Atopic dermatitis АУС 527 С. Зориг

1. Атопийн дерматит

2. AD is a chronic relapsing inflammatory skin disease
•Primarily affects young children
• More than 50% develop asthma
• 75% developAR
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition 893-1999
Introduction

3. Epidemiology
•Affects 15-30% of children, 2-10% of adult
•45% begin within the first 6 mo
•60% begin during the first yr
•85% begin before 5 yrs
•Up to 75%: spontaneous remission before
adolescence
•Үлдсэн 25% нь насанд хүрээд дахидаг. Hand
eczema
•Анх үйлдвэржсэн орнуудад их тохиолдож
байсан.
NJEM 2008;358:1483-94

4. Risk factor
• Genetics
Fillagrin gene mutation
Other gene mutation
• Environment
Hygiene hypothesis

5. Pathophysiology
1. Immunological hypothesis. (hypersensitive 1 )

7. Pathophysiology
2. The Skin Barrier Hypothesis.
• Fillagrin уургийн мутацийн улмаас эвэрлэг давхарга болон мөхлөгт
давхаргын кератиноцит эсүүдийн хоорондын холбоо алдагдана.
(desmosom)
• Barier dysfunction
• Transepidermal water loss
• Үр дүнд нь арьс хуурайшиж, арьсанд аллерген нэвтрэх нь ихэснэ.

8. Morphology

9. Acute AD
• Intensely pruritic, erythematous papule associated with
excoriations, vesiculation, and serous exudate
• Pathology : spongiosis (intercellular epidermal edema), superficial
epidermal hypertrophy and acantholysis
• marked infiltration of CD4 activated memory T cells, APCs,(LCs,
inflammatory dendritic epidermal cells (IDECs), macrophages),
and degranulated mast cell
Histology: Spongiotic area within the epidermis

11. Chronic AD
• thickened plaques with increased lichenification
• Pathology : marked epidermal hyperplasia, acanthosis
• macrophage-dominated mononuclear cell infiltrate in dermis, and
perivascular accumulation of lymphocytes in smaller numbers than
seen in acuteAD
Hyperplastic of epidermis with hyperkeratosis
Adv Immunol.2009;102;135-226

13. Diagnosis
• Essential features Itch
• Eczema with typical morphology and age-specic pattern
Important features
• Early age of onset
Atopy (personal or family history) Dry skin
• Associated features
Atypical vascular response (i.e., facial pallor, white
dermographism)
• Keratosis pilaris, palmar hyperlinearity, ichthyosis Ocular
and periorbital changes
Other regionalndings (e.g., perioral and
periauricular lesions)
• Perifollicular accentuation, lichenification, and excoriations
Modied from American Academy of Dermatology

14. Distribution
• In infants, the face is often affected first, then the
hands and feet; dry red patches may appear all
over the body.
• In older children, the skin folds are most often
affected, especially the elbow creases and behind
the knees.
• In adults, the face and hands are more likely to be
involved.

15. Distribution

21. Atopic
Derm
Adults

22. Atopic Derm Adults

23. Atopic Dermatitis:
Associated features
• The skin is usually dry, itchy & easily irritated by:
• soap
• detergents
• wool clothing
• May worsen in hot weather & emotional stress.
• May worsen with exposure to dust & cats.

24. Associated Findings
• Pityriasis alba

25. Associated Findings
• Xerosis

26. Associated Findings
• Keratosis Pilaris

27. Associated
Findings
• Ichthyosis

28. Differential Diagnosis
• Seborrheic
dermatitis

29. Differential Diagnosis
• Seborrheic dermatitis
• Scabies

30. Differential Diagnosis
• Seborrheic dermatitis
• Scabies
• Drugs

31. Differential Diagnosis
• Seborrheic dermatitis
• Scabies
• Drugs
• Psoriasis

32. Differential Diagnosis
• Seborrheic dermatitis
• Scabies
• Drugs
• Psoriasis
• Allergic contact
dermatitis

33. Differential Diagnosis
• Seborrheic dermatitis
• Scabies
• Drugs
• Psoriasis
• Allergic contact
dermatitis
• Cutaneous T-cell
lymphoma

34. Assessment of severity
• Clear – normal skin no evidence of active atopic
eczema
• Mild – areas of dry skin, frequent itching + - small
areas of redness
• Moderate - areas of dry skin, frequent itching,
redness, +- excoriation and localised thickening.
• Severe – widespread areas of dry skin, incessant
itching, redness (+- excoriation, extensive skin
thickening, bleeding, oozing, cracking.

35. Impact on quality of life
• None – no impact on quality of life
• Mild – little impact on everyday activities, sleep and
psychosocial well being
• Moderate - Moderate impact on everyday activities,
psychosocial well being, frequently disturbed sleep
• Severe – severe limitation of everyday activities and
psychosocial well being, loss of sleep every night

37. Management
• Identify trigger factors
• Irritants – Management
• soaps and detergents
• Contact allergens
• Food allergens
• Inhalant allergens
• Skin infections

40. • Topical treatments
• Corticosteroids
• Calcineur ininhibitors
• Phototherapy
• Ultravioletlight A (UVA)
• Ultravioletlight B (UVB)
• Ultravioletlight A + Psoralene (PUVA)
• Systemic treatments
• Oralcorticosteroids
• Azathioprine
• Cyclosporine A
• Methotrexate

41. Stepped treatment
• Tailor treatment to severity
• Start with emollients – should be used even when skin
clear
• Mild disease – emollients + mild steroid creams 1%
hydrocortisone
• Moderate disease – emollients + moderate steroid
creams. Topical calcineurin inhibitors, bandages.
• Severe disease – potent steroid creams (short periods
only) topical calcineurin inhibitors, bandages,
phototherapy, systemic therapy

42. Management
• Use topical antibiotics + steroid for localised
infection for no longer than 2 weeks
• Non-sedating antihistamines if eczema is severe or
severe itching or urticaria
• Sedating antihistamines children aged > 6/12 during
acute flares if sleep disturbance for child or carers.
• Recognise indications for referral

47. Баярлалаа…