Diagnosis & Management

of Atopic Dermatitis
Presenter: Dr. Sasmita Mishra
Moderator: Dr. Biswanath Behera
Diagnosis
• History & clinical examination
a) Pruritus
b) Course of disease
c) Morphology & distribution
Diagnostic criteria : Four
a) Hanifin & Rajka criteria (1980)
b) UK working party criteria( 1994)
c) AAD criteria (2003)
d) JDA criteria (2008)
Hanifin & Rajka criteria (1980)
• Major criteria: (>/3)

• Pruritus

• Typical morphology & distribution

a) Flexural involvement in adults

b) Face, extensors in infants & children

• Chronic relapsing-remitting course

• Personal /family h/o atopy ( asthma, allergic rhinitis)

Minor criteria( >/3)
• Xerosis,
• Ichthyosis
• Palmar hyper linearity
• Keratosis pilaris
• Immediate skin test reactivity
• Raised serum IgE
• Nipple eczema
• Anterior neck folds
• Cheilitis
• Recurrent conjunctivitis
• S. Aureus colonization
Cont.………
• Dennie-morgan fold
• Orbital darkening
• Perifollicular accentuation
• Keratoconus
• Anterior subcapsular cataract
• P. alba
• itch when sweat
• Intolerance to wool
• White dermographism
UK working party criteria(1994)
Mandatory Criteria An itchy skin condition (or parental report of scratching or
rubbing in a child)

Minor features (Three or • Onset < 2yrs (not used if child < 4 yrs)
more)
• H/O skin crease involvement (including cheeks in children
< 10 yrs.)
• H/O generally dry skin
• P/H/O other atopic disease (or h/o any atopic in a 1st
degree relatives in children < 4 yrs.)
• Visible flexural dermatitis (or dermatitis of cheeks/forehead
and outer limbs in children < 4 yrs.)
AAD Criteria ( 2003)
Disease severity scales
• 28 different scales identified

• commonly used:
a) SCORAD
b) EASI Clinical research & trial
c) PO- EASI
d) Severity index- Easiest
Routine practice

Ikeda M, Ohya Y, Katoh N et.al. Japanese guidelines for atopic dermatitis 2020. Allergology International 69 (2020) 356-369
Severity index

• Mild : Mild erythema, dry skin, or desquamation irrespective of BSA

• Moderate: Eruption with severe inflammation in < 10% of the BSA
• Severe: Eruption with severe inflammation 10% to <30% of the BSA.
• Most severe: Eruption with severe inflammation in >/30% of the BSA

• SCORAD- Both objective and subjective.

• EASI- Only objective.

[Ikeda M, Ohya Y, Katoh N et.al. Japanese guidelines for atopic dermatitis 2020. Allergology International 69 (2020) 356-369]
Histopathology
• Acute atopic eczema-
a) Spongiosis,
b) Perivascular infiltrates
c) Parakeratosis.
• Chronic eczema-
a) Hyperkeratosis, hypergranulosis
b) Acanthosis
c) Sparse infiltrates.
Routine skin biopsy - NOT recommended
 Investigations
• In Vivo Tests- Skin prick test (SPT), Skin scratch test, Intradermal test
• In Vitro Test (RAST)- To detect allergen-specific IgE levels
Seen in 55% cases
• Anti- Malassezia specific IgE –
almost all cases of HNAD, 28% in other cases
M. Sympodialis (54%-61%)
M. Furfur (15-29%)
• Peripheral eosinophils count- Inconsistent
• Others- IL-30,IL-31,IL-12,1L-16,TARC
no sensitivity/specificity
[Eichenfield LF, Tom WL, Chamlin SL, Feldman SR, Hanifin JM, Simpson EL, et al. Guidelines of care for the management of atopic dermatitis: Section 1.
Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol 2014;70:338-51]

[Kim TY, Jang IG, Park YM, Kim HO, Kim CW. Head and neck dermatitis: the role of Malassezia furfur, topical steroid use and environmental factors in its
causation. Clinical and Experimental Dermatology. 1999;24(3):226–231]
Cont.……
• Atopic patch test :

Sensitivity- 42%-75%

Specificity- 69-92%

• ROAT test :

To detect minimal amount of

contact allergen
[Krcmovab I, Bukacc j, Vaneckovaa J, Sensitivity and specificity of specific IgE,

skin prick test andatopy patch test in examination of food allergy,

FOOD AND AGRICULTURAL IMMUNOLOGY, 2017 VOL. 28, NO. 2, 238–247]

Treatment

• Two modes :

a)Non- pharmacological

b) Pharmacological

1) First line therapy

2) Second line therapy

3) Third line therapy

[Michael J, Tidman, Catherine HS. Atopic Eczema. In: Griffiths MD, editor. Rook’s Textbook of Dermatology, 9th ed. New Delhi: Wiley publisher; 2016]
Non-pharmacological methods
• Patient & parents education
• Avoidance of triggering factors
• Bathing , showering, wearing
• Appropriate cleanser use
• Selection of Occupation
• Avoidance of perfumes & cosmetic products
• Contact with pets
• Psychological & psychosomatic intervention

[Michael J, Tidman, Catherine HS. Atopic Eczema. In: Griffiths MD, editor.
Rook’s Textbook of Dermatology, 9th ed. New Delhi: Wiley publisher; 2016]
Pharmacological methods
• Divided into Topical therapy ( Moisturizer therapy
a) First line steroid therapy)

b) Second line - Systemic therapy

1) TCI
2) Wet-wrap therapy
3) Phototherapy

c) Third line- Immunosuppressants

Moisturizer therapy

• In form of emollient/occlusive

• As frequently as possible ( acute flare-ups)

• Twice daily (maintenance)

• 250 g/wk. (child), 500g/wk. (adults)

• Barrier ointments/bath oil/ shower gel/ emulsions

• Emollient plus therapy (Designer emollient)

Anti-inflammatory & immunosuppressants
• Topical steroid : Three ways
1) Continuous therapy (2-3wks) Acute-flares
2) Proactive therapy (16-20) Maintenance
3) Wet-wrap therapy Severe, resistant

• Monthly amount- 15 g in infants,

30 g in children
60–90 g in adolescents and adults
Cont.…….

• Usually low-medium potency

• Finger tip unit

• Tapering strategy maintained

Systemic therapy
• Oral steroid (Prednisolone)-
In resistant/ crusted dermatitis/severe flares
Started at 0.5mg/kg

• Oral antihistaminic-
Sedative 1st generation

• Antibiotics(Oral & topical)

• Antiherpetic medication if
superadded herpes infection
• Antifungals( Oral/topical)- In head & neck variant
Second line therapy
• Topical calcineurin inhibitors :
a) Tacrolimus ointment (0.03% & 0.1%)
b) Pimecrolimus cream (1%)
• M/c A/E - Tingling, burning sensation (within the first days)
Disappears within few days
• Indication: Topical steroid resistance (>/2 yrs age)
As maintainace therapy
Face, anogenital, intertriginous areas (adults)
Wet wrap therapy
• Indication: Severe AE in younger children
• Method: Two layers of tubular bandage
a)Inner - wet layer
b)Outer- Dry layer
• Low-medium potent topical steroid with
emollient before dressing
• Changed every 12 hrs
• Duration- 3 days
Phototherapy

• NB-UVB : Chronic moderate AE

Medium dose UVA1 : Severe AE

PUVA : Not 1st choice

• Limitation : Lack of adherence to frequent visits

• Improvement- by 30-50%

• Advice : Should continue routine topical therapy

Third line therapy

• Cyclosporine

• Azathioprine

• Methotrexate

• Mycophenolate mofetil

• Alitretinoin
Cyclosporine in AE

• Indication: Severe, chronic, refractory AE

• Both children & adults

• Start dose- 2.5-3.5 mg/kg/d

Maximal dose- 5mg/kg/d ( tapering- 0.5-1mg/kg/d every 2 wks)

• Improvement- 55% after 6-8wks of use

• Limitation: Rapid recurrence on discontinuation

• Maintainance: may be upto 1 yr with close monitoring

Biological therapy
• Dupilumab Approved
• Rituximab
• Omalizumab
• Mepolizumab Off-label use
• Ustekinumab
• Lebrikizumab
• Nemolizumab
• Tralokinumab Upcoming
• Tezepelumab
• Upadasatinib,Tofacitinib
• Apremilast, Crisaborole
Others

• Allergen Specific Immunotherapy (ASIT)

a) Subcutaneous immunotherapy (SCIT)

b) Sublingual immunotherapy(SLIT)
[Yang EJ, Sekhon S, Isabelle M S, et.al. Recent Developments in Atopic Dermatitis:Pediatrics.2018;142(4):e20181102]
Treatment ladder for children
Treatment ladder for adults
Thank You
Bleach bath
• bleach baths containing 0.005% dilute hypochlorite solution given for 5–10 min, 2–3 times per week
• Therapeutic role in patients with high S. aureus colonization, reduce AD severity , the need for topical corticosteroids [29],
and S. aureus density , which may contribute to AD flares or otherwise require the use of systemic antibiotics
• No statistically significant change in skin barrier function between subjects who received bleach baths and those who
received water baths. chlorine bath additives may exacerbate AD, as the water-holding capacity of the SC in atopic skin is
more sensitive to free residual chlorine exposure
• low concentration of citric acid to bath water and demonstrated improvement in EASI scores, TEWL and SC hydration, with
• no side effects other than a tingling sensation. colloidal oatmeal suspensions to baths. rice starch to bath water as a skin-
repair additive for barrier damaged skin resulted in improved barrier function.
• Balneotherapy involves bathing in natural thermal or mineral waters. . One of the most common forms of balneotherapy
involves bathing with water or salts from the Dead Sea, which has a very high salt content and is particularly rich in
magnesium. Magnesium salts bind to water, influence epidermal proliferation and differentiation, and may inhibit the
antigen-presenting capacity of Langerhans cells and thus reduce inflammation.Bathing in 5% Dead Sea salt solution
improves skin barrier function and reduces skin roughness . Previous study shows 90% cases with complete clearance of
AD after 6-8 wks. synchronous balneophototherapy- consisting of narrow-band (NB) UVB treatment and synchronous
bathing in 10% Dead Sea salt solution, is significantly more effective in treating AD than NB UVB monotherapy in chronic
AD with lichenification & pruritus. Balneotherapy with acidic hot-spring baths-. Manganese and iodide ions in acidic
conditions have bactericidal activity and, in addition, sulfur in hotspring baths may reduce degranulation of cutaneous
basophils, potentially explaining its observed therapeutic effects in AD
Cleansers
• Soap is the prototype anionic surfactant used in skin cleansers and is composed of long-chain fatty acid alkali salts with a pH between 9
and . In addition to basic soap bars, also available are glycerin bars which contain humectant-glycerin to counter the drying effects of soap,
superfatted soaps which contain increased numbers of lipids, and antibacterial soaps which contain antibacterial agents. Soaps are
considered irritants, and it is known that individuals with AD have a lower threshold for irritant dermatitis positive patch test reactions to
the surfactant cocamidopropyl betaine, which is often found in cleansers . syndets, which are often called cleansing bars- The word ‘syndet’
is a condensation of ‘synthetic’ and ‘detergent,’ referring to the binding between various detergents, or surfactants. Both bar and liquid
syndets have a slightly acidic or neutral pH, which may be preferred to other more alkaline cleansers. Syndet action occurs by reducing the
interaction between tensioactive agents and skin proteins and lipids as well as replacing lost lipids and moisturizers. They are well tolerated.
daily bathing with weekly/ twice weekly acidic syndets followed by emollient application reduced AD symptoms . ceramide cleanser and a
ceramide moisturize, urea emulsion cleanser (longer TEWL inhibition capacity)

• Am J Clin Dermatol
• Julia K. Gittler1 • Jason F. Wang1 • Seth J. Orlow1
• Hanifin and Rajka diagnostic criteria sensitivity and specificity ranged from 87.9% to 96.0% and from 77.6% to 93.8%, respectively. the Hanifin and Rajka criteria were found to have a statistical
advantage over the UK criteria, which had traded off sensitivity against simplicity: 96.0% versus 86.0% with respect to sensitivity, 93.8% versus 95.8% with respect to specificity, 97.0% versus
97.8% with respect to PPV, and 91.8% versus 76.7% with respect to NPV.
• LEE SC, Various diagnostic criteria for atopic dermatitis (AD): Aproposal of Reliable Estimation of Atopic Dermatitis in Childhood (REACH) criteria, a novel questionnaire-based diagnostic tool for
AD, Journal of Dermatology 2016; 43: 376–384
• Balneology (lat. balneum: bath) is the science that studies the healing effects of natural thermal waters, and their use in the treatment of diseases [1]. To be defined as “thermal,” a natural
occurring water requires a temperature of a minimum of 20°C when emerging from the spring and, according to German regulations, must contain a minimum amount of, at least, 1 g dissolved
minerals per liter.
• Emollients provide an occlusive barrier for AD skin, retain moisture and protect it from irritants. An ideal emollient should contain a combination of occlusive agents to
slow down water loss, humectants to increase capacity to withhold moisture and lubricants to reduce friction against skin. As well as the general moisturizing/ water-
trapping ingredients, it is common to find other herbal/animal-derived active ingredients added into commercial emollients for supposed advanced beneficial effects.
• A major issue to be clarified is why a favorable effect on AD
• emerged for dog and pet exposure but not for cat keeping. The gut
• microbial communities differ across various mammalian species.56 In particular, the fecal microbiota of dogs and cats is highly
• diverse,57 and it is likely that their skin and mucosal microbiomes
• differ as well. Thus, contact with dogs and cats can have a different effect on the risk of AD because of the diverse microbial exposures experienced by children living
with these animal species.
• In fact, changes in the (intestinal) colonization pattern during infancy have been related to the increasing allergy prevalence in
• high-income countries58 through an effect of the microflora by
• driving the maturation of the immune system.59 Increasing