atopic dermatitis treatment, from conventional to unconventional
DESCRIPTION
Definition, pathognesis,diagnosis, conventional treatment, new treatment strategyTRANSCRIPT
Atopic Dermatitis Treatment: from Conventional to Unconventional
Prof Ariyanto Harsono MD PhD SpA(K)
Atopic dermatitis is a disease that begin to arise at the age of infants and children
characterized by itching of the skin. chronic and relapsing inflammatory reaction based on hereditary factors and environmental
factors, the symptoms are chronic recurrent erythema,
papules, vesicles, crusting, and 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)
5Prof DR Dr Ariyanto Harsono SpA(K)
IgE
IL-4, IL-5IL-13
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IgE
IL-4, IL-5IL-13
v
2
CD4+Th1 Cell
IFN-
CD8+Th1 Cell
DTH
Super antigen
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Prof DR Dr Ariyanto Harsono SpA(K)
Spongious
InfiltrasiEosinofil
Udem
8Prof 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
9Prof 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
10Prof 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 atopy11Prof 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 atopy12Prof 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 atopy13Prof DR Dr Ariyanto Harsono SpA(K)
Hanifin and Rajka criteria
Major criteria (minimal 3)
14Prof 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)
15Prof 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
16
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
17
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
18Prof 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
19Prof 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
20Prof DR Dr Ariyanto Harsono SpA(K)
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)
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•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)
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 (Staphylococcus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis
Hanifin and Rajka criteria
Minor criteria (minimal 3)
24Prof 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)
25Prof 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)
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•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)
27Prof 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
28Prof DR Dr Ariyanto Harsono SpA(K)
Hanifin and Rajka criteria
Minor criteria (minimal 3)
Kriteria Hanifin and Rajka
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
30Prof 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
31Prof 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
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
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
•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 34Prof 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 35Prof DR Dr Ariyanto Harsono SpA(K)
Hanifin and Rajka criteria
Minor criteria
Kriteria Hanifin and Rajka
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
Minor criteria
Kriteria Hanifin and Rajka
37Prof 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
38Prof 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
39Prof 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
40Prof 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
41Prof 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
42Prof 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
43Prof 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
44Prof 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 45Prof DR Dr Ariyanto Harsono SpA(K)
Minor criteria(minimal 1 minor)
•Hand/foot dermatitis•Cheilitis•Vulnerable to infection (Herpes/Strep/S aureus)
46Prof DR Dr Ariyanto Harsono SpA(K)
Minor criteria(minimal 1 minor)
•Hand/foot dermatitis•Cheilitis•Vulnerable to skin infetions (Herpes/Strep/S aureus)
47Prof DR Dr Ariyanto Harsono SpA(K)
Minor criteria(minimal 1 minor)
•Hand/foot dermatitis•Cheilitis•Vulnerable to skin infetions (Herpes/Strep/S aureus)
48Prof DR Dr Ariyanto Harsono SpA(K)
Minor criteria(minimal 1 minor)
•Hand/foot dermatitis•Cheilitis•Vulnerable to skin infetions (Herpes/Strep/staphilococcus)
49Prof DR Dr Ariyanto Harsono SpA(K)
50Prof DR Dr Ariyanto Harsono SpA(K)
Seborrhoic dermatitis
51Prof DR Dr Ariyanto Harsono SpA(K)
Pompholix
52Prof DR Dr Ariyanto Harsono SpA(K)
Principle of Conventional Therapy
Eczema
Target for skin care
Target for anti inflammatory
53Prof DR Dr Ariyanto Harsono SpA(K)
EducationHidration
EmolientMoisturizerWet dressing
Allergen/irritants avoidanceAntihistamineTopical Steroid
54Prof DR Dr Ariyanto Harsono SpA(K)
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)
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
56Prof DR Dr Ariyanto Harsono SpA(K)
IVIG
Arachidonic Acid (ARA)
Phospholiphase A
Cyccloxygenase Lipoxygenase
Prostaglandine
TXA
Prostacyclin
Leukotriene A
Leukotriene B
Leukotriene C
-linoleic acid
HETE,5-HETE, PAF57Prof DR Dr Ariyanto Harsono SpA(K)
Mechanism of IVIG blocking apoptosis via Procaspase-8 pathway
Macrophage Keratinocyte
58Prof DR Dr Ariyanto Harsono SpA(K)
Use of IVIG
Prof DR Dr Ariyanto Harsono SpA(K)
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60Prof DR Dr Ariyanto Harsono SpA(K)
Thank you