Atopic dermatitis

hanifin and rajka criteria, entymology, definition of AD, atopy, etiopathogenesis of AD, genetics in AD, filaggrin, epidermal barrier dysfunction, atopic march, hygiene hypothesis, infantile phase of AD, childhood phase of AD, adult phase of AD, pityriasis alba, denne morgan folds, dirty neck appearence, nipple dermatitis, hanifin and rajka criteria, UK refinement of hanifin and rajka criteria, millenium criteria of AD, japanese dermatological association criteria, management of AD, wet wrap therapy,

1. Dr. Sabha Talib Neazee . ATOPIC DERMATITIS 1

2. Dermatitis: greek word- derma + itis = INFALMMATION OF SKIN Etymology: Atopic derived from atopia in greek = UNUSUALNESS 2

3. AN ITCHY, CHRONIC OR CHRONICALLY RELAPSING SKIN CONDITION OFTEN STARTING EARLY IN CHILHOOD WITH RASH CHARACTERIZED BY ERYTHEMA , ITCHY PAPULES/ PAPULOVESICLES WHICH MAY BECOME EXCORIATED AND LICHENIFIED . DEFINITION 3

4. PERSONAL OR FAMILIAL TENDENCY TO PRODUCE ige antibodies in response to low dose of allergens ,usually proteins and to develop typical symptoms of asthma, rhinoconjuctivitis or eczema / dermatitis. ATOPY 4

5. Inside outside model Outside inside model 5 Etiopathgenesis

6. Etiopathogenesis 6

7. Genetics in AD Skin barrier dysfunction genes Filaggrin gene Genes for loricrin S 100 proteins Proteases Anti-proteases Tight junctions Adaptive & innate immune response genes CD 14 IL-4, IL-5, IL-13 Toll-like recepters Pattern recognition receptors RANTES

8. Filaggrin 8 Profillagrin is the major component of keratohyaline granules of stratum corneum which is degraded to produce fillagrin . Defense against entry of allergens and microorganisms. Serves as NMF ( natural moisturizing factor) Maintains the pH of skin. Prevents trans epidermal water loss. Photoprotective and immunomodulatory effect.

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10. Tendency of AD to precede the other allergic disorders in temporal sequence. Atopic March : Natural history of allergic manifestations . 10

11. Atopic march There may be reverse atopic march where some atopic children first present with asthma and later develop eczema 11

12. IMMUNE DYSREGULATION IN AD 12 Increased Th2-derived cytokine activity. Increased numbers of T-cells expressing cutaneous lymphocytes-associated antigen(CLA) Increase numbers of regulatory T-cells( Tregs ) in the peripheral blood– these cells normally inhibit antigen-specific Th2 responses Increased total and specific serum IgE level Increased expression of the IgE receptor Fc έ R1 on Langerhans cells & dendritic cells Decreased expression of antimicrobial peptides Increased thymic stromal lymphopoietin (TSLP)

13. Hygiene Hypothesis 13 Early childhood infections caused by unhygienic contact with older siblings confers protection from development of allergic diseases Farm effect- children living on farms, having contact with farm animals, drinking unprocessed cow`s milk, increased exposure to microbes have less incidence of AD and asthma.

14. Trigger factors 14 Changes in temperature Sweating Decrease in huminity Contact with irritants Aeroallergens Food allergens Emotional stress harmones

15. Clinical features Atopic dermatitis 15

16. Infantile phase 16

17. Childhood phase 17

18. Childhood phase 18

19. Adult phase 19

20. Pityriasis alba 20

21. Denne morgan folds 21

22. Dirty neck appearence 22

23. Nipple dermatitis 23

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25. Hanifin & Rajka criteria for the diagnosis of AD Major criteria( must have three or more) 1. Pruritus 2. Typical morphology & distribution Facial/extensor involvement in infants & children Flexural lichenification in adults 3. Chronic or chronically relapsing dermatitis 4.Personal or family history of atopy(Asthma, allergic rhinitis, atopic dermatitis) 25

26. Minor criteria 26 MUST HAVE 3 OR MORE Xerosis Ichthyosis vulgaris/palmar hyperlinearity /keratosis pilaris Immediate (Type 1) skin test reactivity Elevated serum IgE Early age of onset Tendency toward cutaneous infections(especially Staphylococcus aureus & herpes simplex)/impaired cell-mediated immunity Hand/foot eczema Nipple eczema Cheilitis Recurrent conjunctivitis Dennie -Morgan infraorbital fold Keratoconus

27. 27 Anterior subcapsular cataract Orbital darkening Facial pallor/Erythema Pityriasis alba Anterior neck folds Itch when sweating Intolerance to wool & lipid solvents Perifollicular accentuation Food intolerance Course influenced by environmental/emotional factor White dermographism

28. The UK refinement of Hanifin & Rajka’s diagnostic criteria of atopic dermatitis(Eczema) 28 Essential criteria An itchy skin condition(or parental report of scratching or rubbing in a child ) Plus three more or following: Onset below age of 2 years(not used if child is under 4 years) History of skin crease involvement(including cheeks in children under 10 years) History of a generally dry skin Personal history of other atopic disease(or history of any atopic disease in a first-degree relative in children under 4 years) Visible flexural dermatitis(or dermatitis of cheeks/forehead & outer limbs in children under 4 years)

29. Millennium criteria 29 Mandatory criteria(must be fulfilled) Allergen specific IgE Principal criteria(must have two or more) Pruritis Typical morphology & distribution Chronic & relapsing course

30. 30 Additional criteria Related to eczema Cheilitis Nipple eczema Pityriasis alba Facial pallor/Erythema Orbital darkening Cradle cap Tendency for nonspecific hand/foot eczema b. Related to dry skin Xerosis Ichthyosis vulgaris palmar hyperlinearity keratosis pilaris

31. 31 Perifollicular accentuation Perleche Itch when sweating Intolerance to wool & lipid solvents c . Extra skin folds Dennie -Morgan infraorbital fold Anterior neck fold Auricular rhagades d. Ophthalmological pathology Hertoghe sign Photophobia Anterior subcapsular cataract

32. Japanese dermatological association criteria: 32 Pruritis Typical morphology & distribution Eczematous dermatitis a) Acute lesions- erythema,exudate,papules , vesicopostular holes, crust. b)Chronic lesion- infiltrated erythema, lichenification, peurige , sealer, crust. Distribution: a ) symmetrical- prediction sites: forehead, periorbital area , perioral area, lips, periauricular area, neck, joint area of limb, trunk

33. 33 b ) Age related characteristics Infantile phase-starts on scalp & face, often spreads to trunk & extremity Childhood phase- neck, flexural surface of arms & legs Adolescent/adult phase-tendency to be severe, on upper half of the body (iii) Chronic or chronically relapsing course : More than 2 months in infancy More than 6 months in childhood, adolescence & adulthood

34. american academy of dermatilogy 34 Guidelines of care for management of AD

35. Recommendation for non pharmacologic interventions for the treatment of atopic dermatitis 35 Moisturizers should be an integral part of the treatment. Bathing is suggested for the patient with AD as part of treatment &maintenance Moisturizers should be applied soon after bathing Limited use of non soap cleansers is recommended T he additions of oils, emollients & most other additives to bath waters cannot be recommended Use of wet-wrap therapy with or without a topical corticosteroid can be recommended for patient with moderate to severe AD to decrease disease severity & water loss during flares.

36. Recommendation for the use of topical corticosteroids for the treatment of atopic dermatitis. 36 Recommended for AD-affected individuals who have failed to respond to good skin care & regular use of emollients alone. A variety of factors should be considered including patient age , body area , & other patient factors such as degree of xerosis , patient preference & cost of medication Twice daily application of corticosteroids is generally recommended Proactive intermittent use of topical corticosteroids as maintenance therapy(1-2 times/ wk ) on area that commonly flare is recommended to help prevent relapses & is more effective than use of emollients alone

37. Recommendations for the use of topical calcineurin inhibitors for the treatment of atopic dermatitis 37 Effective for acute & chronic treatment along with maintenance, in both adults & children with AD and are particularly useful in selected clinical situation: Recalcitrant to steroids Sensitive areas( eg , Face, anogenital , skin folds) Steroid-induced atrophy Long-term uninterrupted topical steroid use

38. 38 As a steroid-sparing agent For patient with AD < 2 years of age with mild to severe disease, off label use of 0.03 % tacrolimus or 1 % pimecrolimus ointment can be recommended. Initial treatment of patient with AD using topical corticosteroids should be considered to minimize TCI Proactive treatment use of TCI as maintenance therapy(2-3 times per week) on area that commonly flare is recommended. The concomitant use of a topical corticosteroid with a TCI may be recommended for the treatment of AD

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40. Topical antimicrobials and antiseptics 40 Except for bleach baths with intranasal mupirocin, no topical antistaphylococcal treatment has been shown to be clinically helpful in patient with AD & is not routinely recommended . In patient with moderate to severe AD & clinical signs of secondary bacterial infection , bleach baths & intranasal mupirocin may be recommended to reduce disease severity

41. Topical antihistamines 41 The use of topical antihistamines for the treatment of patients with atopic dermatitis is not recommended because of the risk of absorption & of contact dermatitis.