atopic dermatitis(eczema)

Dr Muhammad Raza

PG Trainee MCPS

1. To know about basic concept of atopic dermatitis.

2. Signs and symptoms of the disease

3. Etiology and pathogenesis.

4. Diagnosis, management and referral of the disease.

By the end of my presentation each participant should be able to:

Atopic Dermatitis(Eczema)

• Atopic dermatitis (eczema) is a condition that makes your skin cracked, swollen, red and itchy. It's common in children but can occur at any age.

• Atopic dermatitis is long lasting (chronic)and tends to flare periodically.

• It may be accompanied by asthma or hay fever

People with atopic dermatitis

• More than 50% develop asthma

• 75% develop allergic rhinitis

Signs and symptoms

Dry skin

Itching , especially at night

Red to brownish-gray patches, especially on the hands, feet,

ankles, wrists, neck, upper chest, eyelids, inside the bend of the

elbows and knees, and in infants, the face and scalp

Small, raised bumps, which may leak fluid and crust

over when scratched

Thickened, cracked, scaly skin

Raw, sensitive, swollen skin from scratching.

UK Diagnostic criteria

Itchy skin and at least three of the

followings:

History of itch in skin creases or

cheeks(if < 4yrs)

Dry skin

(Xeroderma)

Visible flexural

eczema(cheeks,fore

head,outer limbs if

< 4yrs

History of

asthma/hay fever(in

1st-degree relatives

if < 4yrs)

Onset in first 2

years of life

Infancy

• Often acute and involves the face and trunk

sparing of napkin area

Childhood

• Back of the knees, front of the elbows, wrists and

ankles

Adults

• Face and trunk, lichenification is common

Distribution and character of rash

Typical AD for Infants and Toddlers

Erythematous, ill-

defined plaques on

the lateral lower

with overlying scale

Erythematous, ill-

defined plaques on

the cheeks with

overlying scale and

More Examples of Atopic Dermatitis

• Note the distribution of AD on face and extensor surfaces

Affects flexural areas of neck, elbows, knees,

wrists, and ankles

• Antecubital fossa • Lichenified, erythematous plaques behind the knees

Acute

• Redness and

swelling,usually

with ill defined

margins

• Papules,vesicles

and large blisters

• Exudation and

cracking

Chronic

• Usually less

vesicular and

exudative.

• Lichenification,

secondary to

rubbing and

scratichng

• Fissures, scratch

marks

Continue….

EPIDEMIOLOGY

Age Of Onset 60% develop in 2 months to 1 year of life. 30% are seen for the first time by age 5, and 10% develop AD between 6

20 years of age. Rarely AD has an adult onset

Gender Slightly More Common in males than females

The cause of AD is multifactorial and not completely understoodThe following factors are thought to play varying roles:

Genetics

Skin Barrier Dysfunction

Impaired Immune Response

Eliciting factors

Exacerbating factors

• Mutation in filaggrin gene(FLG), which encodes a

protein that aggregates keratin filaments during

terminal differentiation of the epidermis

• Filaggrin is an important component of barrier of

the skin

Filaggrin

Atopic Dermatitis: Cause

ELICITING FACTORS

Inhalants Specific aeroallergens, especially dust mites and pollens.

Microbial Agents Exotoxins of Staphylococcus aureus may act as super-antigents and stimulate the T cells and macrophages

Auto-allergens IgE antibodies directed at human proteins cause release of auto-

allergens from damaged tissue which trigger IgE or T cell responses.

Foods Eggs, milk, soya-beans, fish and wheat

Exacerbating Factors

Skin Barrier Disruption Increase transepidermal water loss by frequent bathing, handwashing and dehydration

Infections S.aureus present in severe cases; rarely fungus (dermatophytosis, candidiasis)

Season AD improves in summer, flares in winter

Clothing Wool is an important trigger; wool clothing or blankets.

Emotional Stress is an exacerbating factor in flares of the disease

Diagnosis

Skin biopsy elevated

numbers of a certain type of

white blood cells

(eosinophils) and elevated

serum IgElevel)

Skin scratch/prick

test which involve

scratching or pricking the skin with a needle that contains a

small amount of a suspected

allergen)

Patch test is performed in

suspected cases of contact allergic

dermatitis

Bacterial and viral

swabs are useful in

suspected secondary infections

Total & specific IgE antibodies

to determine specific

environmental allergens.

RAST

(Radioallergosorbenttest may

suggest dust mite allergy)

Atopic dermatitis is typically diagnosed

clinically by UK diagnostic criteria ,

however further labs are helpful in

diagnosing AD.

Management

Primary preventionMoisturize your skin at least twice a day (Creams,

ointments and lotions)

Identify and avoid triggers that worsen the condition (sweat, stress, obesity, soaps, detergents, dust and pollen)

Take shorter baths or showers (Limit your baths and showers to 10 to 15 minutes. And use warm, rather than hot, water)

Continue….

Take a bleach bath (A diluted-bleach bath with household bleach for 10 minutes decreases bacteria on the skin and related infections)

Use only gentle soaps (Choose mild soaps,Because deodorant soaps and antibacterial soaps can remove more natural oils and dry your

skin.)

Dry yourself carefully (After bathing gently pat your skin dry with a soft towel and apply moisturizer

while your skin is still damp)

Atopic Dermatitis

Irritants

Wool Clothing

Winter Chapping

Excessive Heat

Sweating

Airborne allergens

Food allergens

Skin infections

Stress

Habitual scratching

Supportive Care

• Emollients (Moisturizers)

• (Alpha-Hydroxy acid) is made up of glycolic

acid(8%) + lactic acid(12%) + Urea (6%).

• Vanicream,Eucerin,Lubiderm,Curel and vaseline

petroleum jelly.

• Urea creams

• Oils

• Apply emollients once in a day after bathing

and the times when the skin is usually dry.

1st line treatment

( Emollients+ Topical steroids)

Topical steroids

• Hydrocortisone 1-2.5% applied to all skin

• Quite safe and often use for months

• Use intermittently on thin areas(face and

• Stronger potency topical steroids for non

facial/genital regions.

• Avoid potent/ultrapotent topical steroid

preparations on face,armpit,groins & bottom.

2nd line treatment

• Topical immunosuppresants and topical calcineurin

inhibitors like tacrolimus and pimecrolimus.

Use when the continued use of topical steroids is

ineffective or inadvisable

3rd line treatment

• Phototherapy with ultraviolet (UV) light can be an effective treatment for severe atopic dermatitis.

Combined UVA and UVB light have a more beneficial

effect than UVA or UVB light alone. UV light may also

help to prevent bacterial infections.

Systemic Treatment

→Antihistamines for itching

Linoleic acid and linoleic gamma for pruritis

→Macrolide and cephalosporin for secondary bacterial infection

→Acyclovir for “Herpeticumeczema”

Advance Therapies

Cyclosporine Methotrexate AzathioprineBiologics(Anti-

IgE i-e omaltizumab)

Differential Diagnosis

• seborrheic dermatitis

• Scabies

• Drug reactions

• Psoriasis

• Allergic contact dermatitis

• Cutaneous T-cell lymphoma

• Lichen planus

• Palmoplanter pustulosis

• Staph areus is most commonBacterial

• Herpes simplex virus cause a widespread severe eruption( eczema herpeticum)

• Papillomavirus and moluscum contagiosum.Viral

• Defective barrier functionIrritant reaction

• Loss of schooling and behavioural difficultiesSleep disturbance

• Eggs, cow’s milk, protein, fish, wheat and soya may cause an immediate urticarial eruption.Food allergy

Complications of atopic eczema

When to Refer

Patients should be referred to a

dermatologist when:→Patients have recurrent skin

infections

→Patients have extensive and/or

severe disease

→Herpeticum eczema

→Symptoms are poorly controlled

with topical steroids

Resources

• http://www.nhs.uk/conditions/pregnancy-and-baby/pages/eczema-in-children.

• https://nationaleczema.org/eczema/child-eczema/

• https://www.allergyuk.org/atopic-dermatitis-and-eczema-in-children/atopic-dermatitis-eczema-in-children