Atopic Dermatitis

Dr. Maged El-Batawi, MD. Professor of Dermatology Cairo University 2004

What is atopic dermatitis?

A chronic relapsing, intensely pruritic dermatitis, with a characteristic distribution pattern, in an atopic individual.

What is atopy?
An inherited tendency to develop a hypersensitivity response (i.e. allergy) to certain environmental stimuli (i.e. allergens), in presence of a characteristic immunologic profile. A = no, topos = place Atopos = out of place or strange

Atopic Disorders
Asthma Allergic rhinitis (hay fever) Atopic dermatitis Allergic gastroenteritis Allergic conjunctivitis

Aetiology
Genetic predisposition, inherited tendency Immunologic profile Environmental triggers (allergens) Pathogenesis

Immunologic Profile in Atopy

Elevated total serum IgE (RIST) Elevated serum allergen-specific IgE
(RAST)

Frequent positive prick tests to many environmental allergens Eiosinophilia; blood and tissue, MBP

Immunologic Profile in Atopy (cont)

Biphasic Th1/Th2 reversal response:
Th2 predominance in acute and subacute lesions (early phases)
Elevated IL-4, IL-5 and IL-13 Relative anergy for eliciting allergic contact dermatitis ( Th1) Increased susceptibility to viral and fungual infections ( Th1)

Th1 responses predominate in chronic lesions (late phase)

Elevated Interferon- Reversal of DTH suppression

Environmental Trigger Factors

Inhalants
Dust mites Animal furs, dander Pollens

Microbial agents
Staph. aureus (superantigen) Candida

Climate
Extremes of temperature Dryness

Ingestants
Cows milk Nuts; peanuts, Eggs

Emotional stress

Contactants
Wool fibers Lipid solvents; soaps, detergents Chlorine in swimming pools

Pathogenesis
High PDE activity cAMP
hyperreleasibility of mast cells

Carriage of FcRI on:

FcRI gene abnormality

Mast cells immediate reaction Langerhans cells late phase reaction

Neuropeptide abnormality
Abnormal vascular responses Intense pruritus

Clinical Phases
Infantile phase Childhood phase Adolescent and adulthood phase

Infantile phase
2 months to 2 years Face, extensors Acute oozing lesions Subacute crusted lesions

Childhood phase
4 to 10 years Less acute lesions More dry subacute and lichenified lesions Flexors

Adolescent and Adult phase

Early teens to early twenties Dry lichenified hyperpigmented plaques Flexors

Infantile Eczema

Infantile Eczema

Infantile Eczema

Childhood phase

Childhood phase

Childhood phase

Lichenification

Lichenification

Adulthood AD

Adulthood AD

Other Presentations of AD
Nummular dermatitis Eyelid dermatitis Ear dermatitis; post-auricular fissures Cheilitis Nipple dermatitis Facial dermatitis Hand dermatitis Juvenile plantar dermatosis

Nummular dermatitis

Nummular dermatitis

Eyelid dermatitis

Ear lobe dermatitis

Simple Cheilitis

Angular cheilitis

Nipple dermatitis

Facial dermatitis

Hand dermatitis

Juvenile plantar dermatosis

Associated Features
Skin conditions Atopic stigmata Eye

Associated Features (1)

Cutaneous
Xerosis Ichthyosis Pityriasis alba Keratosis pilaris Reticulate pigmentation of the neck (dirty neck) Keratosis punctata palmaris et plantaris Chapping of the digits (pulpitis sicca) Periorbital milia White dermographism Cholinergic urticaria Infections; Staph. aureus, HSV (eczema herpeticum)

Pupitis sicca

Staph. Infected AD

Eczema Herpeticum

Eczema Herpeticum

Eczema Herpeticum

Eczema Herpeticum

Associated features (2)

Atopic stigmata:
Low hairline Perinasal pallor (headlight sign) Darkening of orbital skin (allergic shiners) Hertoghes sign (thinning of outer eyebrows) Dennie-Morgan fold Anterior Neck fold Hyperlinearity of the palms

Palmar hyperlinearity

Hertoghes sign

Denne-Morgan lines

Associated Features (3)

Eye complications
Cataract Keratoconus Atopic keratoconjunctivitis

Diagnosis
Clinical criteria
Major; Pruritus, Dermatitis, Atopy history Minor
Hypersensitivity to environmental factors Dry skin Dermatitis in specific areas Associated
Dermatologic conditions Stigmata Eye conditions

IgE; (RIST, RAST)

Investigations
Skin prick test Total IgE (RIST) Specific IgE (RAST) Eosinophilia; blood, lesions Th2 cytokine profile; IL-4, IL-5, IL-13 Reduced Th1 response; interferon-, DTH to
contact allergens

Skin Prick Test

Treatment
General
Avoid any possible environmental trigger factors:
cows milk, nuts, eggs, extremes of temperature and humidity, hot water showers over bathing, swimming pools, harsh soaps and detergents wools, non-absorbent or tight clothes emotional stress, anxiety

Wear absorbent comfortable clothes (cotton) Avoid dryness of the skin, use emollients Elimination diets (doubtful benefit) Breast feeding

Treatment
Topical
Wet compresses for oozing lesions:
Aluminum acetate 5% (Burows solution) 20-30 minutes, 4-6 times daily

Topical corticosteroids (problems!) Hydrating agents for dry skin:

10% urea in hydrophilic cream Eucerin cream

Tar preparations Macrolide immunomodulators:

Tacrolimus 0.3% ointment Ascomycin macrolactam derivatives (Pimecrolimus 1%)

Treatment
Systemic
Antihistamines
Sedating; hydroxyzine, doxepin,

Antistaphylococcal antibiotics
Penicillins, cephalosporins, erythromycin,

Systemic corticosteroids
Side effects! Only for acute flare-ups Phototherapy; PUVA, UVB

Cyclosporine
Side effects! Expensive Interferon-; Th1 promoter Papaverine; PDE inhibitor Evening Primrose oil; -linolenic acid, PG modulator