Atopic Dermatitis

Insp Dr Mahadev Deuja

Wednesday, May 30, 2018
 Outline
• Introduction
• Classification
• Atopic dermatitis
– Introduction
– Epidemiology
– Clinical features
– Complications
– Diagnosis
– Treatment
 Introduction
• Dermatitis- a distinctive inflammatory response of the skin,
secondary to a number of exogenous or endogenous factors
• Not a single health condition but a recognizable reaction
pattern seen in a number of skin diseases.
– Red, swollen, itchy and painful skin lesion
• Dermatitis = eczema
– synonymously and interchangeably
 Etiological classification of dermatitis
Endogenous Exogenous Combined
Seborrheic dermatitis Irritant dermatitis Atopic dermatitis
Numullar dermatitis Allergic dermatitis Pompholix
Lichen simplex Photodermatitis
chronicus
Pityriasis alba Radiation dermatitis
Stasis dermatitis Infective dermatitis
 Atopic dermatitis
• Most common type of dermatitis
• A chronic, pruritic, inflammatory skin disease with a wide range of
severity
• Non contagious
• Primary symptom is pruritus (itch)
– Hallmark of disease
– Most debilitating symptom
– AD is often called “the itch that rashes”
– Scratching to relieve itch gives rise to the ‘itch-scratch’ cycle and can
exacerbate the disease
• Usually develops AD in infancy or early childhood.
• However can appear at any stage of life.
• Patients experience periods of remission and exacerbation
– Often for unexplained reasons.
– Tooth erruptions, psychoemotional or stressful events are common
known triggers
• Often improves towards 5-6y of age.

Exacerbation Remission
 Pathophysiology of AD
• Multifactorial condition whose etiology is not entirely
understood.
Environment
Disruption of skin
Genetic barrier function
+
Abnormalities in
immune response
 Disruption of skin Barrier function
• Defective renewal of the stratum corneum
– Water can easily get out out skin – dry skin
– Allergen and infectious agents can easily get in
• Prone for infection
• IgE reactivity
 Molecular basis of skin barrier dysfunction
Multiple molecular abnormalities have been identified
• Most important being reduced levels of the protein filaggrin
• An important structural component of the stratum corneum
• Others are
– Reduced level of the source of natural moisturizing factor (NMF).
• Mixture of small molecules that bind water and help maintain skin hydration.
– Reduced levels of ceramides -- waxy lipids that are also important for preventing
water loss.
• Tight junction formation also appears to be defective
 Epidemiology
• The prevalence rate for atopic dermatitis (AD) is 10-12% in children
and 0.9% in adults (US).
• Race
– AD affects persons of all races.
• Sex
– The male-to-female ratio for AD is 1:1.4.
• Age
– In 85% of cases, AD occurs in the first year of life
– In 95% of cases, it occurs before age 5 years.
 Symptoms of AD
• Varies
– Significantly from one individual to another
– With the age of the patient
– Between flare-up and remission
 Phases of AD

Infantile Cure
60%
Atopic
Childhood Cure
dermatitis

Adult 40%
 Clinical findings
• Lesions typically begin as erythematous papules
• Which then coalesce to form erythematous
plaques
– that may display weeping, crusting, or scaling

• May often get infected causing pustules

 Infantile phase

Key features • AD is usually noticed soon after birth

• Usually sparing the diaper area and the nose.

Area of • The earliest lesions affect the creases (antecubital and popliteal fossae)
• Later localize to the cheeks, forehead, scalp and extensor surface of legs
distribution • However, they may occur in any location on the body

Charecteristic • ill-defined, erythematous, scaly, and crusted patches and plaques.

• Lichenification is seldom seen in infancy.
skin lesion
 Childhood phase

• Xerosis is often generalized

Key features • Erythema and scaling arround the eyes can be seen
• Dennie-Morgan folds (ie, increased folds below the eye)- often seen

Area of • Flexural creases

• The antecubital and popliteal fossae
distribution • Buttocks -thigh creases are often affected.

Charecteristic • Lichenification is characteristic of childhood AD.

• It signifies chronic scratching and is seen mostly over the folds,
skin lesion bony protuberances, and forehead.
 Adult phase

Key features • Xerosis is prominent

Area of • Lesions become more diffuse

• Cubital fossa and poplitial fossa and some times neck, face
distribution and hand

Charecteristic • Lichenification may be present

• A brown macular ring around the neck is typical but not
skin lesion always present
 Evolution of AD……
• Patients with AD often experience an "atopic march,“
– i.e early AD gives way to food allergy, allergic rhinitis and asthma
later in life.

• Clinical evaluation
 Concerns for skin infections
• Skin is prone for infection
• Staphylococcus aureus is common in AD lesions
– Can trigger inflammation
– Appears as crusts or pustules

crusts
• Other possible infections
– Eczema herpiticum
– Coxsackievirus
– Molluscum contagiosum (warts)

pustules
AAD 2014 guidelines (modifications to Hanifin-Rajka
criteria)
Essential features(must be present)
• Pruritus
• Eczema
• Typical morphology/ age-specific pattern
• Chronic/relapsing history

Important features (present in most cases, adds diagnostic support)

• Early age onset
• Atopy
• Personal/ family history
• IgE reactivity
• Xerosis
Exclusionary conditions (conditions that should be excluded)
• Scabies
• Seborrheic dermatitis
• Contact dermatitis
• Ichthyoses
• Cutaneous T-cell lymphoma
• Psoriasis
• Photosensitivity dermatoses
• Immune deficiency diseases
• Erythroderma of other causes
Additional considerations in the diagnosis of AD
• No reliable biomarker exists for the diagnosis of AD
• Laboratory testing is seldom necessary
• CBC can be useful to exclude immune deficiency
• IgE level can be helpful to confirm an atopic pattern
• Skin swab can be helpful to identify S aureus superinfection
• Allergy and RAST is of little value
• Biopsy can be helpful to rule out other conditions (eg, cutaneous T-cell
lymphoma)
 Pearls of AD Treatment
• The current therapeutic options for AD is not curative.
• Approach should be
– Individualized because of varied clinical presentations and disease
burdens.
– Dynamic to respond to changes over time.
 Objective of Treatment

Short Long
To control symptom
term term between flares
To manage flares • Active lesion absent
• But skin is dry and
itchy

Exacerbation Remission
Treatment during exacerbation
Supportive
measures
2. Topical calcineurin • Antihistaminics
inhibitors • Antibiotics
•• Generally
Tacrolimusmoderate
(0.1 and
potency
0.03% steroids and
• 1st ointment)
gerneration
•• Daily (betn 8 to 10 daysfor
Pimecrolimus
antihistaminics-
Others • Directly and exclusively
(0.1%cream)
sedation and to
to inflammatory
• Use overcome lesions
when the continued
• Oral steroids itch
1 topical • Combined
• Immunosuppresents withsteroids
use of topical salicyclic
is
corticosteroids • Crisaborole acid in lichenified
ineffective lesions
or inadvisable
• Dupilumab • Oral antibiotics
• Phototherapy
Exacerbations • Topical antibiotics
• Dilute bleach bath

Exacerbation Remission
Treatment during remission

2. Emolients 3. Trigger
(mosturiser) avoidance ••Temerature extremes of
Form cornerstone
• Dry skin
therapy
• Heat and sweating
• Applied over non
• Proven allergens
inflammatory area
• Pollen, Pet dander, Mold, Dust
4. Topical immediate after hydration
mites
of skin
1. Daily steroids on
• Irritants
•• Metals,
Alleviate itching nickel,
in particular,
bathing intermitent
• household
May suffice Cleaners,
in mild Certain
cases
fabrics such as wool and polyester
basis without any additional
• Emotional stress
Remission therapy
• Infection
 Take home message
• AD is a chronic, pruritic, inflammatory skin disease with a wide range of severity
• The pathogenesis of AD is multifactorial
– Genetics
– skin barrier dysfunction
– impaired immune response and the
– Environmental factor play a role
• Diagnosis is mainly clinical
– Itching
– Early age of onset
– Age wise distribution
– Comes and goes
• Treatment for AD includes long-term use of emollients and gentle skin care as well as short-
term treatment for acute flares
 Mcq’s
• Which of the following statements supports the diagnosis of
atopic dermatitis:
1. Chronic nature of the rash
2. Distribution of the rash
3. Family history of atopic disease
4. Symptom of pruritus
5. All of the above
• Is atopic dermatitis contagious?
1. Yes
2. No
 Refrences
• India E. Illustrated Synopsis of Dermatology and Sexually
Transmitted Diseases. 2011.
• emedicine.com. Accessed May 28, 2018].
• Khanna N. Bhutani’s Color Atlas of Dermatology. Jaypee
Brothers,Medical Publishers Pvt. Limited; 2015.
Thank you