTIC CRITERIA OF AD (Hanifin & Rajka, 1980)OF AD (Hanifin & Rajka, 1980)
�� Must have 3 or more Must have 3 or more MAJORMAJOR features:features:
�� PruritusPruritus
�� Typical morphology and distribution Typical morphology and distribution
�� flexural lichenification in adult flexural lichenification in adult
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�� flexural lichenification in adult flexural lichenification in adult
�� facial and extensor involvement in infant and facial and extensor involvement in infant and
children children
�� Personal and family history of atopyPersonal and family history of atopy
�� Chronic and chronically relapsing course Chronic and chronically relapsing course
�� ANDAND
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DIAGNOSTIC CRITERIA OF ADDIAGNOSTIC CRITERIA OF AD
(Hanifin & Rajka, 1980)(Hanifin & Rajka, 1980)
�� Must also have 3 or more Must also have 3 or more MINOR featuresMINOR features::
�� XerosisXerosis
�� Ichthyosis/palmar hyperlinearity/keratosis pilaris Ichthyosis/palmar hyperlinearity/keratosis pilaris
�� Immediate (type I) skin test reactivity Immediate (type I) skin test reactivity
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�� Immediate (type I) skin test reactivity Immediate (type I) skin test reactivity
�� Elevated serum IgEElevated serum IgE
�� Early age of onset dermatitisEarly age of onset dermatitis
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DIAGNOSTIC CRITERIA
OF AD (Hanifin & Rajka, 1980)
�� MINOR featuresMINOR features ::
�� Tendency toward cutaneous infectionsTendency toward cutaneous infections
�� Tendency toward nonspecific hand & foot Tendency toward nonspecific hand & foot
dermatitisdermatitis
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dermatitisdermatitis
�� Nipple eczemaNipple eczema
�� CheilitisCheilitis
�� Recurrent conjunctivitisRecurrent conjunctivitis
�� DenniDenni--Morgan infraorbital foldMorgan infraorbital fold
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�� MINOR featuresMINOR features
�� KeratoconusKeratoconus
�� Anterior subcapsular cataractAnterior subcapsular cataract
Orbital darkeningOrbital darkening
DIAGNOSTIC CRITERIA DIAGNOSTIC CRITERIA OF AD (Hanifin & Rajka, 1980)OF AD (Hanifin & Rajka, 1980)
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�� Orbital darkeningOrbital darkening
�� facial pallor/facial erythemafacial pallor/facial erythema
�� Pityriasis albaPityriasis alba
�� Sweating itchSweating itch
�� Intolerance to wool and lipid solventIntolerance to wool and lipid solvent
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DIAGNOSTIC CRITERIA DIAGNOSTIC CRITERIA OF AD (Hanifin & Rajka, 1980)OF AD (Hanifin & Rajka, 1980)
�� MINOR featuresMINOR features::
�� Perifollicular accentuationPerifollicular accentuation
�� Food hypersensitivityFood hypersensitivity
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�� Course influenced by environmental/emotional Course influenced by environmental/emotional
factorsfactors
�� White dermagraphism/delayed blanchWhite dermagraphism/delayed blanch
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ComplicationsComplications
Secondary infection of the lession withSecondary infection of the lession with
bacterial, fungal, or viral.bacterial, fungal, or viral.
Treatment
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Treatment
• Avoid extreme temperature & humidity• Sweating leads to itching and aggravation of the disease
• Exposure to sunlight and salt water may beneficial
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Treatment ……..
• Avoid the use of soap and detergent for the dry skin
• During acute flare-up, wet dressings (e.g. Burrow’s solution 1:20) → antipruritic & anti-inflammatory
• If infection is present (acute weeping or crusting)
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• If infection is present (acute weeping or crusting) → systemic antibiotic. Drug of choice : erythromycin or cephalexin (because of frequent resistance of penicillin by Staphylococcus aureus)
• Topical triamcinolone acetonide ointment, 0,1% is useful but best limited to 1-3 weeks at a time; after improvement
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What improvements are needed?
� Ideally, a cure
Managing atopic eczema:
New opportunities
� Ideally, a cure
� The next best alternative is a treatment that is
safe and effective and adds a significant
dimension to existing therapies
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