Atopic Dermatitis (1 of 13) 1 Patient presents w/ skin manifestations suggestive of atopic dermatitis 2 DIAGNOSIS No ALTERNATIVE Do history & physical exam DIAGNOSIS confirm atopic dermatitis? Yes Patient suff ers from acute fl are-up Patient suff ers from disease of pruritus & inflammation persistence or frequent recurrences ACUTE FLAREUP TREATMENT MAINTENANCE TREATMENT A Non-pharmacological therapy A Non-pharmacological therapy • Patient/caregiver education • Same as acute fl are-up • Avoidance of trigger factors • Investigate precipitating factors of each fl are-up • Skin care • Phototherapy* - Bathing B Pharmacological therapy - Moisturizers/emollients Start at earliest sign of local recurrence: - Wet dressing • Calcineurin inhibitor (topical) B Pharmacological therapy or Any one of the following agents: Long-term: • Corticosteroid (topical) • Calcineurin inhibitor (topical), combined w/ • Calcineurin inhibitor (topical) • Corticosteroids (topical), intermittent use If skin infection is present: If skin infection is present: • Appropriate antibiotics, antifungals, • Antibiotics, antifungals, antivirals (oral &/or topical) antivirals (oral &/or topical) Symptomatic relief of pruritus: Symptomatic relief of pruritus: • Antihistamine (oral) • Antihistamine (oral) MIMS • • Continue Expert referral is recommended • non- Psychotherapeutic/ pharmacological psychopharmacological options therapy may be combined w/ the therapies EVALUATION listed below • Discontinue Yes No Disease A topical Non-pharmacological therapy remission (Severe • Continue therapy above corticosteroid &/ Refractory • Phototherapy or calcineurin Atopic B inhibitor Dermatitis) Pharmacological therapy • Potent corticosteroids (topical) © • Systemic corticosteroids • Systemic immunosuppressants *May be considered in patients >6 years of age w/ Scoring of Atopic Dermatitis (SCORAD) score of 25-50. Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. B22 © MIMS Pediatrics 2020 Atopic Dermatitis (2 of 13) 1 ATOPIC DERMATITIS • A familial, chronic relapsing infl ammatory skin disease characterized by intense itching, dry skin, w/ infl am- mation & exudation that commonly presents during early infancy & childhood, but can persist or start in adulthood • Also referred to as “atopic eczema” • One of the most common skin diseases affl icting both adults & children • Infant’s skin has a developing epidermal barrier & would only fully mature at least at 1st year of age thus their ATOPIC DERMATITIS ATOPIC skin absorb more water & lose excess water faster than adult skin - is skin characteristic makes them susceptible to irritation & infections Pathophysiologic Features: • Heredity (80% in monozygous twins, 20% in heterozygous twins) • Increased IgE production • Lack of skin barrier producing dry skin due to abnormalities in lipid metabolism & protein formation • Susceptibility to infections caused by Staphylococcus aureus/epidermidis & Malassezia furfur • Common causes include allergens such as food, soaps, detergents, inhalant allergens & skin infections 2 DIAGNOSIS • Diagnosis is based on patient history & physical exam • Investigate exacerbating factors - Eg aeroallergens, foods, irritating chemicals, emotional stress - Not very useful clinically Hanifi n & Rajka Criteria for Diagnosis of Atopic Dermatitis Major Criteria (must have ≥3) • Pruritus • Typical morphology & distribution • Facial & extensor involvement in infants & children • Dermatitis - chronic or chronically relapsing • Personal or family history of atopy - asthma, allergic rhinitis, atopic dermatitis Minor Criteria (must have ≥3) • Facial features: Facial pallor, facial erythema, hypopigmented patches, infraorbital darkening, infraorbital folds (Dennie-Morgan folds), cheilitis, recurrent conjunctivitis, anterior neck folds • Triggers: Foods, emotional factors, environmental factors, skin irritants • Complications: Susceptibility to cutaneous infections, impaired cell-mediated immunity, immediate skin-test reactivity, elevated IgE, keratoconus, anterior subcapsular cataracts • Others: Early age of onset, dry skin, ichthyosis, hyperlinear palms, keratosis pilaris, hand & foot dermatitis, nipple eczema, white dermatographism, perifollicular accentuation United Kingdom Working Party Diagnostic Criteria for Atopic Dermatitis • Itchy skin condition plus ≥3 of the following: - Visible fl exural dermatitis w/ involvement of skin creases or on the cheeks & extensor surfaces for infants <18 months old - Flexural involvement (eg antecubital & popliteal fossa) or on the cheeks & extensor surfaces for infants <18 months old - History of dry skin within the last 12 months - Personal history of asthma or allergic rhinitis, or atopic dermatitis in a 1st-degree relative if <4 years old - Signs & symptoms started when <2 yearsMIMS of age in patients ≥4 years old Signs & Symptoms Infants <2 years usually present w/: • Signs of infl ammation usually develop during the 3rd month of life • Patient commonly presents w/ red, scaling, dry areas - Usually found on the facial cheeks &/or chin - Lip licking may result in scaling, oozing & crusting on the lips & perioral skin, eventually leading to secondary infections - Perioral & perinasal sparing can be characteristic & patient may present w/ no lesions in these areas • Continued scratching or washing will create scaling, oozing, red plaques on cheeks - Infant may be restless or agitated during sleep • A small number© of infants may present w/ generalized eruptions - Papules, redness, scaling & lichenifi cation - Diaper area is usually not aff ected Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. B23 © MIMS Pediatrics 2020 Atopic Dermatitis (3 of 13) 2 DIAGNOSIS (CONT’D) Signs & Symptoms (Cont’d) Children 2-12 years usually present w/: • Infl ammation in the fl exural areas (eg neck, wrists, ankles, antecubital fossae) • Rash may be contained to 1 or 2 areas - May progress to involve more areas eg neck, antecubital & popliteal fossae, wrists & ankles • Papules that quickly change to plaques then lichenifi ed when scratched ATOPIC DERMATITIS ATOPIC • Constant scratching may lead to excoriations & eventual areas of hypo- or hyperpigmentation Adolescents ≥12 years usually present w/: • Resurgence of infl ammation that recurs near puberty • Pattern of infl ammation is the same as in a child 2-12 years • Dry, scaling, erythematous papules & plaques Disease Severity • A holistic approach may be applied when assessing severity of disease Severity Skin Quality of Life & Social Wellbeing Mild W/ areas of dry skin, infrequent Minimal impact on quality of life (some pruritus w/ or without areas of disturbance during the day & during sleep, mild redness changes in psychosocial wellbeing) Moderate W/ areas of dry skin, frequent Moderately aff ects quality of life including everyday pruritus, redness w/ or without activities & psychosocial wellbeing, sleep excoriation & skin thickening frequently disrupted Severe Extensive areas (>20%) of dry skin, Signifi cant disruption of quality of life; sleepless intensely pruritic, erythema w/ or nights; lost school days without excoriation & skin thickening; often complicated by persistent infections • Ocular or infectious complications may also be present in severe atopic dermatitis • May require hospitalization for severe eczema or skin infections • Severity may also be assessed using diff erent scoring methods (eg Scoring of Atopic Dermatitis [SCORAD], Eczema Area & Severity Index [EASI], Patient Oriented Eczema Measure [POEM]) A NON-PHARMACOLOGICAL THERAPY Patient/Caregiver Education • Discuss the chronic nature of atopic dermatitis, exacerbating factors & appropriate treatment options - Emphasize that atopic dermatitis tends to improve over time • Teach the patient/caregiver how to monitor disease progression & when to seek medical help • Educate the patient about good skin care practices (eg bathing, hydration & use of moisturizers) • Explain potential side eff ects of medications when used over extended periods of time - Patient/caregiver should be instructed to apply topical steroids thinly to skin lesions only & emollients over unaff ected areas MIMS • Keep fi ngernails trimmed short • Use of cotton gloves at night to limit scratching Avoidance of Trigger Factors All Irritants • Lipid solvents (soaps, detergents) - New clothes should be laundered before wearing to decrease levels of formaldehyde & other chemicals added - When washing, use liquid instead of powder detergent, & do another rinse cycle to remove detergent completely from clothes • Disinfectants (swimming pool chlorine) • Occupational irritants • Household© fl uids (meats, juices from fresh fruits) B24 © MIMS Pediatrics 2020 Atopic Dermatitis (4 of 13) A NON-PHARMACOLOGICAL THERAPY (CONT’D) Avoidance of Trigger Factors (Cont’d) Contact & Aeroallergens • Furry animals (cats, dogs) • Molds • Human dander (dandruff ) resulting in overgrowth of yeast • Dust mites ATOPIC DERMATITIS ATOPIC - Avoidance include use of dust mite-proof encasings on pillows & mattresses, washing bedding in hot water weekly remove bedroom carpeting & curtains, decrease indoor humidity level by air conditioning, avoid upholstered sofa Others • Foods - Flaring/occurrence of atopic dermatitis with a specifi c food may warrant elimination diet in patients w/ moderate-severe atopic dermatitis - Skin prick tests (SPT) & measurement of specifi c IgE are used to