atopic dermatitis msd ped point of view_dr. nia

Nia Kurniati

• Pediatrician encounter 1 out of 10-15 patient with skin problems in OPD

• Generally they understand how to diagnose and deliver basic management

• There are many things that is not direct

• Related to “Atopic March”: § As first step

• Around 75-80% will develop allergic rhinitis in later life

• Around 50% will develop asthma

Leung, JACI 2003 (Suppl): S117

Bieber T. Atopic dermatitis. N Engl J Med 2008;358:1491.

ADULT

12 > y.o - adult

CHILDHOOD

2-12 y.o

INFANTILE baby- 2

y.o.

• more dry lesion • more chronic itch scratch lichenification • Recurrence acute erythema, plaque

infiltrate, papules dan erosion • Location in hand, feet, wrist & ankle • Lesion in flexural antecubital & popliteal main sign

William Criteria

Basic feature (obligatory) • Itchy skin

• Skin symptoms in flexural regions & neck (cheeks in children < 10 years)

• Asthma / allergic rhinitis (or atopic diseases in close relatives in children < 4 years)

• Dry skin during the last years • Visible eczema in flexural areas (or on cheeks and/or

forehead in chlidren < 4 years) • Eczema starting before age 2

Additional features

Diagnosis : Itchy skin + minimal 3 of the additional features

ASSESING DISEASE SEVERITY

• Developed by ETFAD on 1993

• Maximum score is 103

•0-34 MILD

•35

-69 MODERATE

•70

-103

SEVERE

Pediatrician do not practice this

Modified Qualitative Scoring for AD – Developed by Prof. Thiru THIRUMOORTHY

Classification of Severity in the Clinic to guide the Intensity of Treatment required

Episodic Localised Flexural (2 or less flexures)

Episodic Extensive Flexural

Persistent Extensive Flexural

Persistent Extensive Flexural & Non-flexural

Generalised Atopic dermatitis – childhood

Generalised Atopic dermatitis – adulthood

Redness – None, Mild, Moderate, Severe Swelling(edema) – None, Mild, Moderate, Severe Oozing / crusting – None, Mild, Moderate, Severe Scratch marks(excoriation) – None, Scattered, Disseminated, Severe Skin thickening (lichenification) None, Mild, Moderate, Severe

Asses the most dominant sign found

None=0; Mild=1; Moderate=2; Severe=3

• Clinical impression of the extend of the lesion • Recurrent and persistent lesion

Standard Treatment: skin hydration, emollient, avoid irritant, identify and

avoid aggravating factor

Systemic Therapy (e.g: Cyclosporin A) or UV therapy

TCS moderate-super potent and/or TCI

TCS mild-moderate and/or TCI

DA severe,recalsitran

DA moderate-severe

DA mild - moderate

Dry Skin Only

4

3

2

1

TCS: topical corticosteroid ; TCI: topical calcineurin inhibitor

1. Education and empowerment of patients and caregiver(s) 1. Eczema school/eczema camps

2. Avoidance and modification of environmental trigger factors 1. Lifestyle modification 2. Avoidance of skin injury 3. Rebuilding and maintenance of optimal barrier

function 4. Clearance of inflammatory skin disorders 5. Control and elimination of the itch–scratch cycle

Rubel D, et al. Consensu guideline for the management of Atopic Dermatitis: An

Asia-Pacific perspectives. J Dermatol 2013;40:161-70

Recognize trigger factors Use of standardize lists ( house dust mite,

chemical substance, 5 food)

Clearance of inflammatory skin disorders Use of Topical Corticosteroid (TCS)

Control and elimination of the itch–scratch cycle Oral antihistamine

1. Education and empowerment of patients and caregiver(s)

2. Avoidance and modification of environmental trigger factors

1. Lifestyle modification

2. Avoidance of skin injury

3. Rebuilding and maintenance of optimal barrier function

4. Clearance of inflammatory skin disorders

5. Control and elimination of the itch–scratch cycle

It could be an easy or hardest part History taking---taking time

Allergy tests --- are not in straight causal relationship (positive result doesn’t translate as the cause of AD, negative result is often misleading)

The patient (and family) should have discipline to avoid trigger factors Develop a relationship with the family

Severity of

AD

Inhalant and/or food allergen

Food allergen only

Mild 15% 20%

Moderate 18% 26%

Severe 20% 45%

Patrizi A, et al. The natural history of sensitizations to food and aeroallergens in atopic dermatitis: a 4-year follow up, Pediatr Dermatol 2000;17:261-5

Severity of AD Inhalant and/or food allergen

Food allergen only

Asthma and/ or allergic rhinitis

Mild 31% 6% 15%

Moderate 52% 6% 32%

Severe 100% 0% 75% Patrizi A, et al. The natural history of sensitizations to food and aeroallergens in atopic dermatitis: a 4-year follow up, Pediatr Dermatol 2000;17:261-5

Topical Corticosteroid, Topical Calcineurin, systemic

The wise ways to choose corticosteroid

Correct indication and know the contraindication Choose the appropriate potency

Minimal side effects

Acceptability

Cost and benefit

C27H30Cl2O6

9α,21-dichloro-11β, 17 α -dihydroxy-16 α -methylpregna- 1,4 diene-3,20 dione 17-(2- furoate) 1 http:/ / www.chemspider.com/ ImageView.aspx?mode=3d&id=390091

27

Need to address concerns regarding steroid phobia

If used correctly, AEs such as suppression of adrenal function, diabetes mellitus, and moon face

Low potential for skin atrophy with mometasone and fluticasone in children/adults

1 Hanifin J, et al. Br J Dermatol 2002;147:528-537; 2Berth-Jones J, et al. BMJ 2003;326:1367.3Hong E, et al. Pediatr Dermatol 2011;28:393-396; 4Saeki H, et al. J Dermatol 2009;36:563-577.

• Acute• Chronic (maintenance): intermittent, week end, hot

spot, has proven to control inflammation in recalcitrant cases

A number of defects in innate cutaneous immunology may explain the high rate of cutaneous

colonization with Staphylococcus aureus in AD

• This led to the clinical concept that patients with high numbers of colonizing S. aureus can benefit

from combination treatment with corticosteroids and antimicrobial treatment (Diprogenta®)

Improving eczema with anti-inflammatory regimen decreases staphyloccocal colonization.

TCIs=topical calcineurin inhibitors; TCS=topical corticosteroids

Journal of Dermatology 2013; 40: 160–171

• Atopic Dermatitis is an important step in allergic march in children

• Stepwise management also apply in children, with emphasis on triggering factors management