به نام خدا

1. به نام خدا

2. BehzadShakerian MD Childhood Atopic Dermatitis

3. How common is Atopic Eczema ? * VERY! 10-20% of children in developed countries (Harper et al,2000) * Incidence has trebled over the last 30 years (Harper et al , 2000) * Positive correlations of eczema with higher social classes and airpollution has been confirmed (Simpson, Hanifin, 2005) * 80% of children will develop eczema in 1st year * 50% of children will clear by 2 years of age * 85% of children will clear by 5 years of age * About 5% of children with eczema will continue into adulthood

4. Xerotic eczema

6. Immunological Features of Atopic Dermatitis • Increased IgE production • Specific IgE to multiple antigens • Increased basophil spontaneous histamine release • Decreased CD8 suppressor/cytotoxic number and function • Increased expression of CD 23 on mononuclear cells • macrophage activation with increased secretion of GM-CSF(IL-5), PGE2 and IL-10 • Decreased numbers of IFN-gamma-secreting from Th 1-like cells

7. Taking a good history First appointment is important in managing the eczema effectively and gain the trust of the patient and family * Family history * Coexisting atopic disease * Immunization * Allergies, tests, diet manipulation and adequacy * Growth * Previous treatments used and outcomes * Most distressing element * Sleep disturbance * Environmental aggravators, assess heat/prickle/dryness * Effect on family life, school * Parents expectations from treatment * YOUR expectation from treatment

8. STAGES of Atopic Eczema PHASES Infantile stage:( 0-2 years ) tends to start around 3-6 months.Usually affects the face, wrists,nappy area and when severe every part of the body.Often gets infected. Childhood stage:( 2-12 years )the skin starts to become dry cracked and thickened.Usually affects the elbows,back of knees,ankles and back of ears.Severe thickening of the skin is very common in Afro-Caribbeans and Asians. Adolescent and adult phase: (puberty onwards)lichenification of the skin is very prominent now.Affects the elbows,knees, neck and bottom of the eyes.

9. INVESTIGATIONS • Serum IgE levels • Skin prick tests(Allergy test) • Skin patch tests • RAST(checks to see if the body is producing antibodies against common things like house dustmite,pollens,cat and dog hair and food substances) • Skin biopsy

11. Atopic Derm Adults

12. Hand Eczema

13. Foot Eczema

14. Diagnostic criteria • Must have:Major Features • itchy skin • family history of atopy • typical picture,( facial, flexures, lichenification) • Plus three or more of the following:Minor Features • Xerosis/ichthyosis/hyper linear palms, keratosispilaris • periaricularfissures,dennie-morgan lines • chronic scalp scaling,pityriasisalba,cataract

15. Associated Findings • Pityriasis alba

16. Associated Findings • Xerosis

17. Associated Findings • KeratosisPilaris

18. Associated Findings • Ichthyosis

19. HyperlinearPalmar Creases

20. Patch Test

21. What aggravates Atopic Eczema? * Heat * Dry skin and environment * Prickle * Allergies * Irritants * Infection * Saliva * Water

22. What makes eczema hot and itchy? * Too many clothes * Hot baths >29 degrees * Too many blankets * Sport/running around * Hot cars * Heaters * Hot school classrooms

23. What makes eczema dry and itchy? * Soap, use bath oils or washes * Air blowing heaters * Swimming pools * Australia!!!! * Therefore apply moisturiser from top to toe regularly and more often when flaring

24. Selection of treatment This depends on • Disease severity • Age • Compliance • Efficacy • Safety data • Treatment costs

25. Eczema Treatments Topical Treatments Every day * avoid aggravators * moisturiser * bath oil Flaring Treatments * every day treatments + * steroid ointments * wet dressings * cool compresses * antibiotics

26. Second line treatment(severe cases): All these require specialist treatment in the Hospital. *Phototherapy(using ultraviolet rays UVA,nUVB) * Immunity suppressing drugs(e.g.oral steroids,azathioprine,ciclosporin,tacrolimus) * Diet and nutrition (food allergy) *Alternative therapies (Chinese medicine herbalism)

27. Management • Identify trigger factors • Irritants – soaps and detergents • Contact allergens • Food allergens • Inhalant allergens • Skin infections • Refer for specialist advice when necessary

28. 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

29. 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

30. Infection

31. Treating S. Aureus • Treat the AD! • Oral antibiotics • Cephalexin (50 mg/kg divided BID-TID) • Dicloxacillin • Septra, clindamycin, doxycycline if concerned about MRSA

32. Treating S. Aureus • Dilute bleach • ¼ cup household bleach in half-full bathtub once to twice weekly • Dilute bleach + intranasal mupirocin improved AD severity over 3 month study period • Swimming in chlorinated pool may have similar effect

33. Indications for referral • Immediate (same day) • if eczema herpeticum suspected • Urgent (within 2 weeks) • If severe and not responded to optimal treatment for 1 week • Treatment of bacterial infected eczema has failed

34. Indications for referral • Routine referral • Diagnosis uncertain • Eczema on face not responded • Eczema is associated with sever recurrent infections • Contact allergic eczema suspected • Causing serious social or psychological problems for child or carers • Eczema not controlled to the satisfaction of carers or child

35. THE END