Atopic Dermatitis Treatment: from Conventional to Unconventional

Prof Ariyanto Harsono MD PhD SpA(K)

Atopic dermatitis is a disease that begin to arise at the age of infants and children

characterized by itching of the skin. chronic and relapsing inflammatory reaction based on hereditary factors and environmental

factors, the symptoms are chronic recurrent erythema,

papules, vesicles, crusting, and skuama.

2Prof DR Dr Ariyanto Harsono SpA(K)

Atopic Dermatitis:

Itch that erupts Not eruption that itches

3Prof DR Dr Ariyanto Harsono SpA(K)

4Prof DR Dr Ariyanto Harsono SpA(K)

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IgE

IL-4, IL-5IL-13

6Prof DR Dr Ariyanto Harsono SpA(K)

IgE

IL-4, IL-5IL-13

v

2

CD4+Th1 Cell

IFN-

CD8+Th1 Cell

DTH

Super antigen

7

Prof DR Dr Ariyanto Harsono SpA(K)

Spongious

InfiltrasiEosinofil

Udem

8Prof DR Dr Ariyanto Harsono SpA(K)

Major criteria (minimal 3)

•Pruritus

•Characteristic Distribution and morphology of skin lesions

•Flexural Lichenification

•Facial and extensor Lichenification in babies and children

•Chronic

•History of family atopy

9Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

•Pruritus

•Characteristic Distribution

and morphology of skin lesions

•Flexural Lichenification

•Facial and extensor

Lichenification in babies and children

•Kronik

•History of family atopy

•Riwayat atopi dan keluarga atopi

10Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Major criteria (minimal 3)

•Pruritus

•Characteristic Distribution

and morphology of skin lesions

•Flexural Lichenification

•Facial and extensor

Lichenification in babies and

children

•Kronik

•History of family atopy11Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Major criteria (minimal 3)

•Pruritus

•Characteristic Distribution

and morphology of skin lesions

•Flexural Lichenification

•Facial dan ekstensor pada bayi

dan anak

•Kronik

•History of family atopy12Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Major criteria (minimal 3)

Kriteria Hanifin and Rajka

•Pruritus

•Characteristic Distribution

and morphology of skin lesions

•Flexural Lichenification

•Facial and extensor in babies

and children

•Chronic

•History of family atopy13Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Major criteria (minimal 3)

14Prof DR Dr Ariyanto Harsono SpA(K)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

Hanifin and Rajka criteria

Minor criteria (minimal 3)

15Prof DR Dr Ariyanto Harsono SpA(K)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

16

Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

17

Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

18Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

19Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

20Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Minor criteria (minimal 3)

21Prof DR Dr Ariyanto Harsono SpA(K)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

Hanifin and Rajka criteria

Minor criteria (minimal 3)

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•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive

•High IgE levels•Early Onset of age•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Vulnerable of infections (Stafilokokus/herpes)

23Prof DR Dr Ariyanto Harsono SpA(K)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Staphylococcus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

Hanifin and Rajka criteria

Minor criteria (minimal 3)

24Prof DR Dr Ariyanto Harsono SpA(K)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

Hanifin and Rajka criteria

Minor criteria (minimal 3)

25Prof DR Dr Ariyanto Harsono SpA(K)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

Hanifin and Rajka criteria

Minor criteria (minimal 3)

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•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections •Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

Hanifin and Rajka criteria

Minor criteria (minimal 3)

27Prof DR Dr Ariyanto Harsono SpA(K)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Tes kulit positif•Peningkatan IgE serum•Onset usia muda•Mudah infeksi kulit (Stafilokokus/herpes)•Kecenderungan nonspesific dermatitis•Nipple eczema•Cheilitis•Reccurent conjunctivitis

28Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Minor criteria (minimal 3)

Kriteria Hanifin and Rajka

29Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria

Minor criteria

Kriteria Hanifin and Rajka

30Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria

Minor criteria

31Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria

Minor criteria

32Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria

Minor criteria

33Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria

Minor criteria

Kriteria Hanifin and Rajka

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism 34Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Minor criteria

Kriteria Hanifin and Rajka

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism 35Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Minor criteria

Kriteria Hanifin and Rajka

36Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria

Minor criteria

Kriteria Hanifin and Rajka

37Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria

Minor criteria

Kriteria Hanifin and Rajka

38Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria

Minor criteria

Kriteria Hanifin and Rajka

39Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria

Minor criteria

Hanifin and Rajka criteria

Minor criteria

40Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria for baby

Kriteria mayor (minimal 2 mayor)

•History of family atopy•Evidence of pruritic Dermatitis•Dermatitis fasial, ekstensor, lichenification

Minor criteria (minimal 1 minor)

•Xerosis/ichtyosis/hyperlinear palm•Perifollicular accentuation•Chronic scalp scalling•Periauricular fissures

41Prof DR Dr Ariyanto Harsono SpA(K)

Major criteria(minimal 2 major)

Hanifin and Rajka criteria for baby

Kriteria mayor (minimal 2 mayor)

•History of family atopy•Evidence of pruritic Dermatitis•Dermatitis fasial, ekstensor, lichenification

Minor criteria (minimal 1 minor)

•Xerosis/ichtyosis/hyperlinear palm•Perifollicular accentuation•Chronic scalp scalling•Periauricular fissures

42Prof DR Dr Ariyanto Harsono SpA(K)

Major criteria(minimal 2 major)

Hanifin and Rajka criteria for baby

Kriteria mayor (minimal 2 mayor)

•History of family atopy•Evidence of pruritic Dermatitis•Dermatitis fasial, ekstensor, lichenification

Minor criteria(minimal 1 minor)

•Xerosis/ichtyosis/hyperlinear palm•Perifollicular accentuation•Chronic scalp scalling•Periauricular fissures

43Prof DR Dr Ariyanto Harsono SpA(K)

Major criteria(minimal 2 major)

Hanifin and Rajka criteria for baby

Major criteria(minimal 2 major)

•History of family atopy•Evidence of pruritic Dermatitis•Dermatitis fasial, ekstensor, lichenification

Minor criteria (minimal 1 minor)

•Xerosis/ichtyosis/hyperlinear palm•Perifollicular accentuation•Chronic scalp scalling•Periauricular fissures

44Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin criteria for children

Major criteria (minimal 3 major)

•Pruritus•Characteristic Distribution and morphology of skin lesions•Dermatitis fasial, ekstensor selama bayi dan awal usia anak•Flexural lichenification dan linearity by adolescence•Chronic Dermatitis

Minor criteria(minimal 1 minor)•Xerosis/ichtyosis/hyperlinear palm/keratosis pilaris•IgE reactivity•Chronic scalp scalling•Perifollicular accentuation•Periauricular fissures 45Prof DR Dr Ariyanto Harsono SpA(K)

Minor criteria(minimal 1 minor)

•Hand/foot dermatitis•Cheilitis•Vulnerable to infection (Herpes/Strep/S aureus)

46Prof DR Dr Ariyanto Harsono SpA(K)

Minor criteria(minimal 1 minor)

•Hand/foot dermatitis•Cheilitis•Vulnerable to skin infetions (Herpes/Strep/S aureus)

47Prof DR Dr Ariyanto Harsono SpA(K)

Minor criteria(minimal 1 minor)

•Hand/foot dermatitis•Cheilitis•Vulnerable to skin infetions (Herpes/Strep/S aureus)

48Prof DR Dr Ariyanto Harsono SpA(K)

Minor criteria(minimal 1 minor)

•Hand/foot dermatitis•Cheilitis•Vulnerable to skin infetions (Herpes/Strep/staphilococcus)

49Prof DR Dr Ariyanto Harsono SpA(K)

50Prof DR Dr Ariyanto Harsono SpA(K)

Seborrhoic dermatitis

51Prof DR Dr Ariyanto Harsono SpA(K)

Pompholix

52Prof DR Dr Ariyanto Harsono SpA(K)

Principle of Conventional Therapy

Eczema

Target for skin care

Target for anti inflammatory

53Prof DR Dr Ariyanto Harsono SpA(K)

EducationHidration

EmolientMoisturizerWet dressing

Allergen/irritants avoidanceAntihistamineTopical Steroid

54Prof DR Dr Ariyanto Harsono SpA(K)

Conventional Therapy is not always safe

Topical steroid: cutaneous atrophy, striae, bruisability, telangiectasia

High-potency topical steroids can cause systemic side effects in children.

55Prof DR Dr Ariyanto Harsono SpA(K)

Mild Moderate Severe

Mild to Moderate Potency Topical Steroids

Pimecrolimus

Tacrolimus

Oral Steroids

Cyclosporine, mycophenolate

Light treatment

New Treatment Strategy in AD

Emolient

Dry skin

Itching and/or early sign of inflammation

Flare

56Prof DR Dr Ariyanto Harsono SpA(K)

IVIG

Arachidonic Acid (ARA)

Phospholiphase A

Cyccloxygenase Lipoxygenase

Prostaglandine

TXA

Prostacyclin

Leukotriene A

Leukotriene B

Leukotriene C

-linoleic acid

HETE,5-HETE, PAF57Prof DR Dr Ariyanto Harsono SpA(K)

Mechanism of IVIG blocking apoptosis via Procaspase-8 pathway

Macrophage Keratinocyte

58Prof DR Dr Ariyanto Harsono SpA(K)

Use of IVIG

Prof DR Dr Ariyanto Harsono SpA(K)

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60Prof DR Dr Ariyanto Harsono SpA(K)

Thank you