dr. Chairiyah Tanjung, SpKK(K) Department of Dermato-Venereology Medical Faculty, North Sumatera University

Atopic dermatitis (AD) = Atopic eczema o A chronically relapsing skin disease o Occurs most commonly during early infancy and childhood o Frequently associate with elevated serum IgE levels o A personal/family history of atopy(+)

 Prevalence 3x than 1960s  Industrialized countries > agricultural countries  Female : male = 1,3:1  AD, associated with : - small family size - increased income and education - migration rural  urban - use of antibiotic

Hereditary (genetic) Food & aero Allergy (hypersensitivity) Irritan allergens Infection Climate Cellular immunity ATOPIC DERMATITIS defect Xerosis Decrease skin barrier Psychological effect

 Strong maternal influence  Chromosome 5q31-33, contains a clustered family of functionally related cytokine genes : - IL-3, IL-4, IL-5, IL-13 expressed - GM-CSF by Th2 cell - Differences in transcriptional activity of the IL-4 gene influence AD predisposition - A significant association between a specific polymorphism in the mast cell chymase gene and AD

Key cells in AD skin : Langerhans cells Lymphocyte cells Eosinophils Mast cells

 Increased synthesis of IgE  Increased specific IgE to multiple allergens, including foods, aeroallergens, microorganism, bacterial toxins, autoallergens  Increased expression of of CD23 (affinity IgE receptor) on B cells and monocytes  Increased basophil histamine release

 Impaired delayed-type hypersensitivity response  Eosinophilia  Increased secretion of IL-4, IL-5 dan IL-13 by Th2 cells  Decreased secretion of IFN-γ by Th1 cells  Increased soluble IL-2 receptor levels  Elevated levels of monocyte CAMP- phosphodiesterase with increased IL-10 and prostaglandin E2

Epidermal lipid ↓ TEWL ↑ Skin capacitance ↓ Soap & detergen Decrease skin barrier function Allergen absorption ↑ Microbial colonization ↑ Treshold of pruritus ↓

 Food  infant and children :milk and eggs  adult : seafood and nuts  Aeroallergens : dust mites, animal danders, molds, pollens.  Temperature & humidity  Intense perspiration  Emotional stress

 Diagnostic criteria of AD : various  The UK working party’s : proposed alternative system, the criteria of Hanifin & Rajka (1994)  Diagnose of AD: -Three or more of the major criteria -Three or more of the minor criteria

 Pruritus  Typical morphology & distribution  Involvement during infancy & early childhood flexural  Flexural dermatitis in adult  Chronic or chronically relapsing dermatitis  Personal or family history of atopy

 Xerosis  Skin infection  Hand/foot dermatitis  Ichthyosis/palmar hyperlinearity/keratosis pilaris  Pityriasis alba  Nipple eczema  White dermatografism & delayed blanched response

 Cheilitis  Infra orbital fold  Anterior subcapsular cataracts  Orbital darkening  Facial pallor  Itchiness when sweating

 Perifollicular accentuation  Food hypersensitivity  Duration of AD influenced by environment and psychis factors  Immediate skin test reactivity  Elevated serum IgE  Early age of AD

Hyperlinearity of palmaris Dennie Morgan folds

1. Seborrhoic dermatitis 2. Contact dermatitis 3. Numular dermatitis 4. Scabies 5. Ichthyosis 6. Psoriasis 7. Dermatitis herpetiformis 8. Sezary syndrome 9. Leterrer-Siwe disease

In infant 1. Wiskott-Aldrich syndrome 2. Hyper- IgE syndrome

 Education  Appropriate skin hydration & use of emollient skin barrier repair measure  Avoidance of irritants  Identification & treatment of complication bacterial, viral of fungal infection  Treatment of psychosocial aspect of disease  Antipruritic intervention

1. Topical therapy 2. Systemic therapy

1. Cutaneus hydration 2. Topical glucocorticoid 3. Topical calcineurine inhibitor (tacrolimus & pimocrolimus) 1. Tar preparation 2. Topical anti histamine : not recommended except : doxepine cream 5%

1. Systemic glucocorticoid 2. Anti histamine 3. Infection agent 4. Interferon 5. Cyclosporine 6. Phototherapy (UVB, UVA+UVB, PUVA)

 Many factor correlate with AD → difficult to predict prognosis  The predictive factors correlate with a poor prognosis of AD : 1. Widespread AD in childhood 2. Associated allergenic rhinitis & asthma 3. Family history of AD in parents or sibling 4. Early age at onset of AD 5. Being an only children 6. Very high serum IgE levels

 30-35% infatile AD → asthma / hay fever  Often develop non specific irritant hand dermatitis THANK YOU