Atopic dermatitis treatment, from conventional to unconventional

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Definition, pathognesis,diagnosis, conventional treatment, new treatment strategy

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Atopic dermatitis treatment, from conventional to unconventional

  1. 1. Atopic Dermatitis Treatment: from Conventional to Unconventional Prof Ariyanto Harsono MD PhD SpA(K)
  2. 2. Atopic dermatitis is a disease that begin to arise at the age of infants and children  characterized by itching of the skin.  chronic and relapsing  inflammatory reaction  based on hereditary factors and environmental factors,  the symptoms are chronic recurrent erythema, papules, vesicles, crusting, and skuama. 2Prof DR Dr Ariyanto Harsono SpA(K)
  3. 3. Atopic Dermatitis: Itch that erupts Not eruption that itches 3Prof DR Dr Ariyanto Harsono SpA(K)
  4. 4. 4Prof DR Dr Ariyanto Harsono SpA(K)
  5. 5. 5Prof DR Dr Ariyanto Harsono SpA(K)
  6. 6. IgE IL-4, IL-5 IL-13 6Prof DR Dr Ariyanto Harsono SpA(K)
  7. 7. IgE IL-4, IL-5 IL-13 v 2 CD4+Th1 Cell IFN-γ CD8+Th1 Cell DTH Super antigen 7 Prof DR Dr Ariyanto Harsono SpA(K)
  8. 8. Spongious Infiltrasi Eosinofil Udem 8Prof DR Dr Ariyanto Harsono SpA(K)
  9. 9. Major criteria (minimal 3) •Pruritus •Characteristic Distribution and morphology of skin lesions •Flexural Lichenification •Facial and extensor Lichenification in babies and children •Chronic •History of family atopy 9Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria
  10. 10. •Pruritus •Characteristic Distribution and morphology of skin lesions •Flexural Lichenification •Facial and extensor Lichenification in babies and children •Kronik •History of family atopy 10Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Major criteria (minimal 3)
  11. 11. •Pruritus •Characteristic Distribution and morphology of skin lesions •Flexural Lichenification •Facial and extensor Lichenification in babies and children •Kronik •History of family atopy 11Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Major criteria (minimal 3)
  12. 12. •Pruritus •Characteristic Distribution and morphology of skin lesions •Flexural Lichenification •Facial dan ekstensor pada bayi dan anak •Kronik •History of family atopy 12Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Major criteria (minimal 3)
  13. 13. Kriteria Hanifin and Rajka •Pruritus •Characteristic Distribution and morphology of skin lesions •Flexural Lichenification •Facial and extensor in babies and children •Chronic •History of family atopy 13Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Major criteria (minimal 3)
  14. 14. 14Prof DR Dr Ariyanto Harsono SpA(K) •Ichtyosis , palmar hyperlinearity, keratosis pilaris •Xerosis •Skin Test positive •High IgE levels •Early Onset of age •Vulnerable of infections (Stafilokokus/herpes) •Tend to nonspesific dermatitis •Nipple eczema •Cheilitis •Recurrent Conjunctivitis Hanifin and Rajka criteria Minor criteria (minimal 3)
  15. 15. 15Prof DR Dr Ariyanto Harsono SpA(K) •Ichtyosis , palmar hyperlinearity, keratosis pilaris •Xerosis •Skin Test positive •High IgE levels •Early Onset of age •Vulnerable of infections (Stafilokokus/herpes) •Tend to nonspesific dermatitis •Nipple eczema •Cheilitis •Recurrent Conjunctivitis Hanifin and Rajka criteria Minor criteria (minimal 3)
  16. 16. •Ichtyosis , palmar hyperlinearity, keratosis pilaris •Xerosis •Skin Test positive •High IgE levels •Early Onset of age •Vulnerable of infections (Stafilokokus/herpes) •Tend to nonspesific dermatitis •Nipple eczema •Cheilitis •Recurrent Conjunctivitis 16 Hanifin and Rajka criteria Minor criteria (minimal 3)
  17. 17. •Ichtyosis , palmar hyperlinearity, keratosis pilaris •Xerosis •Skin Test positive •High IgE levels •Early Onset of age •Vulnerable of infections (Stafilokokus/herpes) •Tend to nonspesific dermatitis •Nipple eczema •Cheilitis •Recurrent Conjunctivitis 17 Hanifin and Rajka criteria Minor criteria (minimal 3)
  18. 18. •Ichtyosis , palmar hyperlinearity, keratosis pilaris •Xerosis •Skin Test positive •High IgE levels •Early Onset of age •Vulnerable of infections (Stafilokokus/herpes) •Tend to nonspesific dermatitis •Nipple eczema •Cheilitis •Recurrent Conjunctivitis 18Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Minor criteria (minimal 3)
  19. 19. •Ichtyosis , palmar hyperlinearity, keratosis pilaris •Xerosis •Skin Test positive •High IgE levels •Early Onset of age •Vulnerable of infections (Stafilokokus/herpes) •Tend to nonspesific dermatitis •Nipple eczema •Cheilitis •Recurrent Conjunctivitis 19Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Minor criteria (minimal 3)
  20. 20. •Ichtyosis , palmar hyperlinearity, keratosis pilaris •Xerosis •Skin Test positive •High IgE levels •Early Onset of age •Vulnerable of infections (Stafilokokus/herpes) •Tend to nonspesific dermatitis •Nipple eczema •Cheilitis •Recurrent Conjunctivitis 20Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Minor criteria (minimal 3)
  21. 21. 21Prof DR Dr Ariyanto Harsono SpA(K) •Ichtyosis , palmar hyperlinearity, keratosis pilaris •Xerosis •Skin Test positive •High IgE levels •Early Onset of age •Vulnerable of infections (Stafilokokus/herpes) •Tend to nonspesific dermatitis •Nipple eczema •Cheilitis •Recurrent Conjunctivitis Hanifin and Rajka criteria Minor criteria (minimal 3)
  22. 22. 22 •Ichtyosis , palmar hyperlinearity, keratosis pilaris •Xerosis •Skin Test positive •High IgE levels •Early Onset of age •Tend to nonspesific dermatitis •Nipple eczema •Cheilitis •Recurrent Conjunctivitis Hanifin and Rajka criteria Minor criteria (minimal 3) •Vulnerable of infections (Stafilokokus/herpes)
  23. 23. 23Prof DR Dr Ariyanto Harsono SpA(K) •Ichtyosis , palmar hyperlinearity, keratosis pilaris •Xerosis •Skin Test positive •High IgE levels •Early Onset of age •Vulnerable of infections (Staphylococcus/herpes) •Tend to nonspesific dermatitis •Nipple eczema •Cheilitis •Recurrent Conjunctivitis Hanifin and Rajka criteria Minor criteria (minimal 3)
  24. 24. 24Prof DR Dr Ariyanto Harsono SpA(K) •Ichtyosis , palmar hyperlinearity, keratosis pilaris •Xerosis •Skin Test positive •High IgE levels •Early Onset of age •Vulnerable of infections (Stafilokokus/herpes) •Tend to nonspesific dermatitis •Nipple eczema •Cheilitis •Recurrent Conjunctivitis Hanifin and Rajka criteria Minor criteria (minimal 3)
  25. 25. 25Prof DR Dr Ariyanto Harsono SpA(K) •Ichtyosis , palmar hyperlinearity, keratosis pilaris •Xerosis •Skin Test positive •High IgE levels •Early Onset of age •Vulnerable of infections (Stafilokokus/herpes) •Tend to nonspesific dermatitis •Nipple eczema •Cheilitis •Recurrent Conjunctivitis Hanifin and Rajka criteria Minor criteria (minimal 3)
  26. 26. 26 •Ichtyosis , palmar hyperlinearity, keratosis pilaris •Xerosis •Skin Test positive •High IgE levels •Early Onset of age •Vulnerable of infections •Tend to nonspesific dermatitis •Nipple eczema •Cheilitis •Recurrent Conjunctivitis Hanifin and Rajka criteria Minor criteria (minimal 3)
  27. 27. 27Prof DR Dr Ariyanto Harsono SpA(K) •Ichtyosis , palmar hyperlinearity, keratosis pilaris •Xerosis •Skin Test positive •High IgE levels •Early Onset of age •Vulnerable of infections (Stafilokokus/herpes) •Tend to nonspesific dermatitis •Nipple eczema •Cheilitis •Recurrent Conjunctivitis Hanifin and Rajka criteria Minor criteria (minimal 3)
  28. 28. •Ichtyosis , palmar hyperlinearity, keratosis pilaris •Xerosis •Tes kulit positif •Peningkatan IgE serum •Onset usia muda •Mudah infeksi kulit (Stafilokokus/herpes) •Kecenderungan nonspesific dermatitis •Nipple eczema •Cheilitis •Reccurent conjunctivitis 28Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Minor criteria (minimal 3)
  29. 29. Kriteria Hanifin and Rajka 29Prof DR Dr Ariyanto Harsono SpA(K) •Dennie Morgan infraorbital fold •Keratoconus •Anterior subcapsular cataract •Orbital darkening •Facial pallor/erythem •Pityriasis alba •Itch when sweating •Wool intolerant /lipid solvent •Perifollicular accentuation •Food Intolerant •Emotional and environmental influence •White dermatographism Hanifin and Rajka criteria Minor criteria
  30. 30. Kriteria Hanifin and Rajka 30Prof DR Dr Ariyanto Harsono SpA(K) •Dennie Morgan infraorbital fold •Keratoconus •Anterior subcapsular cataract •Orbital darkening •Facial pallor/erythem •Pityriasis alba •Itch when sweating •Wool intolerant /lipid solvent •Perifollicular accentuation •Food Intolerant •Emotional and environmental influence •White dermatographism Hanifin and Rajka criteria Minor criteria
  31. 31. 31Prof DR Dr Ariyanto Harsono SpA(K) •Dennie Morgan infraorbital fold •Keratoconus •Anterior subcapsular cataract •Orbital darkening •Facial pallor/erythem •Pityriasis alba •Itch when sweating •Wool intolerant /lipid solvent •Perifollicular accentuation •Food Intolerant •Emotional and environmental influence •White dermatographism Hanifin and Rajka criteria Minor criteria
  32. 32. 32Prof DR Dr Ariyanto Harsono SpA(K) •Dennie Morgan infraorbital fold •Keratoconus •Anterior subcapsular cataract •Orbital darkening •Facial pallor/erythem •Pityriasis alba •Itch when sweating •Wool intolerant /lipid solvent •Perifollicular accentuation •Food Intolerant •Emotional and environmental influence •White dermatographism Hanifin and Rajka criteria Minor criteria
  33. 33. 33Prof DR Dr Ariyanto Harsono SpA(K) •Dennie Morgan infraorbital fold •Keratoconus •Anterior subcapsular cataract •Orbital darkening •Facial pallor/erythem •Pityriasis alba •Itch when sweating •Wool intolerant /lipid solvent •Perifollicular accentuation •Food Intolerant •Emotional and environmental influence •White dermatographism Hanifin and Rajka criteria Minor criteria
  34. 34. Kriteria Hanifin and Rajka •Dennie Morgan infraorbital fold •Keratoconus •Anterior subcapsular cataract •Orbital darkening •Facial pallor/erythem •Pityriasis alba •Itch when sweating •Wool intolerant /lipid solvent •Perifollicular accentuation •Food Intolerant •Emotional and environmental influence •White dermatographism 34Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Minor criteria
  35. 35. Kriteria Hanifin and Rajka •Dennie Morgan infraorbital fold •Keratoconus •Anterior subcapsular cataract •Orbital darkening •Facial pallor/erythem •Pityriasis alba •Itch when sweating •Wool intolerant /lipid solvent •Perifollicular accentuation •Food Intolerant •Emotional and environmental influence •White dermatographism 35Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Minor criteria
  36. 36. Kriteria Hanifin and Rajka 36Prof DR Dr Ariyanto Harsono SpA(K) •Dennie Morgan infraorbital fold •Keratoconus •Anterior subcapsular cataract •Orbital darkening •Facial pallor/erythem •Pityriasis alba •Itch when sweating •Wool intolerant /lipid solvent •Perifollicular accentuation •Food Intolerant •Emotional and environmental influence •White dermatographism Hanifin and Rajka criteria Minor criteria
  37. 37. Kriteria Hanifin and Rajka 37Prof DR Dr Ariyanto Harsono SpA(K) •Dennie Morgan infraorbital fold •Keratoconus •Anterior subcapsular cataract •Orbital darkening •Facial pallor/erythem •Pityriasis alba •Itch when sweating •Wool intolerant /lipid solvent •Perifollicular accentuation •Food Intolerant •Emotional and environmental influence •White dermatographism Hanifin and Rajka criteria Minor criteria
  38. 38. Kriteria Hanifin and Rajka 38Prof DR Dr Ariyanto Harsono SpA(K) •Dennie Morgan infraorbital fold •Keratoconus •Anterior subcapsular cataract •Orbital darkening •Facial pallor/erythem •Pityriasis alba •Itch when sweating •Wool intolerant /lipid solvent •Perifollicular accentuation •Food Intolerant •Emotional and environmental influence •White dermatographism Hanifin and Rajka criteria Minor criteria
  39. 39. Kriteria Hanifin and Rajka 39Prof DR Dr Ariyanto Harsono SpA(K) •Dennie Morgan infraorbital fold •Keratoconus •Anterior subcapsular cataract •Orbital darkening •Facial pallor/erythem •Pityriasis alba •Itch when sweating •Wool intolerant /lipid solvent •Perifollicular accentuation •Food Intolerant •Emotional and environmental influence •White dermatographism Hanifin and Rajka criteria Minor criteria
  40. 40. Hanifin and Rajka criteria Minor criteria 40Prof DR Dr Ariyanto Harsono SpA(K) •Dennie Morgan infraorbital fold •Keratoconus •Anterior subcapsular cataract •Orbital darkening •Facial pallor/erythem •Pityriasis alba •Itch when sweating •Wool intolerant /lipid solvent •Perifollicular accentuation •Food Intolerant •Emotional and environmental influence •White dermatographism
  41. 41. Hanifin and Rajka criteria for baby Kriteria mayor (minimal 2 mayor) •History of family atopy •Evidence of pruritic Dermatitis •Dermatitis fasial, ekstensor, lichenification Minor criteria (minimal 1 minor) •Xerosis/ichtyosis/hyperlinear palm •Perifollicular accentuation •Chronic scalp scalling •Periauricular fissures 41Prof DR Dr Ariyanto Harsono SpA(K) Major criteria(minimal 2 major)
  42. 42. Hanifin and Rajka criteria for baby Kriteria mayor (minimal 2 mayor) •History of family atopy •Evidence of pruritic Dermatitis •Dermatitis fasial, ekstensor, lichenification Minor criteria (minimal 1 minor) •Xerosis/ichtyosis/hyperlinear palm •Perifollicular accentuation •Chronic scalp scalling •Periauricular fissures 42Prof DR Dr Ariyanto Harsono SpA(K) Major criteria(minimal 2 major)
  43. 43. Hanifin and Rajka criteria for baby Kriteria mayor (minimal 2 mayor) •History of family atopy •Evidence of pruritic Dermatitis •Dermatitis fasial, ekstensor, lichenification Minor criteria(minimal 1 minor) •Xerosis/ichtyosis/hyperlinear palm •Perifollicular accentuation •Chronic scalp scalling •Periauricular fissures 43Prof DR Dr Ariyanto Harsono SpA(K) Major criteria(minimal 2 major)
  44. 44. Hanifin and Rajka criteria for baby Major criteria(minimal 2 major) •History of family atopy •Evidence of pruritic Dermatitis •Dermatitis fasial, ekstensor, lichenification Minor criteria (minimal 1 minor) •Xerosis/ichtyosis/hyperlinear palm •Perifollicular accentuation •Chronic scalp scalling •Periauricular fissures 44Prof DR Dr Ariyanto Harsono SpA(K)
  45. 45. Hanifin criteria for children Major criteria (minimal 3 major) •Pruritus •Characteristic Distribution and morphology of skin lesions •Dermatitis fasial, ekstensor selama bayi dan awal usia anak •Flexural lichenification dan linearity by adolescence •Chronic Dermatitis Minor criteria(minimal 1 minor) •Xerosis/ichtyosis/hyperlinear palm/keratosis pilaris •IgE reactivity •Chronic scalp scalling •Perifollicular accentuation •Periauricular fissures 45Prof DR Dr Ariyanto Harsono SpA(K)
  46. 46. Minor criteria(minimal 1 minor) •Hand/foot dermatitis •Cheilitis •Vulnerable to infection (Herpes/Strep/S aureus) 46Prof DR Dr Ariyanto Harsono SpA(K)
  47. 47. Minor criteria(minimal 1 minor) •Hand/foot dermatitis •Cheilitis •Vulnerable to skin infetions (Herpes/Strep/S aureus) 47Prof DR Dr Ariyanto Harsono SpA(K)
  48. 48. Minor criteria(minimal 1 minor) •Hand/foot dermatitis •Cheilitis •Vulnerable to skin infetions (Herpes/Strep/S aureus) 48Prof DR Dr Ariyanto Harsono SpA(K)
  49. 49. Minor criteria(minimal 1 minor) •Hand/foot dermatitis •Cheilitis •Vulnerable to skin infetions (Herpes/Strep/staphilococcus) 49Prof DR Dr Ariyanto Harsono SpA(K)
  50. 50. 50Prof DR Dr Ariyanto Harsono SpA(K) Seborrhoic dermatitis
  51. 51. 51Prof DR Dr Ariyanto Harsono SpA(K) Pompholix
  52. 52. 52Prof DR Dr Ariyanto Harsono SpA(K)
  53. 53. Principle of Conventional Therapy Eczema Target for skin care Target for anti inflammatory 53Prof DR Dr Ariyanto Harsono SpA(K)
  54. 54. Education Hidration Emolient Moisturizer Wet dressing Allergen/irritants avoidance Antihistamine Topical Steroid 54Prof DR Dr Ariyanto Harsono SpA(K)
  55. 55. Conventional Therapy is not always safe Topical steroid: cutaneous atrophy, striae, bruisability, telangiectasia High-potency topical steroids can cause systemic side effects in children. 55Prof DR Dr Ariyanto Harsono SpA(K)
  56. 56. Mild Moderate Severe Mild to Moderate Potency Topical Steroids Pimecrolimus Tacrolimus Oral Steroids Cyclosporine, mycophenolate Light treatment New Treatment Strategy in AD Emolient Dry skin Itching and/or early sign of inflammation Flare 56Prof DR Dr Ariyanto Harsono SpA(K) IVIG
  57. 57. Arachidonic Acid (ARA) Phospholiphase A Cyccloxygenase Lipoxygenase Prostaglandine TXA Prostacyclin Leukotriene A Leukotriene B Leukotriene C γ-linoleic acid HETE,5-HETE, PAF 57Prof DR Dr Ariyanto Harsono SpA(K)
  58. 58. Mechanism of IVIG blocking apoptosis via Procaspase-8 pathway Macrophage Keratinocyte 58Prof DR Dr Ariyanto Harsono SpA(K) Use of IVIG
  59. 59. Prof DR Dr Ariyanto Harsono SpA(K) 59
  60. 60. 60Prof DR Dr Ariyanto Harsono SpA(K) Thank you

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