eczeme dermatite oct2012

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 10/31/12 1 ECZEME/DERMATITE  Terminologie   Termenii de eczema/dermatita sunt considerati sinonimi.   Termenul de dermatita este mai frecvent in literatura anglo-americana, iar cel de eczema in cea francofona.  Etimologic, eczema deriva din limba greaca si inseamna “oparit”. Eczema/dermatita = sindrom cutanat inflamator definit:  Clinic: succesiune de modificari cutanate: eritem, veziculatie, exsudatie, crustificare, descuamare si uneori lichenificare + prurit  Histopatologic: spongioza, vezicule spongiotice si infiltrat limfohistiocitar perivascular in dermul superior. Clinic Sindrom clinic caracterizat prin eritem, veziculaţie, exudaţie şi prurit

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  • 10/31/12

    1

    ECZEME/DERMATITE

    Terminologie

    Termenii de eczema/dermatita sunt considerati sinonimi.

    Termenul de dermatita este mai frecvent in literatura anglo-americana, iar cel de eczema in cea francofona.

    Etimologic, eczema deriva din limba greaca si inseamna oparit.

    Eczema/dermatita

    = sindrom cutanat inflamator definit: Clinic: succesiune de modificari cutanate:

    eritem, veziculatie, exsudatie, crustificare, descuamare si uneori lichenificare + prurit

    Histopatologic: spongioza, vezicule spongiotice si infiltrat limfohistiocitar perivascular in dermul superior.

    Clinic

    Sindrom clinic caracterizat prin eritem, veziculaie, exudaie i

    prurit

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    2

    eritem

    papule

    vezicule

    pustule

    exudaie

    cruste

    scuame

    ECZEM

    regresie

    PR

    UR

    IT

    vindecare progresie Eczem cronic

    Spongioza trasatura histopatologica esentiala

    Vezicula spongiotica = vezicula clinic

    Eczeme forme clinico-evolutive

    Eczem acut Eczem subacut Eczem cronic

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    3

    Eczem acut

    Eczem subacut

    Eczem cronic

    ECZEM DE CONTACT CRONIC

    Clasificarea eczemelor (dermatitelor) Dermatite exogene

    Dermatita de contact Alergic (mecanism alergic) Iritativ (ortoergic) - fr mecanism alergic

    Eczeme (dermatite endogene Eczema (dermatita) atopic

    Eczeme mixte (exo-endogene) Eczema numular Dishidroza, eczema dishidrozic Eczema (dermatita) de staz Eczema (dermatita) seboreic Eczema fisurar (craquel) Eczema prin diseminare secundar

    I. Dermatite de contact iritative (fr substrat alergic)

    Nu necesita expunere anterioara Zone afectate: locul contactului, extensie mica in jur Susceptibilitate: universala Debutul leziunilor: rapid (ore de la expunere) Legatura cu expunerea: apar de la prima expunere

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    II. Dermatite de contact alergice

    Expunere anterioara este obligatorie Zone afectate: locul contactului, posibil si la distanta Susceptibilitate: numai persoane sensibilizate Debutul leziunilor: lent (48 ore) Legatura cu expunerea: nu apar la prima expunere

    Dermatite de contact cu substrat alergic

    Forme clinico-evolutive: acute subacute cronice

    Teritorii limitate, sugernd contactul cu alergenul Diseminare:

    hematogen transpiraie friciune

    Forme clinice particulare: dermatite fotoalergice dermatite de contact aeropurtate dermatite de contact pe cale sistemic

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    5

    Dermatita de contact alergic

    D.C.A TANANTI

    Dermatita de contact alergic-localizri

    Cosmetice, deodorant, ampon, lac de unghii

    Gablonuri, nichel, crom Ageni chimici, detergent, ciment

    Plante

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    6

    Test epicutan (patch-test) Clasificarea eczemelor (dermatitelor)

    Dermatite exogene Dermatita de contact

    Alergic (mecanism alergic) Iritativ (ortoergic) - fr mecanism alergic

    Eczeme (dermatite) endogene Eczema (dermatita) atopic

    Eczeme mixte (exo-endogene) Eczema numular Dishidroza, eczema dishidrozic Eczema (dermatita) de staz Eczema (dermatita) seboreic Eczema fisurar (craquel) Eczema prin diseminare secundar

    Eczema (dermatita) atopic Afeciune cutanat inflamatorie, cronic, pruriginoas, survenind

    la indivizi cu antecedente personale sau familiale de atopie Prevalen variabil ( 0,5-20%), n continu cretere, predominant

    la copii Corelaie pozitiv a prevalenei cu nivelul socio-economic ridicat

    i gradul de poluare "Ipoteza Igienei" ( expunere insuficient la antigene bacteriene n copilrie n mediile

    favorizate determin dezechilibru Th1/Th2, i manifestri de atopie)

    Imunitate celular Dezechilibru Th1/Th2

    Citokine proinflamatorii

    Piele uscat, deficit al secreiei

    de sebum i sudoare, prag redus de prurit

    Blocaj al receptorilor beta-adrenergici

    Alergii alimentare i de mediu

    Nivel ridicat de IgE

    Predispoziie imunologic ereditar

    Tip de personalitate: Astenic, stres emoional

    ECZEMA ATOPIC

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    Stigmate de atopie

    Pliuri Dennie-Morgan Halou periorbital

    Dermografism alb Hiperliniaritate palmar

    Eczema atopic

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    Lichen simplex cronic

    (Neurodermit)

    ECZEM ERITRODERMIC

    ECZEMA HERPETICUM

    Criteriile de diagnostic Hanifin-Rajka CRITERII MINORE ( 3 DIN 23) Xeroz cutanat Ichtioz/hiperlinairitate palmar/keratosis pilaris Reacii cutanate de hipersensibilitate imediat ( tipI) IgE seric crescut Debut n copilrie Tendin la infecii cutanate, aprare imun mediat celular

    sczut Tendin la dermatite nespecifice palmo-platare Eczem perimamelonar Cheilit Conjunctivit recurent Pliuri Dennie-Morgan Keratoconus Cataract subcapsular anterioar Hiperpigmentare periocular Paloare facial/ eritem Pitiriazis alba Riduri anterocervicale Prurit asociat transpiraiei Intoleran la ln i detergeni Accentuare perifiolicular Intolerane alimentare Evoluie influenat de factori d emediu i emoionali Dermografism alb

    Criteriile Hanifin-Rajka

    Prea complicate Utilizeaza date de laborator Nu au fost niciodata validate in populatie Stabilite prin consens de experti

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    Criteriile britanice de diagnostic a dermatitei atopice Afectiune cutanata pruriginoasa

    + minimum 3 dintre urmatoarele:

    istoric de eruptie in zone flexurale istoric personal de astm sau febra de fan istoric de xeroza cutanata debut sub varsta de 2 ani dermatita flexurala vizibila Sensibilitate: 74%; Specificitate: 99% (Romania)

    Clasificarea eczemelor (dermatitelor) Dermatite exogene

    Dermatita de contact Alergic (mecanism alergic) Iritativ (ortoergic) - fr mecanism alergic

    Eczeme (dermatite) endogene Eczema (dermatita) atopic

    Eczeme mixte (exo-endogene) Eczema numular Dishidroza, eczema dishidrozic Eczema (dermatita) de staz Eczema (dermatita) seboreic Eczema fisurar (craquel) Eczema prin diseminare secundar

    Eczem numular

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    Eczem dishidrozic

    DISHIDROZ ECZEM SEBOREIC

    ECZEMA SEBOREIC

    Eczema de staz (varicoasa)

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    Clasificarea dermatocorticoizilor

    Necesarul de dermatocorticoid - the fingertip unit (FTU) -

    A finger tip unit (FTU) is defined as the amount of ointment, cream or other semi-solid dosage form expressed from a tube with a 5mm diameter nozzle, applied from the distal skin-crease to the tip of the index finger of an adult.

    One FTU is enough to treat an area of skin twice the size of the flat of an adult's hand with the fingers together, i.e. a handprint.

    Finlay et al. Lancet, 1989

    2 FTU = 1g topic = 4 palme= 4% din suprafata corpului

    One handprint is 0.8% (i.e. approximately 1%) of the total body surface area, and one FTU covers approximately two handprints.

    As two FTUs are approximately equivalent to 1g of topical application, the Rule of Hand states that 4 hand areas = 2 FTU = 1g.

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    Efecte adverse specifice ale corticoizilor topici

    Efecte locale Atrofie cutanat, striuri,

    telangiectazii Purpur steroid Ulceraii , pseudoescare Acnee steroid Hipertricoz Dermatit perioral Hiperpigmentare Hipopigmentare Alergii de contact Favorizarea infeciilor

    Efecte sistemice Inhibiia axei hipotalamo-

    hipofizo-cortico-suprarenalian Sindrom Cushing Hirsutism Vergeturi, purpur Acnee steroid Hipertensiune Hiperglicemie Galucom ntrzierea creterii la copii

    Traditional stepwise management paradigm

    Step 1: Dry skin only

    Step 2: Mild to moderate AD

    Step 3: Moderate to severe AD

    Step 4: Recalcitrant, severe AD

    Basic treatment: skin hydration, emollients, avoidance of irritants, identification and

    addressing of specific trigger factors

    Lowmid potency TCS or TCI* (TCI if moderate AD not adequately

    responsive or intolerant to TCS)

    Midhigh potency TCS or TCI* (TCI if not adequately responsive

    or intolerant to TCS)

    Systemic therapy (e.g. ciclosporin A) or UV therapy

    1. Akdis C, et al. Allergy 2006; 61:969987. 2. Wollenberg A, et al. J Dtsch Dermatol Ges 2009; 7:117121.

    * Over the age of 2 years. AD = atopic dermatitis; TCS = topical corticosteroid; TCI = topical calcineurin inhibitor

    Many acute flares can be treated successfully using the stepwise treatment paradigm2

    However, repeatedly recurrent flares constitute a frustrating and frequent problem for both patient and physician2