atopic dermatitis

ATOPIC ATOPIC DERMATITISDERMATITIS

(ATOPIC ECZEMA)(ATOPIC ECZEMA)

A A WWholistic approachholistic approach

David W. YoungDavid W. YoungDermatologistDermatologist

ATOPIC DERMATITISATOPIC DERMATITIS

Does not have a single causeDoes not have a single cause

Monotherapy does not exist!!Monotherapy does not exist!!

Aetiology and exacerbations are Aetiology and exacerbations are multifactorial in originmultifactorial in origin

ATOPIC DERMATITISATOPIC DERMATITIS

Is not an allergyIs not an allergy

People with atopic dermatitis have People with atopic dermatitis have an increased incidence of allergiesan increased incidence of allergies

ATOPIC DERMATITISATOPIC DERMATITIS

Patients are frequently very Patients are frequently very uncomfortableuncomfortable

Often aggressive treatment is Often aggressive treatment is required required

ATOPIC DERMATITISATOPIC DERMATITIS

Genetically determinedGenetically determined 70+% have a FH of atopy70+% have a FH of atopy

10 – 20% of <5’s have ADs10 – 20% of <5’s have ADs Increasingly prevalent in industrialised Increasingly prevalent in industrialised

temperate countries.temperate countries.

Occurs in first year in 85%, 95% before 5 Occurs in first year in 85%, 95% before 5 yrsyrs

ATOPIC DERMATITISATOPIC DERMATITIS

Spontaneous improvement occursSpontaneous improvement occurs

Many carry the disorder into Many carry the disorder into adulthoodadulthood

Underlies 80% of occupational Underlies 80% of occupational dermatosesdermatoses

CAUSES OF ATOPIC CAUSES OF ATOPIC DERMATITISDERMATITIS

Skin structurally differentSkin structurally different

Skin ‘biochemically’ differentSkin ‘biochemically’ different

Immunological changes. Immunological changes.

STRUCTURAL CHANGESSTRUCTURAL CHANGES

Impaired skin barrier functionImpaired skin barrier function

Xeroderma Xeroderma

Keratosis pilarisKeratosis pilaris AD ichthyosis (ichthyosis vulgaris)AD ichthyosis (ichthyosis vulgaris) Pityriasis albaPityriasis alba Denny-Morgan foldsDenny-Morgan folds

‘‘BIOCHEMICAL CHANGES’BIOCHEMICAL CHANGES’

White dermographismWhite dermographism

IMMUNOLOGICAL CHANGESIMMUNOLOGICAL CHANGES

Up to 80% have increased IgEUp to 80% have increased IgE

Some decrease in cell mediated Some decrease in cell mediated immunityimmunity

Fundamental imbalance between the Fundamental imbalance between the response of TH1 and TH2 lymphocytesresponse of TH1 and TH2 lymphocytes

PRACTICAL CAUSES AND PRACTICAL CAUSES AND AGGRAVATING FACTORSAGGRAVATING FACTORS

XerodermaXeroderma IrritantsIrritants Climatic changesClimatic changes InfectionInfection Food and other allergiesFood and other allergies

IRRITANTSIRRITANTS

‘‘Usual’ irritantsUsual’ irritants

Soaps, soap powders, detergents.Soaps, soap powders, detergents.

Chlorine in swimming poolsChlorine in swimming pools

FibresFibres

FrictionFriction

CLIMATE CHANGESCLIMATE CHANGES

Hot or cold temperaturesHot or cold temperatures

Sudden changes in temperatureSudden changes in temperature

Low humidityLow humidity

INFECTIONINFECTION

Staph. Aureus most importantStaph. Aureus most important

Uninfected atopic skin has increased Uninfected atopic skin has increased number of Staph.number of Staph.

May act as a ‘superantigen’ May act as a ‘superantigen’ activating lymphocytesactivating lymphocytes

FOOD AND OTHER FOOD AND OTHER ALLERGIESALLERGIES

Literature on role of food allergens is Literature on role of food allergens is extensive, controversial, & extensive, controversial, & contradictorycontradictory

Majority have +ve skin prick tests or Majority have +ve skin prick tests or RAST/EAST tests to foodsRAST/EAST tests to foods

Very few appear to be relevantVery few appear to be relevant Small % aggravated by certain foodsSmall % aggravated by certain foods Most common: cow’s milk, eggs, soy, Most common: cow’s milk, eggs, soy,

peanuts, wheat, & fish peanuts, wheat, & fish

FOOD AND OTHER FOOD AND OTHER ALLERGIESALLERGIES

Ask parents!Ask parents!

RAST or skin prick tests often more RAST or skin prick tests often more useful if negative useful if negative

FOOD AND OTHER FOOD AND OTHER ALLERGIESALLERGIES

House dust miteHouse dust mite

Grasses, pollens, etc.Grasses, pollens, etc.

PATTERN - INFANCYPATTERN - INFANCY

XerodermaXeroderma Face and scalp often first involvedFace and scalp often first involved Trunk and limbs, especially flexuresTrunk and limbs, especially flexures Nappy rashNappy rash Lichenification seldom seenLichenification seldom seen May be exudativeMay be exudative InfectionInfection

PATTERN - CHILDHOODPATTERN - CHILDHOOD

XerodermaXeroderma Often exudativeOften exudative FlexuralFlexural PeriorbitalPeriorbital ‘‘Lip-lick’ dermatitisLip-lick’ dermatitis Lichenification frequentLichenification frequent Excoriation & crusting commonExcoriation & crusting common InfectionInfection

PATTERN - ADULTHOODPATTERN - ADULTHOOD

XerodermaXeroderma LichenificationLichenification Face and neck frequently involvedFace and neck frequently involved Hand dermatitisHand dermatitis ErythrodermaErythroderma

COMPLICATIONSCOMPLICATIONS

Family dynamics!!Family dynamics!!

Eczema herpeticumEczema herpeticum Molluscum contagiousumMolluscum contagiousum

Occupational dermatosesOccupational dermatoses

TREATMENTTREATMENT

Time consumingTime consuming ‘‘Consumer’ resistanceConsumer’ resistance Unhelpful adviceUnhelpful advice The latest ‘magic cure’The latest ‘magic cure’ Steroid (& antibiotic) phobiaSteroid (& antibiotic) phobia Avoid poor dietary nutrition Avoid poor dietary nutrition

TREATMENTTREATMENT

Aggressive treatment early to show Aggressive treatment early to show ‘something can be done’‘something can be done’

Explanation re the nature of the Explanation re the nature of the diseasedisease

A plan for the various phases of ADsA plan for the various phases of ADs

TREATMENT – AVOID TREATMENT – AVOID IRRITANTSIRRITANTS

SoapsSoaps Soap powdersSoap powders Clothing fibresClothing fibres Extremes of temperatureExtremes of temperature Low humidity environmentsLow humidity environments

TREATMENT - XERODERMATREATMENT - XERODERMA

EmollientsEmollients

EmollientsEmollients

EmollientsEmollients

EMOLLIENTSEMOLLIENTS

Alpha Keri, BK, DP, Hydroderm lotionsAlpha Keri, BK, DP, Hydroderm lotions Glyc. 10% in Aqueous or sorbolene Glyc. 10% in Aqueous or sorbolene

creamcream Urea 10% creamsUrea 10% creams QV, Cetaphil, etc. creamsQV, Cetaphil, etc. creams Lipobase, Lemnis Fatty CreamLipobase, Lemnis Fatty Cream Lipobase RepairLipobase Repair WSP, Emuls. OintWSP, Emuls. Oint Bath oilsBath oils

TREATMENT - ANTIHISTAMINESTREATMENT - ANTIHISTAMINES

It is the sedation rather than the It is the sedation rather than the antihistamine action which is helpful antihistamine action which is helpful at times. Use short termat times. Use short term

If frequent wheal and flare reactionsIf frequent wheal and flare reactions

KetotifenKetotifen

TREATMENT - ANTIBIOTICSTREATMENT - ANTIBIOTICS

Cover Staph aureus (+/-beta haem Cover Staph aureus (+/-beta haem strep)strep)

Required if exudative and crustingRequired if exudative and crusting Occasionally needed medium to long Occasionally needed medium to long

termterm Give parents a script or repeats to Give parents a script or repeats to

have ‘on hand’ have ‘on hand’

TREATMENT – TOPICAL TREATMENT – TOPICAL CORTICOSTEROIDSCORTICOSTEROIDS

Extremely effective in treating and Extremely effective in treating and controlling ADscontrolling ADs

Very safe if used appropriatelyVery safe if used appropriately Use mod. potent or potent short termUse mod. potent or potent short term Use mildly potent for maintenance if Use mildly potent for maintenance if

requiredrequired Safe to use in infected dermatitis if Safe to use in infected dermatitis if

infection also being treatedinfection also being treated

TREATMENT – TOPICAL TREATMENT – TOPICAL CORTICOSTEROIDSCORTICOSTEROIDS

Dermol & Diprosone OVDermol & Diprosone OV

Betnovate, Nerisone, Diprosone, Betnovate, Nerisone, Diprosone, Elocon, AdvantanElocon, Advantan

LocoidLocoid

Aristocort, EumovateAristocort, Eumovate

Hydrocortisone 1%Hydrocortisone 1%

TREATMENT – TOPICAL TREATMENT – TOPICAL CORTICOSTEROIDSCORTICOSTEROIDS

The base is important!The base is important!

Ointments better then creamsOintments better then creams

TREATMENT – TREATMENT – IMMUNOMODULATORSIMMUNOMODULATORS

Topical – tacrolimusTopical – tacrolimus

- pimecrolimus- pimecrolimus

Oral – cyclosporin AOral – cyclosporin A

- methotrexate- methotrexate

- azathioprine- azathioprine

TREATMENT – DIETTREATMENT – DIET

Avoid foods known to flare or Avoid foods known to flare or aggravate patient’s ADsaggravate patient’s ADs

Dietician’s adviceDietician’s advice

TREATMENT – OTHERSTREATMENT – OTHERS

Tar preparationsTar preparations Evening primrose or flax seed oilEvening primrose or flax seed oil ProbioticsProbiotics Chinese herbsChinese herbs Narrowband UVBNarrowband UVB Immunosuppressants – azathioprine, Immunosuppressants – azathioprine,

methotrexatemethotrexate