Atopic Dermatitis

AD can be divided into three stages:

1. Infantile atopic dermatitis:
2 months-2 years of age
2.Childhood atopic dermatitis:
2 years-10 years
3. Adolescent and adult atopic dermatitis

Infantile Atopic Dermatitis

60 % In the first year of life
Usually . 2 month of age
Clinic: Itchy erythema of the cheeks
Intraepidermal vesiclesrupture
moist, crusted areas extend to
other part of the body (scalp, neck,
forehead, wrist, extensor extremities
buttocks and diaper area spared

Chidhood Atopic Dermatitis

Childhood
Clinic: less acute lesions
Lesions less exudative, drier,
>papular
Locations: antecubital, popliteal
fossae, flexor wrist, eyelids, face,
around the neck
lichenified, slightly scaly/ infiltrated
plaques

Adolescents and adult AD

Older patients
Clinic: Localized erythematous, scaly, papular/
vesicular plaques
Pruritic, lichenified plaques
Location: antecubital and popliteal fossae, front and
sides of neck, forehead, area about the eyes
Eruptions generalized more severe in
flexures lichenified
Plaques often erythematous/ hyperpigmented

Major Clinical features of AD (base on

Hanifin and Rajka)
-

Intense pruritus & excoriation

Typical morphology and distribution of skin
lesions:-facial and extensor involvement in
infant and early childhood
-flexural lichenification in adult
Chronic or chronically relapsing dermatitis (>6
weeks)
Personal and family history of atopic disease

Minor
features

-Dryness of the skin (xerosis)

-Ichthyosis, keratosis pilaris, hyperlinear
palms
-Non specific hand/foot dermatitis
-Scalp dermatitis e.g. cradle cap
-Allergic shiners
-Recurrent conjunctivitis and keratoconus
- IgE reactivity
-Dennie-Morgan infraorbital fold
-Orbital darkening
-Pityriasis alba
-Food hypersensitivity

Intense pruritus

Itching, Scratching the day worse at

night sleep disruption
Pat AD threshold of itching decreased
Humidity
Excessive sweating
Exposure to allergens, irritants (soap,
detergent acrylic, wool) itch

Whats the etiology of pruritus in AD

?
- Not well understood
- Local release of proinflammatory mediators &
cytokines

Rukwied and Heyer (1999)

Pruritus:
- Histamine
- Cytokines
- leukotrienes
- neuropeptide
- proteases

Morphological characteristic of AD

-Acute lesions are papules, vesicles on

erythematous background with sign of erosion,
bleeding and serous exudate
-Sub acute lesions are erythematous and scaly
papules on dry background
-Chronic lesions are fibrotic papules on lichenified
(thickened) back ground
-Excoriation due to scratching in a all stage
-Infection may alter the appearance with the presence of
oozing or local abscess
-Even uninvolved skin is often dry and scaly

Investigation

Total Ig E > not helpful diagnosis

Skin prick test (SPT)

Specific Ig E (RAST) more helpful

SPT/RAST

Most children AD sensitized to food

(milk, egg, peanut, soy, wheat, fish)

SPT/RAST

(+) 90% useful screening

-If SPT(+) confirm food elimination

Atopy patch test

-With food, aero allergen specificity &

clinical relevant
-Patch test to detect delayed type skin
hypersensitivity
-40% PAT ad CD to metal, fragance:
lanolin, emollients

TREATMENT OF ATOPIC DERMATITIS

Basic Treatment
Skin care
Emollients
Avoidance of irritants, sudden
changes of temperature, humidity
Identification of
specific
Exacerbating factors
Allergens
Microbes
Emotional factors

Anti inflammatory
Treatment

Avoidance of trigger factors

Irritants
detergents
soap
2. Allergens: Food allergen
Airborne allergens
Child < 5 years : Usually allergy to 1 or > food
cows milk, egg, wheat, bean
3. House dust mite: older children
young adult
4. Emotional stress
1.

TOPICAL EMOLLIENT
BASIS TOPICAL TREATMENT :
2 3 X / DAY

WATER LOSS

ITCHING

Topical treatment

CREAM / LOTION : EARLY PHASE

OINTMENT : LICHENI FIED SKIN

SEVERE CASE :

AFTER OINTMENT WETWRAP DRESSING

EPIDERMAL WATER LOSS

TOPICAL CROMOLYN IN WATER SOLUBLE
EMOLLIENT VEHICLE ANTI INFLAMATORY
EFFECT

ANTIBIOTIC

FUSIDIC ACID
GRAM (+)

TETRA CYCLINE
SKIN CLEANSER 10% POVIDONE
IODINE
GENERALIZED INFECTION : ANTI

MICROBIAL BATH (CHLORHEXIDIN 0,005%)

SISTEMIC ANTIBIOTIC : FLUCLOCXACILLIN :
MUPIROCIN

OTHER TREATMENT
STRATEGIES
UVA PHOTOTERAPY
CICLOSPORIN
IF

Chemical and Functional Classification

H1-antihistamine
Chemical

1st generation

2nd generation

Alkylamine

Chlorpheniramine

Acrivastine

Piperazine

Hydroxyzine

Cetirizine,
levocetetirizine

Piperidine

Cyproheptadine

Astemizol
Desloratadine
Fexofenadine
Loratadine

Ethanolamines

Diphenhidramine

Ethylenediamines

Pyrilamine

Phenothiazine

Promethazine

Anti inflammatory effects of AH

Expression of cell adhesion molecules

Chemotaxis of eosinophilia & others cells

Proinflammatory cytokines

Adhesion protein

Antiallergic activities

Release of mediator from mast cell and

basophil

(Direct inhibitory effect on calcium-ion

channels inward calcium)

Anti-inflammation effect

Atopic Dermatitis in Child

Atopic Dermatitis in Infant and Child

Atopic Dermatitis in Child