Atopic Eczema Sharon Wong Suzy Tinker

Classification EndogenousvsExogenous Acute vsChronic

Acute eczema Acute: pruritus, erythema, vesiculationAcute: pruritus, erythema, vesiculation

Chronic eczema Chronic: pruritus, xerosis, lichenification, hyperkeratosis, +/- fissuringChronic: pruritus, xerosis, lichenification, hyperkeratosis, +/- fissuring

Chronic eczema

Eczema – clinical subtypes Irritant contact dermatitis Allergic contact dermatitis Atopic Discoid Seborrhoeic Venous Pompholyx Asteatotic Follicular/papular Exogenous Endogenous

Atopic dermatitis Chronic relapsing skin disorder (prevalence 20%)Chronic relapsing skin disorder (prevalence 20%) Onset <5 years in 80%Onset <5 years in 80% 40-60% remain symptomatic as adult40-60% remain symptomatic as adult 85% ↑ IgE, 80% associated with asthma/allergy85% ↑ IgE, 80% associated with asthma/allergy Family Hx of atopyFamily Hx of atopy

Pathogenesis of AD Interaction of skin barrier, genetic, environmental, pharmacologic, and immunologic factorsInteraction of skin barrier, genetic, environmental, pharmacologic, and immunologic factors Release of vasoactive substances from mast cells and basophils, that have been sentitized by the interaction of the antigen with IgE.Release of vasoactive substances from mast cells and basophils, that have been sentitized by the interaction of the antigen with IgE.

Exacerbating factors –Inhalants (dust mites, pollens) –Infections –Autoallergens (IgE) –Foods (eggs, milk, peanuts, soy-beans, fish, wheat) –Contact irritants (wools) –Season (improves in summer, flares in winter) –Emotional stress

Clinical features

Atopic eczema

The Itch-Scratch cycle Pruritus usually begins and causes itch sensation Scratch causes skin trauma and precipitates skin inflammation Chronic inflammation leads to lichenification

Clinical variants

Discoid eczema

Seborrhoeic

Seborrhoeic eczema

Lichen simplex

Pompholyx

Follicular

Contact dermatitis (exogenous)

Allergic vs irritant Immunological Type IV hypersensitivity Lifelong Positive patch test Non-immunological Can affect anyone More common atopics

Complications of Atopic Dermatitis

Impact of Atopic Dermatitis Hinders social interactions Disrupts sleep Disturbs schooling Failure to thrive Affects entire family

Treatment

Aim To get the eczema under control Keep the eczema under control

Basic stuff Avoid provoking factors (wool, bubble baths, soaps, perfumes) Avoid dryness: Bath oils (Oilatum, Hydromol, Aveeno, Dermol) Soap substitutes (Aqueous cream, Dermol) Emollients (500g in 2 weeks) Treat any infection Antihistamines Reduce inflammation

Topical steroids Topical immunomodulators Oral prednisolone Oral immunosuppressives Phototherapy

Topical steroids Ointments better than creams Learn 3 topical steroids I) Hydrocortisone ii) Eumovate iii) Betnovate/Elocon

Common topical steroid myths Can’t apply to infected or broken skin Can’t use topical steroids for more than 1 week non stop Hydrocortisone topically can thin the skin Cannot use potent topical steroids on the face

To get the eczema under control Apply steroid daily until skin is back to normal Then stop or wean down Continue emollients

To keep the eczema under control Apply topical steroid immediately the eczema flares Consider maintenance Rx (eg Protopic) Eumovate >30g per month- baby- refer Betnovate>60g per month –child-refer

Tacrolimus ointment Inhibits T cell activation & suppresses cytokine gene transcription Inhibits IgE-induced histamine release from mast cells and basophils Down-regulates high affinity IgE receptor on Langerhans cells

Important instructions to patients Burning/stinging sensation following application which will spontaneously resolve Avoid application after a hot bath or shower Recommend adequate application of tacrolimus ointment, it is NOT a topical steroid Care in sun - long term immunosuppression???

Particular indications for topical tacrolimus ointment Peri-ocular involvement Flexural involvement Facial involvement Requirement for maintenance treatment with moderately potent or potent topical steroids Presence of topical steroid-induced cutaneous atrophy or striae Pigmented skin

Not winning? Compliance? Infected? Contact dermatitis Difficult eczema?

Dressings & bandaging Dressings Wet wraps Comfifast, tubifast, dermasilk garments –Over emollient / weak steroids Quality Nursing Care

Phototherapy UVB/TLO1 Psoralen + UVA = PUVA –Methoxypsoralen –Topical or systemic Whole body or regional

Systemic treatments Short courses prednisolone Ciclosporin Azathioprine Methotrexate Mycophenolate mofetil

Steroid side effects - local Skin atrophy Telangiectasiae Acne Pigmentaion change ALL MORE MARKED IN FLEXURAL SITES!

Steroid side effects - systemic suppression HPA axis cataracts growth suppression loss bone density diabetes cushings

Take home messages Bath oils, soap substitutes and emollients - all stages/severity of eczema Use the most appropriate strength of steroid for the severity and site Steroids can be used for longer than a week – arrange follow-up to review and step down when skin improved Check compliance – ask how long a tube of steroid/pot of emollient lasts Prompt treatment of coexistent infection Assess severity by asking about sleep/school disturbance, weight/height gain (red book), mood, family dynamics