atopic dermatitis
TRANSCRIPT
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ATOPIC ATOPIC DERMATITISDERMATITIS
(ATOPIC ECZEMA)(ATOPIC ECZEMA)
A A WWholistic approachholistic approach
David W. YoungDavid W. YoungDermatologistDermatologist
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ATOPIC DERMATITISATOPIC DERMATITIS
Does not have a single causeDoes not have a single cause
Monotherapy does not exist!!Monotherapy does not exist!!
Aetiology and exacerbations are Aetiology and exacerbations are multifactorial in originmultifactorial in origin
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ATOPIC DERMATITISATOPIC DERMATITIS
Is not an allergyIs not an allergy
People with atopic dermatitis have People with atopic dermatitis have an increased incidence of allergiesan increased incidence of allergies
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ATOPIC DERMATITISATOPIC DERMATITIS
Patients are frequently very Patients are frequently very uncomfortableuncomfortable
Often aggressive treatment is Often aggressive treatment is required required
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ATOPIC DERMATITISATOPIC DERMATITIS
Genetically determinedGenetically determined 70+% have a FH of atopy70+% have a FH of atopy
10 – 20% of <5’s have ADs10 – 20% of <5’s have ADs Increasingly prevalent in industrialised Increasingly prevalent in industrialised
temperate countries.temperate countries.
Occurs in first year in 85%, 95% before 5 Occurs in first year in 85%, 95% before 5 yrsyrs
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ATOPIC DERMATITISATOPIC DERMATITIS
Spontaneous improvement occursSpontaneous improvement occurs
Many carry the disorder into Many carry the disorder into adulthoodadulthood
Underlies 80% of occupational Underlies 80% of occupational dermatosesdermatoses
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CAUSES OF ATOPIC CAUSES OF ATOPIC DERMATITISDERMATITIS
Skin structurally differentSkin structurally different
Skin ‘biochemically’ differentSkin ‘biochemically’ different
Immunological changes. Immunological changes.
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STRUCTURAL CHANGESSTRUCTURAL CHANGES
Impaired skin barrier functionImpaired skin barrier function
Xeroderma Xeroderma
Keratosis pilarisKeratosis pilaris AD ichthyosis (ichthyosis vulgaris)AD ichthyosis (ichthyosis vulgaris) Pityriasis albaPityriasis alba Denny-Morgan foldsDenny-Morgan folds
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‘‘BIOCHEMICAL CHANGES’BIOCHEMICAL CHANGES’
White dermographismWhite dermographism
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IMMUNOLOGICAL CHANGESIMMUNOLOGICAL CHANGES
Up to 80% have increased IgEUp to 80% have increased IgE
Some decrease in cell mediated Some decrease in cell mediated immunityimmunity
Fundamental imbalance between the Fundamental imbalance between the response of TH1 and TH2 lymphocytesresponse of TH1 and TH2 lymphocytes
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PRACTICAL CAUSES AND PRACTICAL CAUSES AND AGGRAVATING FACTORSAGGRAVATING FACTORS
XerodermaXeroderma IrritantsIrritants Climatic changesClimatic changes InfectionInfection Food and other allergiesFood and other allergies
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IRRITANTSIRRITANTS
‘‘Usual’ irritantsUsual’ irritants
Soaps, soap powders, detergents.Soaps, soap powders, detergents.
Chlorine in swimming poolsChlorine in swimming pools
FibresFibres
FrictionFriction
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CLIMATE CHANGESCLIMATE CHANGES
Hot or cold temperaturesHot or cold temperatures
Sudden changes in temperatureSudden changes in temperature
Low humidityLow humidity
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INFECTIONINFECTION
Staph. Aureus most importantStaph. Aureus most important
Uninfected atopic skin has increased Uninfected atopic skin has increased number of Staph.number of Staph.
May act as a ‘superantigen’ May act as a ‘superantigen’ activating lymphocytesactivating lymphocytes
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FOOD AND OTHER FOOD AND OTHER ALLERGIESALLERGIES
Literature on role of food allergens is Literature on role of food allergens is extensive, controversial, & extensive, controversial, & contradictorycontradictory
Majority have +ve skin prick tests or Majority have +ve skin prick tests or RAST/EAST tests to foodsRAST/EAST tests to foods
Very few appear to be relevantVery few appear to be relevant Small % aggravated by certain foodsSmall % aggravated by certain foods Most common: cow’s milk, eggs, soy, Most common: cow’s milk, eggs, soy,
peanuts, wheat, & fish peanuts, wheat, & fish
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FOOD AND OTHER FOOD AND OTHER ALLERGIESALLERGIES
Ask parents!Ask parents!
RAST or skin prick tests often more RAST or skin prick tests often more useful if negative useful if negative
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FOOD AND OTHER FOOD AND OTHER ALLERGIESALLERGIES
House dust miteHouse dust mite
Grasses, pollens, etc.Grasses, pollens, etc.
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PATTERN - INFANCYPATTERN - INFANCY
XerodermaXeroderma Face and scalp often first involvedFace and scalp often first involved Trunk and limbs, especially flexuresTrunk and limbs, especially flexures Nappy rashNappy rash Lichenification seldom seenLichenification seldom seen May be exudativeMay be exudative InfectionInfection
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PATTERN - CHILDHOODPATTERN - CHILDHOOD
XerodermaXeroderma Often exudativeOften exudative FlexuralFlexural PeriorbitalPeriorbital ‘‘Lip-lick’ dermatitisLip-lick’ dermatitis Lichenification frequentLichenification frequent Excoriation & crusting commonExcoriation & crusting common InfectionInfection
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PATTERN - ADULTHOODPATTERN - ADULTHOOD
XerodermaXeroderma LichenificationLichenification Face and neck frequently involvedFace and neck frequently involved Hand dermatitisHand dermatitis ErythrodermaErythroderma
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COMPLICATIONSCOMPLICATIONS
Family dynamics!!Family dynamics!!
Eczema herpeticumEczema herpeticum Molluscum contagiousumMolluscum contagiousum
Occupational dermatosesOccupational dermatoses
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TREATMENTTREATMENT
Time consumingTime consuming ‘‘Consumer’ resistanceConsumer’ resistance Unhelpful adviceUnhelpful advice The latest ‘magic cure’The latest ‘magic cure’ Steroid (& antibiotic) phobiaSteroid (& antibiotic) phobia Avoid poor dietary nutrition Avoid poor dietary nutrition
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TREATMENTTREATMENT
Aggressive treatment early to show Aggressive treatment early to show ‘something can be done’‘something can be done’
Explanation re the nature of the Explanation re the nature of the diseasedisease
A plan for the various phases of ADsA plan for the various phases of ADs
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TREATMENT – AVOID TREATMENT – AVOID IRRITANTSIRRITANTS
SoapsSoaps Soap powdersSoap powders Clothing fibresClothing fibres Extremes of temperatureExtremes of temperature Low humidity environmentsLow humidity environments
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TREATMENT - XERODERMATREATMENT - XERODERMA
EmollientsEmollients
EmollientsEmollients
EmollientsEmollients
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EMOLLIENTSEMOLLIENTS
Alpha Keri, BK, DP, Hydroderm lotionsAlpha Keri, BK, DP, Hydroderm lotions Glyc. 10% in Aqueous or sorbolene Glyc. 10% in Aqueous or sorbolene
creamcream Urea 10% creamsUrea 10% creams QV, Cetaphil, etc. creamsQV, Cetaphil, etc. creams Lipobase, Lemnis Fatty CreamLipobase, Lemnis Fatty Cream Lipobase RepairLipobase Repair WSP, Emuls. OintWSP, Emuls. Oint Bath oilsBath oils
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TREATMENT - ANTIHISTAMINESTREATMENT - ANTIHISTAMINES
It is the sedation rather than the It is the sedation rather than the antihistamine action which is helpful antihistamine action which is helpful at times. Use short termat times. Use short term
If frequent wheal and flare reactionsIf frequent wheal and flare reactions
KetotifenKetotifen
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TREATMENT - ANTIBIOTICSTREATMENT - ANTIBIOTICS
Cover Staph aureus (+/-beta haem Cover Staph aureus (+/-beta haem strep)strep)
Required if exudative and crustingRequired if exudative and crusting Occasionally needed medium to long Occasionally needed medium to long
termterm Give parents a script or repeats to Give parents a script or repeats to
have ‘on hand’ have ‘on hand’
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TREATMENT – TOPICAL TREATMENT – TOPICAL CORTICOSTEROIDSCORTICOSTEROIDS
Extremely effective in treating and Extremely effective in treating and controlling ADscontrolling ADs
Very safe if used appropriatelyVery safe if used appropriately Use mod. potent or potent short termUse mod. potent or potent short term Use mildly potent for maintenance if Use mildly potent for maintenance if
requiredrequired Safe to use in infected dermatitis if Safe to use in infected dermatitis if
infection also being treatedinfection also being treated
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TREATMENT – TOPICAL TREATMENT – TOPICAL CORTICOSTEROIDSCORTICOSTEROIDS
Dermol & Diprosone OVDermol & Diprosone OV
Betnovate, Nerisone, Diprosone, Betnovate, Nerisone, Diprosone, Elocon, AdvantanElocon, Advantan
LocoidLocoid
Aristocort, EumovateAristocort, Eumovate
Hydrocortisone 1%Hydrocortisone 1%
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TREATMENT – TOPICAL TREATMENT – TOPICAL CORTICOSTEROIDSCORTICOSTEROIDS
The base is important!The base is important!
Ointments better then creamsOintments better then creams
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TREATMENT – TREATMENT – IMMUNOMODULATORSIMMUNOMODULATORS
Topical – tacrolimusTopical – tacrolimus
- pimecrolimus- pimecrolimus
Oral – cyclosporin AOral – cyclosporin A
- methotrexate- methotrexate
- azathioprine- azathioprine
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TREATMENT – DIETTREATMENT – DIET
Avoid foods known to flare or Avoid foods known to flare or aggravate patient’s ADsaggravate patient’s ADs
Dietician’s adviceDietician’s advice
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TREATMENT – OTHERSTREATMENT – OTHERS
Tar preparationsTar preparations Evening primrose or flax seed oilEvening primrose or flax seed oil ProbioticsProbiotics Chinese herbsChinese herbs Narrowband UVBNarrowband UVB Immunosuppressants – azathioprine, Immunosuppressants – azathioprine,
methotrexatemethotrexate