Atopic Dermatitis

AD can be divided into three stages:

1. Infantile atopic dermatitis:
2 months-2 years of age
2.Childhood atopic dermatitis:
2 years-10 years
3. Adolescent and adult atopic dermatitis
Infantile Atopic Dermatitis
60 % In the first year of life
Usually . 2 month of age
Clinic: Itchy erythema of the cheeks
Intraepidermal vesiclesrupture
moist, crusted areas extend to
other part of the body (scalp, neck,
forehead, wrist, extensor extremities
buttocks and diaper area spared
Chidhood Atopic Dermatitis
Childhood
Clinic: less acute lesions
Lesions less exudative, drier,
>papular
Locations: antecubital, popliteal
fossae, flexor wrist, eyelids, face,
around the neck
lichenified, slightly scaly/ infiltrated
plaques
Adolescents and adult AD
Older patients
Clinic: Localized erythematous, scaly, papular/
vesicular plaques
Pruritic, lichenified plaques
Location: antecubital and popliteal fossae, front
and sides of neck, forehead, area about the
eyes
Eruptions generalized more severe in
flexures lichenified
Plaques often erythematous/ hyperpigmented
Major Clinical features of AD (base on
Hanifin and Rajka)
- Intense pruritus & excoriation
- Typical morphology and distribution of skin
lesions:-facial and extensor involvement in
infant and early childhood
-flexural lichenification in adult
- Chronic or chronically relapsing dermatitis
(>6 weeks)
- Personal and family history of atopic disease


Minor features
-Dryness of the skin (xerosis)
-Ichthyosis, keratosis pilaris, hyperlinear
palms
-Non specific hand/foot dermatitis
-Scalp dermatitis e.g. cradle cap
-Allergic shiners
-Recurrent conjunctivitis and keratoconus
- IgE reactivity
-Dennie-Morgan infraorbital fold
-Orbital darkening
-Pityriasis alba
-Food hypersensitivity

Intense pruritus
Itching, Scratching the day worse at
night sleep disruption
Pat AD threshold of itching decreased
Humidity
Excessive sweating
Exposure to allergens, irritants (soap,
detergent acrylic, wool) itch
Whats the etiology of pruritus in
AD ?
- Not well understood

- Local release of proinflammatory mediators &
cytokines



Rukwied and Heyer (1999)
Pruritus:
- Histamine
- Cytokines
- leukotrienes
- neuropeptide
- proteases
Morphological characteristic of AD
-Acute lesions are papules, vesicles on
erythematous background with sign of erosion,
bleeding and serous exudate
-Sub acute lesions are erythematous and scaly
papules on dry background
-Chronic lesions are fibrotic papules on lichenified
(thickened) back ground
-Excoriation due to scratching in a all stage
-Infection may alter the appearance with the presence of
oozing or local abscess
-Even uninvolved skin is often dry and scaly
Investigation
Total Ig E > not helpful diagnosis

Skin prick test (SPT)
Specific Ig E (RAST) more helpful
SPT/RAST
Most children AD sensitized to food
(milk, egg, peanut, soy, wheat, fish)

SPT/RAST (+) 90% useful screening

-If SPT(+) confirm food elimination
Atopy patch test
-With food, aero allergen specificity &
clinical relevant

-Patch test to detect delayed type skin
hypersensitivity
-40% PAT ad CD to metal, fragance:
lanolin, emollients

Basic Treatment
Skin care
Emollients
Avoidance of irritants, sudden
changes of temperature, humidity

Identification of
specific
Exacerbating factors
Anti inflammatory
Treatment
TREATMENT OF ATOPIC DERMATITIS
Allergens
Microbes
Emotional factors
Avoidance of trigger factors
1. Irritants detergents
soap
2. Allergens: Food allergen
Airborne allergens
Child < 5 years : Usually allergy to 1 or > food
cows milk, egg, wheat, bean
3. House dust mite: older children
young adult
4. Emotional stress

TOPICAL EMOLLIENT
BASIS TOPICAL TREATMENT :
2 3 X / DAY

WATER LOSS

ITCHING
Topical treatment
CREAM / LOTION : EARLY PHASE

OINTMENT : LICHENI FIED SKIN
SEVERE CASE :
AFTER OINTMENT WETWRAP DRESSING

EPIDERMAL WATER LOSS

TOPICAL CROMOLYN IN WATER SOLUBLE
EMOLLIENT VEHICLE ANTI INFLAMATORY
EFFECT

ANTIBIOTIC
FUSIDIC ACID
GRAM (+)
TETRA CYCLINE
SKIN CLEANSER 10% POVIDONE
IODINE
GENERALIZED INFECTION : ANTI
MICROBIAL BATH (CHLORHEXIDIN 0,005%)
SISTEMIC ANTIBIOTIC : FLUCLOCXACILLIN :
MUPIROCIN
OTHER TREATMENT
STRATEGIES
UVA PHOTOTERAPY
CICLOSPORIN
IF
Chemical and Functional Classification
H1-antihistamine
Chemical 1
st
generation 2
nd
generation
Alkylamine Chlorpheniramine Acrivastine
Piperazine Hydroxyzine Cetirizine,
levocetetirizine
Piperidine Cyproheptadine Astemizol
Desloratadine
Fexofenadine
Loratadine
Ethanolamines Diphenhidramine
Ethylenediamines Pyrilamine
Phenothiazine Promethazine

Anti inflammatory effects of AH
Expression of cell adhesion molecules

Chemotaxis of eosinophilia & others cells

Proinflammatory cytokines

Adhesion protein
Antiallergic activities
Release of mediator from mast cell and
basophil


(Direct inhibitory effect on calcium-ion
channels inward calcium)
Anti-inflammation effect
Atopic Dermatitis in Child

Atopic Dermatitis in Infant and Child

Atopic Dermatitis in Child