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;358:149

1.

INFAN
TIL
b b -E2
a y.
y.
o

CHILDHOO
D2-1 y.o

ADULT
>12y.
adul
o
t

 more dry lesion

itch scratch

more chronic
lichenification
acuteerythema
, plaque
Recurrence
infiltrate
, papules
danerosion
, feet, wrist &ankle
Locationin hand
flexural ante
cubital &
Lesion in
main sign
popliteal

William Criteria
Basic feature (obligatory)

Itchy skin
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
Diagnosis : Itchy skin + minimal 3 of the additional
features

ASSESING
DISEASE
SEVERITY

Pediatrician do
not practice
this

Developed by ETFAD on
1993

MILD
MODERATE
SEVERE

0-34
3 -69
5
7 -10
0 3

Maximum score is 103

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

DA
severe,recalsitran

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

TCS moderate
-super potent and/or
TCI

DA moderate
-sever
e

DA mild
- moderate

TCS mild
-moderate and/or TCI
2

Dry Skin Only

1

Standard Treatment: skin hydratio

emollient, avoid irritant, identify
avoid aggravating factor

TCS: topical corticosteroid ; TCI: topical

calcineurin inhibitor

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 itchscratch cycle
Rubel D, et al. Consensu guideline for the management of
Atopic Dermatitis: An

Patrizi A, et al. The natural history of sensitizations to food and

aeroallergens in atopic dermatitis: a 4-year follow up, Pediatr

Severity of Inhalant Food

Asthma
AD
allerge and/ or
and/or
n only allergic
food
allergen
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

 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-inflammatory

anti
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: 160171

 Atopic Dermatitis is an important step in

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