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Atopic Dermatitis (Eczema)

15/04/09

KIUNG HSIA LING


Eczema
Introduction

“Atopic” refers to a group of often inherited IgE-


mediated diseases, such as allergic rhinitis, asthma,
and AD
Atopic diseases are noted by their tendency to
produce IgE antibodies to harmless inhalants, & dust
mites
Pervasive inflammatory skin condition, vicious cycle
of itching and scratching
Hallmark symptoms: chronic, relapsing, itchy and
inflamed skin
Etiology

Hereditary component: strong


One affected parent: 60%
Both parents are affected: 80%
Children with AD more frequently develop severe
asthma than asthmatic children without AD
Clinical Presentation

Acute
- intensely pruritic, erythematous papules and
vesicles scratching that results in excoriations
and exudates
Subacute
- thicker, paler, scaly, erythematous, and excoriated
plaques
Chronic
- thickened plaques, lichenification and fibrotic
papules
Clinical Features

Often starts in the first few months of life


Initially appears of infant’s cheeks, which continue
to affect the face, neck & trunk
Later manifestations typically present on flexor
surfaces
Lesions are typically symmetric
Exacerbating Factors

Soaps, detergents, chemicals, mold, dust, pollens,


emotional stress, changes in temperature or
humidity, bacterial skin infections, contact with
irritating clothing (especially cially wool)
In some infants, food allergies may provoke AD
Atopic Dermatitis - Distribution

Characteristically involves different parts of the body


at different ages
At 2-3 months, it usually involves the face, sternal
area, nappy area, extensor surfaces of elbow and
knees
For toddlers, it involves the neck, flexural surface of
elbow, knee and ankle joints
For older children, it usually involves the palm, foot,
flexural surfaces of limbs
Diagnosis

Several visit to a doctor may be needed to establish


the diagnosis
No specific test for AD exists
A doctor makes the diagnosis based on the typical
pattern of the rash & often on whether other family
members have allergies
Treatment Goals

Maintain skin hydration


Relieve or minimize symptoms of itching and
weeping
Avoid or minimize factors that triggers of aggravate
the disorders

No cure exists, but certain measures can help


Nonpharmacological Therapy

 Identify & eliminate potential allergens


 Reduce frequency of bathing; bathe every other day
 Use of tepid water in baths
 Avoidance of irritating soaps (dyes, fragrances, &
preservatives can all contribute to further exacerbations)
 Avoid washcloths or irritating scrubs
 Air dry skin and gentle pat dry
 Application of emollient within 3 minutes after bathing
 Keep fingernails short and clean to prevent scratching
 Consider cotton gloves to prevent scratching at night
 Use of cotton sheets and pajamas
 Avoid harsh laundry detergents
 Moisturize as often as necessary to keep skin soft and pliable
(at least twice a day)
Topical Corticosteroids
 Potency of the steroid depends upon the vasoconstrictive properties
- typically, use high-potency steroids:
use no longer than 3 weeks
use on thickened lesions
not for use on face, skinfolds, or mucous membranes, eyelids
 The vehicle is as important as the steroid concentration
- occlusives can increase percutaneous absorption
- ointments are stronger than creams, which are stronger
than lotions
- gels may be beneficial for hairy or oily areas
 Use with moisturizers
- apply corticosteroid first
- the goal is to increase moisturizers while decreasing
corticosteroid use
Topical Corticosteroids

Potency

Potency Drugs
Low Hydrocortisone 1%
Moderate Betamethasone valerate 0.01-0.05%
Clobetasone butyrate 0.05%
High Betamethasone valerate 0.1%
Mometasone furoate 0.05%
Very high Clobetasol propionate 0.05%
Topical Corticosteroids

Choosing a topical steroid

Area Steroid potency Base/carrier


Open, dry Moderate Ointment/cream
Plantar surface of foor, Moderate Ointment
thick skin, hard
Forehead, underarm Low Gel, lotion
Face Low Cream
Groin Low Lotion, cream
Eyes Low Opthalmic preparation
Topical Immunomodulators

E.g. tacrolimus 0.1%, pimecrolimus 1%


MOA: anti-inflammatory, inhibits calcineurin thus
blocking T cell proliferation and preventing release
of inflammatory cytokines
Offer more long-term options, can be used on all
parts of the body for prolonged periods
Common ADRs: transient itching & burning at the
site of application
Antihistamines

Used to attempt to break the itch-scratch cycle


Although commonly believed to have antipruritic
effects, their therapeutic value is primarily due to
their sedative properties
Newer, less sedating antihistamines are of little
value, unless allergies triggers are involved, e.g.
house dust mite
Sedating antihistamines are useful at night in
patients having trouble getting to sleep or waking
regularly because of excessive itching
Tar preparations

Coal tar – reduce itching and inflammation


Used in conjunction with topical corticosteroids, as
adjuncts to lower strengths of corticosteroid
E.g. coal tar (1, 3, 6%)
Should not be used on acute oozing lesions as would
result in stinging and irritation
Limiting factors: strong odor, staining of clothing
Counseling: avoid contact with eyes, may stain skin, hair
and clothes, apply enough to cover affected area and rub
in gently, use at bedtime and wash it off in the morning
Systemic Immunosuppressants

Systemic corticosteroids
- e.g. prednisolone
- short course to control severe flare
Cyclosporine
- severe, recalcitrant
- adults: 5mg/kg
- childrens: 3mg/kg
References

Adams VR, Yee GC. Lymphoma. In: Dipiro JT, Talbert RL, Yee
GC, et al. Pharmacotherapy: a pathophysiologic approach. 6th
edition. New York: McGraw-Hill; 2006. Chapter 97 pg 1785-91
Koda-Kimble MA. Applied therapeutics: the clinical use of
drugs. 8thedition. USA: Lippincott Williams &Wilkins; 2005.
Chapter 38: pg 1-18
Austrlian Medicines Handbook, 2009
Guidelines for the management of atopic eczema. Primary
Care Dermatology Society & British Association of
Dermatologist. 28, 2006