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Atopic dermatitis update

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Ariyanto Harsono
Ariyanto Harsono

Keywords: atopic dermatitis, diagnosis, conventional therapy, inconventional therapy

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Prof Ariyanto Harsono MD PhD SpA(K) Atopic Dermatitis Update
Dermatitis atopik adalah penyakit yang mulai timbul pada usia bayi dan anak. Ditandai dengan  Gejala utama gatal-gatal pada kulit.  kronis dan kambuh  reaksi inflamasi  berdasarkan faktor keturunan dan faktor lingkungan,  eritema kronis berulang, papula, vesikel, krusta, dan skuama. 2Prof DR Dr Ariyanto Harsono SpA(K)
Atopic Dermatitis: Itch that erupts Not eruption that itches 3Prof DR Dr Ariyanto Harsono SpA(K)
4Prof DR Dr Ariyanto Harsono SpA(K)
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 5Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria
•Pruritus •Characteristic Distribution and morphology of skin lesions •Flexural Lichenification •Facial and extensor Lichenification in babies and children •Kronik •History of family atopy 6Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Major criteria (minimal 3)
•Pruritus •Characteristic Distribution and morphology of skin lesions •Flexural Lichenification •Facial and extensor Lichenification in babies and children •Kronik •History of family atopy 7Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Major criteria (minimal 3)
•Pruritus •Characteristic Distribution and morphology of skin lesions •Flexural Lichenification •Facial dan ekstensor pada bayi dan anak •Kronik •History of family atopy 8Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Major criteria (minimal 3)
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 9Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Major criteria (minimal 3)
10Prof 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)
11Prof 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)
•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 12 Hanifin and Rajka criteria Minor criteria (minimal 3)
•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 13 Hanifin and Rajka criteria Minor criteria (minimal 3)
•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 14Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Minor criteria (minimal 3)
•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 15Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Minor criteria (minimal 3)
•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 16Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Minor criteria (minimal 3)
17Prof 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)
18 •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)
19Prof 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)
20Prof 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)
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 •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)
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 (Stafilokokus/herpes) •Tend to nonspesific dermatitis •Nipple eczema •Cheilitis •Recurrent Conjunctivitis Hanifin and Rajka criteria Minor criteria (minimal 3)
•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 24Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Minor criteria (minimal 3)
Kriteria Hanifin and Rajka 25Prof 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
Kriteria Hanifin and Rajka 26Prof 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
27Prof 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
28Prof 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
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
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 30Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Minor criteria
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 31Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Minor criteria
Kriteria Hanifin and Rajka 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
Kriteria Hanifin and Rajka 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
Kriteria Hanifin and Rajka 34Prof 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
Kriteria Hanifin and Rajka 35Prof 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
Hanifin and Rajka criteria Minor criteria 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 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 37Prof DR Dr Ariyanto Harsono SpA(K) Major criteria(minimal 2 major)
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 38Prof DR Dr Ariyanto Harsono SpA(K) Major criteria(minimal 2 major)
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 39Prof DR Dr Ariyanto Harsono SpA(K) Major criteria(minimal 2 major)
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 40Prof DR Dr Ariyanto Harsono SpA(K)
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 41Prof DR Dr Ariyanto Harsono SpA(K)
Minor criteria(minimal 1 minor) •Hand/foot dermatitis •Cheilitis •Vulnerable to infection (Herpes/Strep/S aureus) 42Prof DR Dr Ariyanto Harsono SpA(K)
Minor criteria(minimal 1 minor) •Hand/foot dermatitis •Cheilitis •Vulnerable to skin infetions (Herpes/Strep/S aureus) 43Prof DR Dr Ariyanto Harsono SpA(K)
Minor criteria(minimal 1 minor) •Hand/foot dermatitis •Cheilitis •Vulnerable to skin infetions (Herpes/Strep/S aureus) 44Prof DR Dr Ariyanto Harsono SpA(K)
Minor criteria(minimal 1 minor) •Hand/foot dermatitis •Cheilitis •Vulnerable to skin infetions (Herpes/Strep/staphilococcus) 45Prof DR Dr Ariyanto Harsono SpA(K)
46Prof DR Dr Ariyanto Harsono SpA(K) Seborrhoic dermatitis
47Prof DR Dr Ariyanto Harsono SpA(K) Pompholix
48Prof DR Dr Ariyanto Harsono SpA(K) Dishidrosis
Penanganan Dermatitis Atopik. Ada dua macam: • Pengobatan konvensional • Pengobatan inkonvensional Prof DR Dr Ariyanto Harsono SpA(K) 49
Principle of Conventional Therapy Eczema Target for skin care Target for anti inflammatory 50Prof DR Dr Ariyanto Harsono SpA(K)
Prinsip Pengobatan Konvensional: Education Emolient Allergen/irritants avoidance Antihistamine Topical Steroid 51Prof DR Dr Ariyanto Harsono SpA(K)
Emolient Tidak sekedar membasahi, akan tetapi harus bisa: Menahan air Antioksidan Memperbaiki fungsi skin barrier Melindungi fungsi skin barrier Antipruritus Antiinflamasi Steroid sparring Prof DR Dr Ariyanto Harsono SpA(K) 52
Emolient harus hipoalergenik Tidak ada pengawet Tidak ada pewangi Tidak ada pewarna Prof DR Dr Ariyanto Harsono SpA(K) 53
• Gunakan topikal steroid potensi lemah sampai sedang saja sebab steroid topikal kekuatan kuat bisa menimbulkan efek samping sistemik. Prof DR Dr Ariyanto Harsono SpA(K) 54
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)
PENGOBATAN INKONVENSIONAL. • Prinsipnya adalah pengobatan lanjutan bila pengobatan konvensional gagal atau mengalami efek samping yang serius. • Emolient tetap digunakan di semua lini. • Mulai digunakan Primecrolimus atau Tacrolimus sebagai pengganti steroid topikal. Lebih aman karena anti inflamasi non steroid. Prof DR Dr Ariyanto Harsono SpA(K) 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 57Prof DR Dr Ariyanto Harsono SpA(K) IVIG
Steroid oral dengan menggunakan prednison 1 mg/ kg BB selama 5-7 hari, tanpa tappering, atau steroid lain dengan dosis analog, memberikan efek segera akan tetapi hanya sementara. Sedapat mungkin penggunaan steroid oral dihindari karena terjadi withdrawal setelah dihentikan Prof DR Dr Ariyanto Harsono SpA(K) 58
IVIG dengan dosis 500mg/ kgBB terbagi dalam 3 hari. Diberikan secara infus intravena dalam waktu 6-8 jam. Prof DR Dr Ariyanto Harsono SpA(K) 59
Ciklosporin memberikan hasil pengobatan yang baik pada kasus kasus yang gagal dengan steroid topikal maupun oral. Penggunaannya terbatas karena efek samping berupa  nausea  hipertrichosis,  hipertensi,  parasthesia, dan  gangguan hati/ginjal. Diberikan dengan dosis 2,5mg-4mg/kg/hari selama 6 minggu. Preparat tablet 25mg/tablet atau 100mg/ml 50ml sirup. Prof DR Dr Ariyanto Harsono SpA(K) 60
Data menunjukkan Azathioprin memberikan hasil pengobatan yang baik. Diberikan dengan dosis 1-3mg/kgBB. Preparatnya tablet 50mg/tablet. Prof DR Dr Ariyanto Harsono SpA(K) 61
Mycophenolate mofetil dengan dosis 500 mg 2X perhari. Preparat: tablet 500mg/tablet. Methotrexate dapat digunakan untuk sparing effect kortikosteroid dengan dosis 3-10 mg seminggu sekali. Preparatnya tablet 2,5 mg/tablet. Sebaiknya disertai pemberian Folic acid. Prof DR Dr Ariyanto Harsono SpA(K) 62
Kepustakaan 1. Harsono A. Atopic Dermatitis treatment: from conventional to unconventional. http://www.slideshare.net/ariyantoharsono/atopic 2. Nelson Textbook of Pedatrics. Prof DR Dr Ariyanto Harsono SpA(K) 63
64Prof DR Dr Ariyanto Harsono SpA(K) Thank you

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Atopic dermatitis update

  • 1. Prof Ariyanto Harsono MD PhD SpA(K) Atopic Dermatitis Update
  • 2. Dermatitis atopik adalah penyakit yang mulai timbul pada usia bayi dan anak. Ditandai dengan  Gejala utama gatal-gatal pada kulit.  kronis dan kambuh  reaksi inflamasi  berdasarkan faktor keturunan dan faktor lingkungan,  eritema kronis berulang, papula, vesikel, krusta, dan skuama. 2Prof DR Dr Ariyanto Harsono SpA(K)
  • 3. Atopic Dermatitis: Itch that erupts Not eruption that itches 3Prof DR Dr Ariyanto Harsono SpA(K)
  • 4. 4Prof DR Dr Ariyanto Harsono SpA(K)
  • 5. 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 5Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria
  • 6. •Pruritus •Characteristic Distribution and morphology of skin lesions •Flexural Lichenification •Facial and extensor Lichenification in babies and children •Kronik •History of family atopy 6Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Major criteria (minimal 3)
  • 7. •Pruritus •Characteristic Distribution and morphology of skin lesions •Flexural Lichenification •Facial and extensor Lichenification in babies and children •Kronik •History of family atopy 7Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Major criteria (minimal 3)
  • 8. •Pruritus •Characteristic Distribution and morphology of skin lesions •Flexural Lichenification •Facial dan ekstensor pada bayi dan anak •Kronik •History of family atopy 8Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Major criteria (minimal 3)
  • 9. 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 9Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Major criteria (minimal 3)
  • 10. 10Prof 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)
  • 11. 11Prof 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)
  • 12. •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 12 Hanifin and Rajka criteria Minor criteria (minimal 3)
  • 13. •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 13 Hanifin and Rajka criteria Minor criteria (minimal 3)
  • 14. •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 14Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Minor criteria (minimal 3)
  • 15. •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 15Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Minor criteria (minimal 3)
  • 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 16Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Minor criteria (minimal 3)
  • 17. 17Prof 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)
  • 18. 18 •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)
  • 19. 19Prof 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)
  • 20. 20Prof 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)
  • 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 •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)
  • 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 (Stafilokokus/herpes) •Tend to nonspesific dermatitis •Nipple eczema •Cheilitis •Recurrent Conjunctivitis Hanifin and Rajka criteria Minor criteria (minimal 3)
  • 24. •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 24Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Minor criteria (minimal 3)
  • 25. Kriteria Hanifin and Rajka 25Prof 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
  • 26. Kriteria Hanifin and Rajka 26Prof 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
  • 27. 27Prof 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
  • 28. 28Prof 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
  • 29. 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. 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 30Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Minor criteria
  • 31. 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 31Prof DR Dr Ariyanto Harsono SpA(K) Hanifin and Rajka criteria Minor criteria
  • 32. Kriteria Hanifin and Rajka 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. Kriteria Hanifin and Rajka 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. Kriteria Hanifin and Rajka 34Prof 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
  • 35. Kriteria Hanifin and Rajka 35Prof 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
  • 36. Hanifin and Rajka criteria Minor criteria 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
  • 37. 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 37Prof DR Dr Ariyanto Harsono SpA(K) Major criteria(minimal 2 major)
  • 38. 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 38Prof DR Dr Ariyanto Harsono SpA(K) Major criteria(minimal 2 major)
  • 39. 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 39Prof DR Dr Ariyanto Harsono SpA(K) Major criteria(minimal 2 major)
  • 40. 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 40Prof DR Dr Ariyanto Harsono SpA(K)
  • 41. 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 41Prof DR Dr Ariyanto Harsono SpA(K)
  • 42. Minor criteria(minimal 1 minor) •Hand/foot dermatitis •Cheilitis •Vulnerable to infection (Herpes/Strep/S aureus) 42Prof DR Dr Ariyanto Harsono SpA(K)
  • 43. Minor criteria(minimal 1 minor) •Hand/foot dermatitis •Cheilitis •Vulnerable to skin infetions (Herpes/Strep/S aureus) 43Prof DR Dr Ariyanto Harsono SpA(K)
  • 44. Minor criteria(minimal 1 minor) •Hand/foot dermatitis •Cheilitis •Vulnerable to skin infetions (Herpes/Strep/S aureus) 44Prof DR Dr Ariyanto Harsono SpA(K)
  • 45. Minor criteria(minimal 1 minor) •Hand/foot dermatitis •Cheilitis •Vulnerable to skin infetions (Herpes/Strep/staphilococcus) 45Prof DR Dr Ariyanto Harsono SpA(K)
  • 46. 46Prof DR Dr Ariyanto Harsono SpA(K) Seborrhoic dermatitis
  • 47. 47Prof DR Dr Ariyanto Harsono SpA(K) Pompholix
  • 48. 48Prof DR Dr Ariyanto Harsono SpA(K) Dishidrosis
  • 49. Penanganan Dermatitis Atopik. Ada dua macam: • Pengobatan konvensional • Pengobatan inkonvensional Prof DR Dr Ariyanto Harsono SpA(K) 49
  • 50. Principle of Conventional Therapy Eczema Target for skin care Target for anti inflammatory 50Prof DR Dr Ariyanto Harsono SpA(K)
  • 51. Prinsip Pengobatan Konvensional: Education Emolient Allergen/irritants avoidance Antihistamine Topical Steroid 51Prof DR Dr Ariyanto Harsono SpA(K)
  • 52. Emolient Tidak sekedar membasahi, akan tetapi harus bisa: Menahan air Antioksidan Memperbaiki fungsi skin barrier Melindungi fungsi skin barrier Antipruritus Antiinflamasi Steroid sparring Prof DR Dr Ariyanto Harsono SpA(K) 52
  • 53. Emolient harus hipoalergenik Tidak ada pengawet Tidak ada pewangi Tidak ada pewarna Prof DR Dr Ariyanto Harsono SpA(K) 53
  • 54. • Gunakan topikal steroid potensi lemah sampai sedang saja sebab steroid topikal kekuatan kuat bisa menimbulkan efek samping sistemik. Prof DR Dr Ariyanto Harsono SpA(K) 54
  • 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. PENGOBATAN INKONVENSIONAL. • Prinsipnya adalah pengobatan lanjutan bila pengobatan konvensional gagal atau mengalami efek samping yang serius. • Emolient tetap digunakan di semua lini. • Mulai digunakan Primecrolimus atau Tacrolimus sebagai pengganti steroid topikal. Lebih aman karena anti inflamasi non steroid. Prof DR Dr Ariyanto Harsono SpA(K) 56
  • 57. 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 57Prof DR Dr Ariyanto Harsono SpA(K) IVIG
  • 58. Steroid oral dengan menggunakan prednison 1 mg/ kg BB selama 5-7 hari, tanpa tappering, atau steroid lain dengan dosis analog, memberikan efek segera akan tetapi hanya sementara. Sedapat mungkin penggunaan steroid oral dihindari karena terjadi withdrawal setelah dihentikan Prof DR Dr Ariyanto Harsono SpA(K) 58
  • 59. IVIG dengan dosis 500mg/ kgBB terbagi dalam 3 hari. Diberikan secara infus intravena dalam waktu 6-8 jam. Prof DR Dr Ariyanto Harsono SpA(K) 59
  • 60. Ciklosporin memberikan hasil pengobatan yang baik pada kasus kasus yang gagal dengan steroid topikal maupun oral. Penggunaannya terbatas karena efek samping berupa  nausea  hipertrichosis,  hipertensi,  parasthesia, dan  gangguan hati/ginjal. Diberikan dengan dosis 2,5mg-4mg/kg/hari selama 6 minggu. Preparat tablet 25mg/tablet atau 100mg/ml 50ml sirup. Prof DR Dr Ariyanto Harsono SpA(K) 60
  • 61. Data menunjukkan Azathioprin memberikan hasil pengobatan yang baik. Diberikan dengan dosis 1-3mg/kgBB. Preparatnya tablet 50mg/tablet. Prof DR Dr Ariyanto Harsono SpA(K) 61
  • 62. Mycophenolate mofetil dengan dosis 500 mg 2X perhari. Preparat: tablet 500mg/tablet. Methotrexate dapat digunakan untuk sparing effect kortikosteroid dengan dosis 3-10 mg seminggu sekali. Preparatnya tablet 2,5 mg/tablet. Sebaiknya disertai pemberian Folic acid. Prof DR Dr Ariyanto Harsono SpA(K) 62
  • 63. Kepustakaan 1. Harsono A. Atopic Dermatitis treatment: from conventional to unconventional. http://www.slideshare.net/ariyantoharsono/atopic 2. Nelson Textbook of Pedatrics. Prof DR Dr Ariyanto Harsono SpA(K) 63
  • 64. 64Prof DR Dr Ariyanto Harsono SpA(K) Thank you