Atopic Dermatitis
Joanna Lange
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
Felt to due to abnormal
sweating
Can be due to nickel
Needs potent topical
steroids as soon as itch
starts
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
curettage
Crystacide –
hydrogen
peroxide 1%
Eczema sufferers are
more prone to
molluscum and tend to
have more lesions
Solphadermol
Molutrex
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
effecitiveness
GKS and inhibitors of calcineurin
TA
PI
Group I-III
Group IV-V
Group VI-VII
side effects
Coventional therapy
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
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
Emollients
Emollients
Mild potency steroids
Moderate potency steroids
Potent topical steroids
Topical calcineurin inhibitors
Topical calcineurin inhibitors
Bandages
Bandages
Phototherapy
Systemic therapy (e.g.
systemic steroids,
cyclosporine)
Self
Monitoring
The patientoriented eczema
measure
(Charman, Arch Dermatol,
2004)
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