Prof Ariyanto Harsono MD PhD SpA(K)

Atopic Dermatitis Update

Dermatitis atopik adalah penyakit yang mulai timbul pada usia bayi dan anak. Ditandai dengan

Gejala utama gatal-gatal pada kulit. kronis dan kambuh reaksi inflamasi berdasarkan faktor keturunan dan faktor

lingkungan, eritema kronis berulang, papula, vesikel, krusta,

dan skuama.2Prof DR Dr Ariyanto Harsono SpA(K)

Atopic Dermatitis:

Itch that erupts Not eruption that itches

3Prof DR Dr Ariyanto Harsono SpA(K)

4Prof DR Dr Ariyanto Harsono SpA(K)

Major criteria (minimal 3)

•Pruritus

•Characteristic Distribution and morphology of skin lesions

•Flexural Lichenification

•Facial and extensor Lichenification in babies and children

•Chronic

•History of family atopy

5Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

•Pruritus

•Characteristic Distribution

and morphology of skin lesions

•Flexural Lichenification

•Facial and extensor

Lichenification in babies and children

•Kronik

•History of family atopy

•Riwayat atopi dan keluarga atopi

6Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Major criteria (minimal 3)

•Pruritus

•Characteristic Distribution

and morphology of skin lesions

•Flexural Lichenification

•Facial and extensor

Lichenification in babies and

children

•Kronik

•History of family atopy7Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Major criteria (minimal 3)

•Pruritus

•Characteristic Distribution

and morphology of skin lesions

•Flexural Lichenification

•Facial dan ekstensor pada bayi

dan anak

•Kronik

•History of family atopy8Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Major criteria (minimal 3)

Kriteria Hanifin and Rajka

•Pruritus

•Characteristic Distribution

and morphology of skin lesions

•Flexural Lichenification

•Facial and extensor in babies

and children

•Chronic

•History of family atopy9Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Major criteria (minimal 3)

10Prof DR Dr Ariyanto Harsono SpA(K)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

Hanifin and Rajka criteria

Minor criteria (minimal 3)

11Prof DR Dr Ariyanto Harsono SpA(K)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

12

Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

13

Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

14Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

15Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

16Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Minor criteria (minimal 3)

17Prof DR Dr Ariyanto Harsono SpA(K)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

Hanifin and Rajka criteria

Minor criteria (minimal 3)

18

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive

•High IgE levels•Early Onset of age•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Vulnerable of infections (Stafilokokus/herpes)

19Prof DR Dr Ariyanto Harsono SpA(K)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Staphylococcus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

Hanifin and Rajka criteria

Minor criteria (minimal 3)

20Prof DR Dr Ariyanto Harsono SpA(K)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

Hanifin and Rajka criteria

Minor criteria (minimal 3)

21Prof DR Dr Ariyanto Harsono SpA(K)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

Hanifin and Rajka criteria

Minor criteria (minimal 3)

22

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections •Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

Hanifin and Rajka criteria

Minor criteria (minimal 3)

23Prof DR Dr Ariyanto Harsono SpA(K)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis

Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Tes kulit positif•Peningkatan IgE serum•Onset usia muda•Mudah infeksi kulit (Stafilokokus/herpes)•Kecenderungan nonspesific dermatitis•Nipple eczema•Cheilitis•Reccurent conjunctivitis

24Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Minor criteria (minimal 3)

Kriteria Hanifin and Rajka

25Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria

Minor criteria

Kriteria Hanifin and Rajka

26Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria

Minor criteria

27Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria

Minor criteria

28Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria

Minor criteria

29Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria

Minor criteria

Kriteria Hanifin and Rajka

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism 30Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Minor criteria

Kriteria Hanifin and Rajka

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism 31Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin and Rajka criteria

Minor criteria

Kriteria Hanifin and Rajka

32Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria

Minor criteria

Kriteria Hanifin and Rajka

33Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria

Minor criteria

Kriteria Hanifin and Rajka

34Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria

Minor criteria

Kriteria Hanifin and Rajka

35Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria

Minor criteria

Hanifin and Rajka criteria

Minor criteria

36Prof DR Dr Ariyanto Harsono SpA(K)

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism

Hanifin and Rajka criteria for baby

Kriteria mayor (minimal 2 mayor)

•History of family atopy•Evidence of pruritic Dermatitis•Dermatitis fasial, ekstensor, lichenification

Minor criteria (minimal 1 minor)

•Xerosis/ichtyosis/hyperlinear palm•Perifollicular accentuation•Chronic scalp scalling•Periauricular fissures

37Prof DR Dr Ariyanto Harsono SpA(K)

Major criteria(minimal 2 major)

Hanifin and Rajka criteria for baby

Kriteria mayor (minimal 2 mayor)

•History of family atopy•Evidence of pruritic Dermatitis•Dermatitis fasial, ekstensor, lichenification

Minor criteria (minimal 1 minor)

•Xerosis/ichtyosis/hyperlinear palm•Perifollicular accentuation•Chronic scalp scalling•Periauricular fissures

38Prof DR Dr Ariyanto Harsono SpA(K)

Major criteria(minimal 2 major)

Hanifin and Rajka criteria for baby

Kriteria mayor (minimal 2 mayor)

•History of family atopy•Evidence of pruritic Dermatitis•Dermatitis fasial, ekstensor, lichenification

Minor criteria(minimal 1 minor)

•Xerosis/ichtyosis/hyperlinear palm•Perifollicular accentuation•Chronic scalp scalling•Periauricular fissures

39Prof DR Dr Ariyanto Harsono SpA(K)

Major criteria(minimal 2 major)

Hanifin and Rajka criteria for baby

Major criteria(minimal 2 major)

•History of family atopy•Evidence of pruritic Dermatitis•Dermatitis fasial, ekstensor, lichenification

Minor criteria (minimal 1 minor)

•Xerosis/ichtyosis/hyperlinear palm•Perifollicular accentuation•Chronic scalp scalling•Periauricular fissures

40Prof DR Dr Ariyanto Harsono SpA(K)

Hanifin criteria for children

Major criteria (minimal 3 major)

•Pruritus•Characteristic Distribution and morphology of skin lesions•Dermatitis fasial, ekstensor selama bayi dan awal usia anak•Flexural lichenification dan linearity by adolescence•Chronic Dermatitis

Minor criteria(minimal 1 minor)•Xerosis/ichtyosis/hyperlinear palm/keratosis pilaris•IgE reactivity•Chronic scalp scalling•Perifollicular accentuation•Periauricular fissures 41Prof DR Dr Ariyanto Harsono SpA(K)

Minor criteria(minimal 1 minor)

•Hand/foot dermatitis•Cheilitis•Vulnerable to infection (Herpes/Strep/S aureus)

42Prof DR Dr Ariyanto Harsono SpA(K)

Minor criteria(minimal 1 minor)

•Hand/foot dermatitis•Cheilitis•Vulnerable to skin infetions (Herpes/Strep/S aureus)

43Prof DR Dr Ariyanto Harsono SpA(K)

Minor criteria(minimal 1 minor)

•Hand/foot dermatitis•Cheilitis•Vulnerable to skin infetions (Herpes/Strep/S aureus)

44Prof DR Dr Ariyanto Harsono SpA(K)

Minor criteria(minimal 1 minor)

•Hand/foot dermatitis•Cheilitis•Vulnerable to skin infetions (Herpes/Strep/staphilococcus)

45Prof DR Dr Ariyanto Harsono SpA(K)

46Prof DR Dr Ariyanto Harsono SpA(K)

Seborrhoic dermatitis

47Prof DR Dr Ariyanto Harsono SpA(K)

Pompholix

48Prof DR Dr Ariyanto Harsono SpA(K)

Dishidrosis

Penanganan Dermatitis Atopik.

Ada dua macam:

• Pengobatan konvensional

• Pengobatan inkonvensional

Prof DR Dr Ariyanto Harsono SpA(K) 49

Principle of Conventional Therapy

Eczema

Target for skin care

Target for anti inflammatory

50Prof DR Dr Ariyanto Harsono SpA(K)

Prinsip Pengobatan Konvensional:EducationEmolientAllergen/irritants avoidanceAntihistamineTopical Steroid

51Prof DR Dr Ariyanto Harsono SpA(K)

Emolient

Tidak sekedar membasahi, akan tetapi harus bisa:

Menahan airAntioksidanMemperbaiki fungsi skin barrierMelindungi fungsi skin barrierAntipruritusAntiinflamasiSteroid sparring Prof DR Dr Ariyanto Harsono SpA(K) 52

Emolient harus hipoalergenik

Tidak ada pengawetTidak ada pewangiTidak ada pewarna

Prof DR Dr Ariyanto Harsono SpA(K)

53

• Gunakan topikal steroid potensi lemah sampai sedang saja sebab steroid topikal kekuatan kuat bisa menimbulkan efek samping sistemik.

Prof DR Dr Ariyanto Harsono SpA(K) 54

Conventional Therapy is not always safe

Topical steroid: cutaneous atrophy, striae, bruisability, telangiectasia

High-potency topical steroids can cause systemic side effects in children.

55Prof DR Dr Ariyanto Harsono SpA(K)

PENGOBATAN INKONVENSIONAL.

• Prinsipnya adalah pengobatan lanjutan bila pengobatan konvensional gagal atau mengalami efek samping yang serius.

• Emolient tetap digunakan di semua lini.

• Mulai digunakan Primecrolimus atau Tacrolimus sebagai pengganti steroid topikal. Lebih aman karena anti inflamasi non steroid.

Prof DR Dr Ariyanto Harsono SpA(K) 56

Mild Moderate Severe

Mild to Moderate Potency Topical Steroids

Pimecrolimus

Tacrolimus

Oral Steroids

Cyclosporine, mycophenolate

Light treatment

New Treatment Strategy in AD

Emolient

Dry skin

Itching and/or early sign of inflammation

Flare

57Prof DR Dr Ariyanto Harsono SpA(K)

IVIG

Steroid oral dengan menggunakan prednison 1 mg/ kg BB selama 5-7 hari, tanpa tappering, atau steroid lain dengan dosis analog, memberikan efek segera akan tetapi hanya sementara. Sedapat mungkin penggunaan steroid oral dihindari karena terjadi withdrawal setelah dihentikan

Prof DR Dr Ariyanto Harsono SpA(K) 58

IVIG dengan dosis 500mg/ kgBB terbagi dalam 3 hari. Diberikan secara infus intravena dalam waktu 6-8 jam.

Prof DR Dr Ariyanto Harsono SpA(K) 59

Ciklosporin memberikan hasil pengobatan yang baik pada kasus kasus yang gagal dengan steroid topikal maupun oral. Penggunaannya terbatas karena efek samping berupa

nausea hipertrichosis, hipertensi, parasthesia, dan gangguan hati/ginjal.

Diberikan dengan dosis 2,5mg-4mg/kg/hari selama 6 minggu. Preparat tablet 25mg/tablet atau 100mg/ml 50ml sirup.

Prof DR Dr Ariyanto Harsono SpA(K) 60

Data menunjukkan Azathioprin memberikan hasil pengobatan yang baik. Diberikan dengan dosis 1-3mg/kgBB. Preparatnya tablet 50mg/tablet.

Prof DR Dr Ariyanto Harsono SpA(K) 61

Mycophenolate mofetil dengan dosis 500 mg 2X perhari. Preparat: tablet 500mg/tablet.Methotrexate dapat digunakan untuk sparing effect kortikosteroid dengan dosis 3-10 mg seminggu sekali. Preparatnya tablet 2,5 mg/tablet. Sebaiknya disertai pemberian Folic acid.

Prof DR Dr Ariyanto Harsono SpA(K) 62

Kepustakaan

1. Harsono A. Atopic Dermatitis treatment: from conventional to unconventional. http://www.slideshare.net/ariyantoharsono/atopic-dermatitis-treatment-from-conventional-to-unconventional

2. Nelson Textbook of Pedatrics.

Prof DR Dr Ariyanto Harsono SpA(K) 63

64Prof DR Dr Ariyanto Harsono SpA(K)

Thank you