Atopic dermatitis update

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)

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


Hanifin and Rajka criteria

•Pruritus

•Characteristic Distribution

and morphology of skin lesions


•Facial and extensor

Lichenification in babies and children

•Kronik

•History of family atopy

•Riwayat atopi dan keluarga atopi




•Pruritus




•Facial and extensor

Lichenification in babies and

children

•Kronik

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



•Pruritus




•Facial dan ekstensor pada bayi

dan anak

•Kronik




Kriteria Hanifin and Rajka

•Pruritus




•Facial and extensor in babies

and children

•Chronic





•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


Minor criteria (minimal 3)


12




13



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



•Vulnerable of infections (Stafilokokus/herpes)


•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



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



•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






•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


Minor criteria





Minor criteria


•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)


Minor criteria


•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)


Minor criteria





Minor criteria

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


Major criteria(minimal 2 major)




Minor criteria(minimal 1 minor)




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)


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



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



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



Seborrhoic dermatitis


Pompholix


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


Prinsip Pengobatan Konvensional:EducationEmolientAllergen/irritants avoidanceAntihistamineTopical Steroid


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.


Conventional Therapy is not always safe

Topical steroid: cutaneous atrophy, striae, bruisability, telangiectasia

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


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.


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


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


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


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.


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


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.


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.


http://www.slideshare.net/ariyantoharsono/atopic-dermatitis-treatment-from-conventional-to-unconventional




Thank you

Atopic dermatitis update

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