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Atopic Dermatitis:

From Prevention to Treatment

Sumadiono
Pediatric Department Sardjito Hospital/FK UGM Yogyakarta

Healthy Skin
Allergen
s

Allergen
s

corneocyt
es

Cornified cell
envelope

H2O
H2O
H2O
lipids
Harding 2004

H2O
H2O
H2O

H2O
H2O
H2O

Keratin
macrofibrils

H2O

H2O

H2O
H2O

H2O

Intracellular
humectantants
(natural moisturising
factor)

In normal, healthy skin, the


epidermis acts as a protective barrier
The stratum corneum consists of
dead skin cells held together by
lipids and proteins

Pathogenesis of AD

Defective skin barrier


function

Eczema is an
inflammatory condition
of the skin
In eczema, the lipid
layer is defective
causing:

Water loss
Cracks in the outer layer
of skin (stratum corneum)
Penetration of allergens
and irritants

Cork MJ. (1997) The importance of skin barrier function. J of Dermatological Treatment (1997) 8, S7-13

a
is
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Ato
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,
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skin disorder
a
y
b
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iz
r
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pruritic,
nd
a
s
u
o
t
a
m
e
h
t
y
er
d
e
t
a
c
r
a
m
e
d
ly
r
poo
skin eruption

DIAGNOSIS

From mild to severe form

History
Atopic eczema mostly
appears in childhood
Before the age of 5 years in
85% of cases

Present in 15-20% of
children and 2-10% of
adults
Commonly there is a family
history of eczema or allergy
Beltrani VS, Boguneiwicz M (2003). Dermatology Online Journal, 9(2):1
National Collaborating Centre for Womens and Childrens Health (2007) Atopic eczema in children:
management of atopic eczema in children from birth up to the age of 12 years. Clinical Guideline December
2007 (NICE Eczema Full Guideline) www.nice.org.uk
Uehara M, Kimura C. Descendant family history of atopic dermatitis. Acta Derm Venereol 1993; 73:62-63

Eczema triggers
Eczema can be triggered or exacerbated by
many factors:3
Foods like cow's milk, eggs, peanuts, tree nuts,
wheat, soya, fish and shellfish
Environmental triggers, such as tree or grass
pollens and airborne mould spores
Dander and saliva of cats, dogs and other furry
pets
House dust mites that live in warm, damp places
(such as mattresses, carpets and soft furnishings)

Eczema triggers are often the same as asthma


or hay fever triggers
Stress does not cause, but may aggravate
eczema2
2. Beltrani VS, Boguneiwicz M (2003). Dermatology Online Journal, 9(2):1
3. National Collaborating Centre for Womens and Childrens Health (2007) Atopic eczema in children:
management of atopic eczema in children from birth up to the age of 12 years. Clinical Guideline December
2007 (NICE Eczema Full Guideline) www.nice.org.uk

Signs and symptoms of eczema


Presents as an itchy, red rash which
may be:
Dry, scaly and cracked
Wet and weepy

Often located on flexor surfaces:


Insides of elbows and behind knees
Extensor surfaces and cheeks may be
affected in children under 18 months

Acute cases may also present with


oedema, papules and vesicles
In chronic cases, skin may be
thickened (lichenified)

Typical sign and symptoms


Itchy rash
Weeping rash
Lichenification (skin
thickening)
May appear to be
extremely dry,
cracking skin

Ezcema
Acute
eczema/dermatitis ;
is characterized by :
pruritus, weeping
&crusting erythema;
(redness of the skin
usually with ill define
border)
vesiculation.
Chronic
eczema/dermatitis,
is characterized by : pruritus,
xerosis, lichenification;
(leathery thickened state ,with
increase skin markings)
hyperkeratosis fissuring .

Diagnostic features of AD as suggested by the AAD consensus

Course of the disease


Atopic eczema is a chronic condition characterised
by intermittent flare-ups and periods of remission
In children, the severity of symptoms can fluctuate
throughout the day
Eczema usually clears up during childhood, but
may persist into adulthood5
Children whose parents suffer from eczema are
more likely to develop it themselves6
Adults who had childhood eczema are more likely
to develop irritant contact dermatitis6
5. McHenry PM, Williams HC, Bingham EA: Fortnightly Review: Management of Atopic Eczema; BMJ
1995:310:843-847
6. Holden CA, Parish WE (1998) In: Ebling Textbook of Dermatology. Vol 1, 6th edition: Rook, Wilkinson.
p. 681-708

Consider other diagnosis


Congenital Disorders
Netherton's syndrome
Familial keratosis pilaris
Chronic Dermatoses
Seborrheic dermatitis
Contact dermatitis (allergic or irritant)
Nummular eczema
Psoriasis
Ichthyoses

Infections and Infestations

Scabies
HIV associated dermatitis
Dermatophytosis
Malignancies

Cutaneous T cell lymphoma (mycosis


fungoides/Szary syndrome)
Letterer-Siwe disease
Autoimmune Disorders

Dermatitis herpetiformis
Pemphigus foliaceus
Graft-versus-host disease
Dermatomyositis

Immunodeficiencies
Wiskott-Aldrich syndrome
Severe combined immunodeficiency
syndrome
Hyper-IgE syndrome
Metabolic Disorders
Zinc deficiency
Pyridoxine (vitamin B6) and niacin
Multiple carboxylase deficiency
Phenylketonuria

MANAGEMENT

Principle
Target for
skin care

Eczem
a

Target for
anti
inflammato
ry

Treatment Strategy in AD
Mild
Dry
skin
Emolient

Moderate

Severe

Itching and/or early sign of


inflammation

Flare

Mild to Moderate Potency Topical Steroids


Pimecrolimus
Tacrolimus
Oral Steroids
Light treatment
Cyclosporine,
mycophenolate

Long term plan


SCORA
D

REACTIVE

PROACTIVE

SUBCLINICAL INFLAMMATION

Routine Daily Care


Clip nails to decrease abrasion of skin
Shower in warm/tepid water daily 5 10
minutes
Limit use of soap if possible to areas:
genital, axillae, hand and feet
Use recommended mild soap
Pat dry: before skin is completely dry,
apply lubricant
Avoid contact to allergen or irritant

Mild or breakthrough
symptom
Continue routine daily care
Apply low to mid-potent topical
corticosteroid to rash area
Use antihistamine to relieve itch
If symptom persist: increase potency
of topical steroids

If symptom persists:
Consider superimposed infection
Exclude poor compliance and exposure
to irritants

EVIDENCE

Study of the
anti-inflammatory
activity -of Stimutex-As
+ Saccharide
Isomerate on the skin
Clotilde Verdy
Biopredic International
Rennes, France.
July, 2000

Method
To determine Interleukin 1 released
from the stripped human skin, as a
marker of the anti-inflammatory
activity of Stimutex-As + Saccharide
Isomerate.

Method
A human skin fragment was taken after
abdominal plastic surgery.
The skin was stripped and incubated 18
hours in the presence of
Control
Dexamethasone
Stimutex-As + Saccharide Isomerate

The concentration of Interleukin 1in each


medium was measured.

Results: Anti-inflammatory activity

Stimutex-As + Saccharide Isomerate shows a significant


anti-inflammatory activity when compared with control.
The anti-inflammatory activity of Stimutex-As +
Saccharide Isomerate is equivalent to Dexamethasone, a

Conclusion
Stimutex-As + Saccharide Isomerate
demonstrates anti-inflammatory
activity comparable to
dexamethasone, a moderately
potent steroid.

Moisturization with Saccharide


Isomerate

Smith W
Dermac Laboratory Inc.
Connecticut US

Method
Test creams containing 1.5% of active
ingredient were evaluated on their
moisture retention efficacy under different
relative humidity levels at 37oC.

Control
Urea
Glycerin
Saccharide Isomerate

Saccharide Isomerate: Moisture


Retention Efficacy

Saccharid
e
Isomerate

There were less moisture lost with saccharide isomerate


compared to urea and glycerin at all humidity levels.

Conclusion
Saccharide isomerate regulates and
retains moisture in the skin at all
humidity levels.
The efficacy of saccharide isomerate
has been tested and proven to be
superior to urea and glycerin.

Safety and Efficacy of StimutexAs + Saccharide Isomerate in


children under two years old with
atopic dermatitis
Zakiudin Munasir
Cipto Mangunkusumo Hospital
Faculty of Medicine University of
Indonesia
Jakarta
2008

Objective
This study was performed to
investigate the safety and efficacy of
Stimutex-As + Saccharide Isomerate
in children under two years old with
mild to moderate atopic dermatitis

Method
63 children were entered for a 28-day trial.
Ages between 0.5 to 23 months.
Mild to moderate atopic dermatitis.
Stimutex-As + Saccharide Isomerate was
applied twice a day.

Method
The severity of the disease was
measured using a dermatological
score.
Erythema;
Edema/papulation/induration;
Excoriation;
Anti-pruritus effect.

Erythema score

Erythema

Clear

p value

Baseline

25.4%

After 7 days

36.5%

After 28 days

88.9%

##

p<0.0001%
p<0.001%

Edema/papulation/induration score

Induration

Clear

p value

Baseline

30.2%

After 7 days

47.6%

After 28 days

92.6%

##

p<0.0001%
p<0.001%

Excoriation score

Excoriation

Clear

p value

Baseline

28.6%

After 7 days

69.8%

After 28 days

98.1%

##

p<0.0001%
p<0.002%

Assessment of Pruritus

Pruritus

Clear

p value

Baseline

46%

After 7 days

61.9%

After 28 days

94.3%

##

p<0.0001%
p<0.001%

Summary of the results


Parameters

Baseline

After
7 days

After
28 days

Erythema

25.4%

36.5%

88.9%

Edema/papulation/
induration

30.2%

47.6%

92.6%

Excoriation

28.6%

69.8%

98.1%

Anti-pruritus effect

46.0%

61.9%

94.3%

Safety Profile
There were no serious adverse
events reported except for 2 cases of
erythema which were treated with
topical steroids.

Conclusion
All investigation parameters significantly
improved after application of Stimutex-As
+ Saccharide Isomerate.
Stimutex-As + Saccharide Isomerate is
able to significantly alleviate the
symptoms of atopic dermatitis e.g.

Erythema;
Edema/papulation/induration;
Excoriation;
Anti-pruritus effect.

THANK YOU