cursul 5 urticarie eczeme
TRANSCRIPT
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Urticarie. Eczeme
cursul 5
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Urticaria
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Urticaria: definiii
urticaria afeciune plurifactorial
afectare cutaneo-mucoas
localizat dermic sau hipodermic
caracterizat printr-o erupie urticarian angioedem (edem Quincke)
edemul masiv al esutului subcutanat
reacie anafilactic
reacie alergic acut produs prin mecanism Hsb I eritem / urticarie / angioedem, hTA, aritmii cardiace
reacie anafilactoid este similar clinic reaciei anafilactice
declanat prin mecanism ne-alergic
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Epidemiologie afeciune foarte frecvent
terenul atopic este frecvent întâlnit
20% urticarie
25% urticarie cronic
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Patogenie
eliberarea HIS i altor mediatori (proteaze,PGD2, LTC4, citokine, cresc permeabilitateacapilar i venular = leziuni urticariene
activarea mastocitului mecanism alergic (Hsb tip I)
mecanism ne-alergic
activarea receptorilor H1 cutanai = eritem, edem i prurit
H2 cutanai = eritem, edem
procesul inflamator alergic este amplificat deali mediatori (mastocit, alte celule inflamatorii)
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Clinic
erupie diseminat cu tendin la generalizare
macule, papule, plci, placarde eritematoase
leziuni edematoase, roz-palide, contur circinat
tendin la albire central sau cu halou alb
prurit intens
o leziune individual persist maxim 24 ore
manifestri sistemice: cefale, ameeli, artralgii,grea, dureri abdominale, diaree, tahicardie
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Urticarie
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Clasificare evolutiv
urticarie acut = evoluie < 6 sptmâni
urticaria cronic = evoluie > 6 sptmâni
50%
40%
9%
1%
idiopatic ICARS
medicamente alimente
35%
5%
25% 4%
4%
27%
fizic vasculitic
autoimun nealergic
infecii idiopatic
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Clasificare clinic
urticaria comun
urticaria fizic
urticaria vasculitic
urticaria de contact
angioedemul
sindroame urticariene distincte
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Urticaria comun acut
urticaria acut alergic cauze frecvente: înepturi de insecte, medicamente
(peniciline), crustacee, pete, lapte, nuci, alune,condimente
frecvent la atopici
urticaria acut ne-alergic (intolerana) severitatea leziunilor proporional cu cantitatea de
antigen
cauze frecvente: medicamente (AINS, morfin,codein), substane de contrast, anestezice locale,alimente (brânz, pete, carne, roii, ananas), VHB, VEB
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Urticaria comun cronic cauze frecvente
medicamente (penicilina, AINS, implanturi / proteze dentare)
alimente (tartrazina, colorani din grupul azo)
conservani (benzoat, aspartat)
infecii (Helicobacter pylori, Candida albicans, parazii)
afeciuni sistemice (colagenoze, afeciuni tiroidiene)
factori psihici
urticaria cronic idiopatic diagnostic de exludere
component autoimun
autoAc anti receptori IgE
autoAc anti IgE
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Urticarii fizice sunt produse de stimuli de natur fizic
exemple:
dermografismul urticaria la presiune
urticaria produs de vibraii
urticaria la cldur
urticaira colinergic (asociat cu transpiraia)
urticaria la frig
urticaria solar
urticaria acuagenic
etc.
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Urticaria vasculitic
leziunile urticariene dar leziunile individualepersist peste 24 ore
leziuni purpurice, dureroase, hiperpigmentarerezidual
sistemic sunt prezente artralgii, febr, dureriabdominale, nefrit, obstrucie nazal
HP: reacie inflamatorie perivenular
mecanism de hipersensibilitate de tip III
cauze frecvente lupusul eritematos sistemic
infecii (VH B, VH C, V E-B, Borrelia burgdorferi)
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Urticaria de contact form rar de urticarie.
localizare: mâini, peri-bucal
cauze produse animale (saliv, scuame, pr/lân/mtase)
alimente (fructe de mare, legume, nuci, alune, ou)
plante (urzici, cactui)
produse industriale (lac de unghii, fixativ pr,
lanolina, penicilina, cauciuc)
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Angioedemul
form sever de urticarie ce afecteaz esutulsubcutanat
mecanism de Hsb tip I dar nu numai...
angioedem ereditar (transmis AD) determinatde deficitul de inhibitor de C1 esteraz
localizare: fa (buze, pleoape), genital,
laringian simptomatologia este minim
uneori debut tardiv: 3 sptmâni pentruinhibitori ai enzimei de conversie
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Angioedemul
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Urticaria acut - tratament îndeprtarea agentului etiologic
de elecie: anti H1 nesedative
cazuri severe de urticarie: corticoterapia în cure de scurt durat
edem laringian / afectare respiratorie:
0,2 - 0,4 mL adrenalin 1 urticaria de debut recent (<24 ore) seinterneaz
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Urticaria cronic - tratament reprezint o provocare pentru orice medic
anamnez amnunit ( = cheia succesului)
prima linie terapeutic: anti H1 ne-sedative AERIUS este singurul care a dovedit aciune
eficient în reducerea pruritului i leziunilorurticariene
corticoterapia este indicat numai în cazurilede urticarie cronic acutizat, sever.
terapii alternative: colchicin, plasmaferez,dapson, ciclosporin, androgeni sintetici,
terapie cu ultraviolete etc.
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anti H1 generaia I (clasice) clorfeniramina, ciproheptadina, hidroxizina
efect anti-H1 puternic
strbat bariera hemato-encefalic: sedare,activitate anticolinergic (cresc apetitul),ameeal, tinitus, diplopie, necoordoneareamicrilor, efect antiemetic, disurie, impoten.
debut de aciune este la 1-2 ore de la administrare
efectul se menine 4-6 ore
citocromului P 450.
reacii adverse amplificate de alcool, diazepam
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anti H1 generaia II (moderne) efect anti-H1 fr sedare
exemple: loratadina, desloratadina,
cetirizina, fexofenadina reacii adverse: alungirea intervalului
electrocardiografic Q-T (tulburri deritm severe: torsada vârfurilor)
citocromul P 450
interacionâneaz cu alte medicamente(eritromicina, ketoconazolul, ranitidina,
sucul de grepfruit sau portocale)
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G I
G II
siguran
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G I
G II
siguran
A
AERIUS
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Eczeme-dermatite
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D
efiniie eczema este o reacie inflamatorie
cutanat caracterizat clinic prin
eritem papulo-vezicule
descuamare
cruste
prurit
eczem = dermatit
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Clasificare evolutiv
Eczem acut (durat ore - zile)
durere, arsur, îneptur
plac delimitat imprecis, intens veziculat
HP: edem, spongioz Eczem subacut (durat zile - sptmâni)
prurit
plac delimitat imprecis, scuame
HP: spongioz redus, infiltrat minim
Eczem cronic (durat sptmâni - luni)
prurit
plci bine delimitate, lichenificare
HP: acantoz, hiperkeratoz, infiltrat inflamator
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DC clasificare evolutiv
eczem acut
eczem subacut
eczem cronic
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Dermatita de contact iritativ
dermatit generat de aciunea direct a uneisubstane (iritante) la nivel cutanat
mecanism direct, chimic se manifest
la toate persoanele
de la primul contact cu iritantul
la nivelul zonelor de contact cu iritantul
la scurt timp de la contact (4 - 10 ore)
cu intensitate direct proporional cu concentraia itimpul de expunere la iritant
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DCI
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Dermatita de contact alergic
dermatit aprut la anumite persoane alecror tegumente, sensibilizate în prealabil,
reacioneaz exagerat la un nou contact cualergenul
mecanism de hipersensibilitate mediat celular
(tip IV) faza aferent (de inducie) (dureaz 10 zile)
faza eferent (revelatoare)(imediat dup contact)
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DCA - manifestare
de la al doilea contact cu alergenul
dup perioada de inducie
la nivelul zonelor de contact cu alergenul dar ila distan de contact
cu intensitate maxim indiferent de cantitatea alergenului
concentraia alergenului
timpul de expunere la alergen
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DCA
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Eczema seboreic
eczem cronic ce afecteaz zonele bogate înglande sebacee (scalp, fa i torace superior)
mtreaa (descuamarea vizibil a scalpului)este un semn de debut al dermatitei seboreice
etiologie posibil micotic prin Malassezia ovale
clinic: plci eritematoase, net delimitate,acoperite de scuame grase, glbui
forme evolutive eczema seboreic la nou-nscut (scalp, trunchi...)
eczema seboreic la adult (scalp, fa, trunchi)
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Eczema seboreic
episoade ritmate destress
manifestri clinice ievoluie modificate încazul asocierii cu atopia
psoriazisul
(sebopsoriazis)
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Eczema seboreic
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Eczema dishidrozic (pompholyx)
form de eczem care afecteaz palmele iplantele, caracterizat prin vezicule/bule.
factori declanatori: iritani, neomicina, focarmicotic sau microbian, stress-ul
manifestri clinice frecvent între 10 - 40 de ani
vezicule i bule cu coninut clar, neînsoite de
fenomene inflamatorii, localizate simetric pe feelelaterale ale degetelor
leziunile sunt pruriginoase
evoluia este recurent.
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Eczemadishidrozic(pompholyx)
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Eczema asteatotic
asociat cu scderea lipidelor tegumentare desuprafa
factorii implicai: vârsta, boli consumptive,
malnutriia, declin hormonal, solveni,detergeni, clim uscat sau vântoas, diuretice,defictul de zinc, cimetidina
manifestri clinice
localizare: picioare, brae i mâini tegumentul este uscat, eritematos i acoperit de
scuame mari, ihtioziforme
leziunile sunt pruriginoase
epidermul are tendina de a fisura
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Eczema asteatotic
termeni sinonimi
eczema fisurar
eczema craquelé
evolueaz cronic, ondulant
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Eczema numular
plci rotund-ovalare bine delimitate
etiologie: infecii, traumatisme, ageni chimici,xeroza cutanat
clinic: plci numulare, eritematoase, binedelimitate, de dimensiuni diferite, ce se extindperiferic (tendin la vindecare central)
unice sau multiple
localizare: membre, trunchi evoluie fluctuant, cu tendin la cronicizare
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Eczemanumular
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Tratament
msuri generale îmbrcminte din fibre naturale (bumbac, mtase)
evitare iritante / alergizante de contact
depistare i tratare focare de infecie
igien adecvat
tratament de fond dermatocorticoizi
tratament de atac (7 zile) tratament de întreinere
antihistaminice anti-H1
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Tratament adaptat formei clinice
forme cronice keratolitice
DCT aplicai ocluziv
forme suprainfectate antimicrobiene
forme recalcitrante
corticoterapie sistemic fototerapie (UVA, PUVA)
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Algoritm de
diagnostic itratament
-exclusiv medic specialistdermato-venerolog
DERMATITA DE CONTACT
anamnez, examen clinic, examen paraclinic
DCI DCA
msuri generale
tratament de atac
tratament de întreinere
form rezistent la tratament remisiune
corticoterapie sistemic
remisiune
reevaluare pacient intr-o clinic de specialitate
form rezistent la tratament
tratament: dermatocorticoizi clasa III*
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Dermatita atopic
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Dermatita atopic (D A)
afeciune cutanat frecvent întâlnit
evolueaz cu manifestri inflamatorii cutanateacute (copii) sau cronice (aduli)
se asociaz cu xeroz i diatez atopic (rinit
alergic, astm bronic)
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Dermatita atopic
inciden în continu cretere frecven crescut în rile dezvoltate economic
20% copii în Europa Occidental
15% dintre copiii cu D A au afectare sever
asociere cu afeciuni alergice (SIAS)
debut în copilrie (85% sub 5 ani; 55% sub 1 an)
calitatea vieii este afectat sever mai sever decât psoriazisul cutanat
egal cu diabetul zaharat
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Epidemiologie
factori ambientali responsabili
factori climatici
urbanizare teoria igienei (igien = D A ) împreun cu
teoria junglei
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Patogenie
mecanism genetic
mecanism imunologic
alterarea funciei de barier cutanat
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Mecanism genetic
73% din pacieni au istoric familial de atopie
27% din pacieni au istoric familial de D A
risc de D A mam copil
între frai, surori
modificri cromozomiale
5q31 (gena pentru IL-4) 11q13 (receptorul pentru IgE)
nu exist un marker genetic unic pentru D A
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Mecanism imunologic
AD asociaz
alergie la polen, parazii, pr de animale, alimente
suprainfecie cutanat cu Stafilococ auriu mecanism imunologic mediat celular
celule Langerhans (activare aberant LT)
monocite / macrofage (activare Th2)
limfocite T faz acut predomin Th2 activare LB IgE
faz cronic predomin Th1 IFNK inflamaie
eozinofile, mastocite, bazofile, keratinocite
amplific i întrein procesul inflamator
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celule T în tegumentul D A
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D A - stadiu acut
auto-antigen alergen superantigen
cL
TcL
Mo
Th2 L B
IL-4
IL-13
IgE
Y Y Y Y Y
Y Y
Y
Y Y
Y Y
Y
Y Y Y Y Y
K
EoBz
Mc
DA
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D A - stadiu cronic
auto-antigen alergen superantigen
cL
TcL
Mo
Th1
IFNK
K
Eo
DA
Eo KK
K KKKKK
K
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Alterarea funciei de barier
cutanat
hidratarea cutanat asigurat de ceramide
tegumentele uscate ale atopicilor activitate a sfingomielin-deaciclazei
deficit de ceramide
tegumentul uscat este expus iritanilor
alergenilor microbilor
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diagnosticul D A este susinut de anamnez
examen clinic
forme evolutive ale D A form acut (prurit, papule, vezicule)
form subacut (plci, scuame, escoriaii)
form cronic (lichenificare, prurigo nodular,leucomelanodermie)
D A: aspecte clinice
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D A infantil D A la copil D A la adult
placarde eczematiforme
eritem
edem
vezicule zemuire
localizare:
obraji
menton
frunte
alte teritorii cutanate respect regiuneacentrofacial
uneori aspect de eczemnumular cu localizare pemembre, trunchi
erupie cronic
placarde lichenificateintens pruriginoase
localizare:
feele de flexie alemembrelor (plici)
glezne
retroauricular
polimorfism lezional marcat
placarde de eczem custadiile cunoscute
placarde de lichenificare leziuni de grataj
erupie papulo-veziculoas(prurigo tipic)
piele uscat i aspr
localizare:
simetric, în zonelepredilecte(retroauricular, plici)
Clinca D A
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D A infantil
D A la copil
D.A.
D A la adult
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Manifestri clinice
prurit simptom cardinal în diagnosticul D A
gratajul permite suprainfecia
xeroza (78 - 98 % din cazuri)
keratoz pilar
pliu Dennie-Morgan
hiperliniaritate palmo-plantar
pityriazis alba
cheilit
lichen simplex chronicus
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Manifestri clinice
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D A - asocieri morbide,complicaii
Afeciuni asociate astm bronic 30%
rinit alergic 30%
cataract 10%
ihtioz vulgar 5%
alopecia areata 1%
Complicaii ale D A eczema vaccinatum
eczema herpeticum
erupia
variceliform Kaposi
D A infectat bacterian
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D A - criterii de diagnostic
criteriile Hanifin i Rajka (1980) aplicare dificil în practic
criterii nevalidate statistic
criteriile Grupului Britanic de studiu al D A (1994) validate de studii statistice
criteriile Mileniului pentru diagnosticul D A (1998) orientate investigaional (IgE)
criteriile AAD
(2002) criterii eseniale
criterii importante
criterii asociate
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Criteriile Grupului britanic
de studiu al D A
criteriu major (obligatoriu) afeciune cutanat pruriginoas
criterii minore (3 criterii necesare) debut sub vârsta de 2 ani (pentru copii > 4 ani)
istoric de leziuni flexurale (obrajii la copii < 10 ani)
istoric de xeroz cutanat generalizat APP, AHC ce cuprind alte boli atopice
dermatit flexural manifest (a obrajilor la copiii < 4 ani)
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Criteriile AAD
criterii eseniale (trebuie s fie prezente)
prurit
modificri eczematoase (tipice grupelor de vârst)
criterii importante (sprijin diagnosticul) debut din copilrie
atopie (IgE crescut)
xeroz
criterii asociate (sugereaz diagnosticul)
keratoz pilar / hiperliniaritate cutanat / ihtioz
lichenificare / prurigo
leziuni oculare / perioculare i orale / periorale
rspuns vascular atipic
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Diagnostic paraclinic
biopsie cutanat (examen histopatologic)
confirmarea terenului atopic IgE seric total IgE alergen specifice
examen bacteriologic, examen micologic
DA extrinsec
IgE total alergie respiratorie prezent
DA intrinsec
IgE total normal alergie respiratorie absent
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Evaluarea pacienilor cu D A
SCORAD - (1993) intensitatea a 6 semne iextinderea leziunilor în suprafa
EASI - (1998) Eczema Area and Severity Index
EASI revizuit - (2001) EASI dup PASI
IG A - (2003) Investigator's Global Assessment
scoruri pentru evaluarea calitii vieii pacientului cu DA(EDI, CDLQI, CADI)
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SCORAD
suprafee adaptatevârstei
recomandat pentrumonitorizareaafeciunii la copii
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EASI
proporiile pentru regiunile topografice (p)cap gât trunchi m. sup. m. inf.
copii < 7 ani 20% 20% 30% 20% 30%
copii > 7 ani 10% 10% 30% 20% 40%
evaluare clinic pentru simptomefr leziuni discrete leziuni moderate leziuni severe
eritem 0 1 2 3
infiltraie 0 1 2 3
escoriaie 0 1 2 3
lichenificare 0 1 2 3
EASI = 7 [p(Er + I + Es + L)] cap, gât, trunchi, m sup, m inf.
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D A: opiuni terapeutice
emoliente (p piele uscat)
corticosteroizi topici (= terapia principal)
imunomodulatoare
inhibitori de calcineurin (Elidel - pimecrolimus) ciclosporin
alte tratamente
antihistaminice
fototerapie antibiotice
corticosteroizi sistemici
igien (vaccin, probiotice )
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S E
V E R I T A T E A
B O L I I
T R A T A M E N T
xeroz puseuevolutiv
prurit i / sau semneprecoce de inflamaie
emoliente
D A: strategia terapeutic
DCTElidel
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Limitele opiunilor terapeutice
dermatocorticoizii sunt adesea folosii tardiv
dermatocorticoizii sunt adesea folosii greit
perioad îndelungat putere neadaptat formei clinice de D A
copiii sunt adesea tratai insuficient datorit
temerilor pe care le au prinii/medicii fa de
efectele adverse/potenialul toxic al DCT
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reevaluare pacient in clinic de specialitate
form rezistent la tratament
DERMATITA ATOPIC
msuri generale
tratament de atac
tratament de întreinere
fototerapie, dermatocorticoid clasa IV, corticoterapie sistemic, micofenolat mofetil,
ciclosporin, metotrexat
- exclusiv medic specialistdermato-venerolog
remisiuneform rezistent la
tratament
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Ghid de administrare a DCT
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DCT
cea mai prescris terapie dermatologic
aciune antiinflamatorie, antimitotic
molecul similar cortizolului CSR
avantaje incontestabile: eficacitate înalt
rezultate observate în timp scurt
gam variat, adaptabil afeciunii administrare comod
experien bogat (+50 de ani)
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Clasificare DCT
Clasa I Dermatocorticoizi cu poten sczuthidrocortizon acetat 1%
Clasa II Dermatocorticoizi cu poten medieflumetazon pivalat 0,03%
triamcinolon acetonid 0,025%
Clasa III Dermatocorticoizi potenihidrocortizon butirat 0,1%
metilprednisolon aceponat 0,1%
fluocinolon acetonid 0,025%
mometazona furoat 0,1%fluticazon propionat 0,05%
betametazon dipropionat 0,05%
Clasa IV Dermatocorticoizi superpotenihalcinonid 0,1%
clobetazol propionat 0,05%
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Clasa I Dermatocorticoizi cu poten sczut afeciuni cu inflamaie redus
tratament de întreinere al dermatitelor cronice
aplicaii pe zone sensibile sau foarte extinse
Clasa IID
ermatocorticoizi cu poten medie DCT cu molecul fluorurat
Clasa III Dermatocorticoizi poteni majoritatea dermatozelor inflamatorii
se recomand alegerea preparatelor fr fluor in molecul
Clasa IV Dermatocorticoizi superpoteni dermatoze severe
perioade scurte de timp (maxim 10 zile)
terapia se continu cu DCT cls.III nefluorurai
pacienii trebuie informai asupra riscurilor aplicrii abuzive
Clasificare DCT
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Clasa III*
mometazona furoat (1987) molecul nehalogenat, mono-esterificat
metilprednisolon aceponat (1992) molecul nehalogenat, dublu esterificat
activat prin de-esterificare local
ne-indicat în psoriazis (eficien redus)
fluticazon propionat (1991) molecul fluorurat
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Clasificare D
CT
reacii adverse
poten
ELOCOM
MPA
FP
CP
FDP
HBT A
HA
+
+
Poziionare DCT
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Ghid de administrare a DCT
alegerea vehiculului
unguent / crem / loiune
determinarea tipului leziunii acute / subacute / cronice
determinarea tipului de tegumente afectate
subiri / groase
tegumente sensibile: pliuri, fa, genital alegerea potenei DCT
alegerea duratei i secvenialitii tratamentului
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Administrarea DCT (FTU)
25% din doz pentru copil sub 1 an
33% din doz pentru copil sub 4 ani
regiunea (adult) doza maxim/spt. FTU
fa i gât 15-30 g/spt. 3-6 FTU / aplic
mâinile 15-30 g/spt. 3-6 FTU / aplicscalp 15-30 g/spt. 3-6 FTU / aplicmembre superioare 30-60 g/spt. 6-12 FTU / aplicmembre inferioare 100 g / spt. 20 FTU / aplictrunchi 100 g / spt. 20 FTU / aplicinghinal + genital 15-30 g/spt. 3-6 FTU / aplic
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Absorbia cutanat a DCT
DCT se absorb diferit: poten, vehicul
absorbia DCT variaz cu topografia (DCT III) antebra 1%
plica cotului 4%
faa 7%
pleoape, genital 30%
palme 0,1%
plante 0,05% 40 g crem clobetazol propionat 0,05% aplicat pe
tegumente zemuinde <=> 60 mg Prednison p.o.
N Engl J Med, Vol. 347, No. 2, July 11, 2002, 143-4
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Atenie special
scutecele mresc absorbia DCT
periocular nu se administreaz la persoane cuglaucom sau cataract
tegumentele acoperite (pliuri, sâni, genital) sedezinfecteaz înainte de aplicarea DCT
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DCT: reacii adverse cutanate
atrofie cutanat, vergeturi
echimoze, capilarit purpuric
dermatit perioral telangiectazii
comedoane
suprainfecie cutanat bacterian cu germeni agresivi
tinea incognito
viroze
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DCT: reacii adverse cutanate
peteii
atrofie
telangiectazii
vergeturi
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DCT: reacii adverse sistemice
supresia suprarenalelor survine la o dozsptmânal de:
50 g clobetazol propionat 500 g hidrocortizon acetat
sindromul Cushing
(retenie hidric, HTA, diabet zaharat,
obezitate central, vergeturi, impoten,
osteoporoz, depresie, hiperlipidemie)
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Alergia la DCT
4% din dermatitele de contact suntdatorate DCT
sensibilizanii DCT conservani, stabilizatori
(parabeni, lanolin, etilen- diamin)
antibacteriene (neomicin, clioquinol)
molecula cortizonicului(hidrocortizon, clobetazol)
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Capcane terapeutice
rozacee
dermatit perioral
ulcer de gamb
lupus discoid stabilizat
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Lipsa rspunsului terapeutic
infecie cutanat(viral, bacterian, fungic, parazitar)
diagnostic incorect(boal Paget, micosis fungoides)
DCT ales incorect poten
vehicul zon topografic
complian sczut
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Etape în selecia DCT
Alegerea vehiculului unguent
crem
loiune
Determinarea tipului leziunii acute, tegumente subiri
cronice, tegumente groase Determinarea tipului de
tegumente afectate tegumentle sensibile pliuri, fa
necesit administrare de DCT cuprofil de siguran ridicat Cls. IIInefluorurai
tegumente cu pr
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DCT
efect antiinflamator puternic
tratament preferenial în DC, D A, PSO
administrare în funcie de molecula DCT
poten
vehicul
reacii adverse cutanate
DCT de nou generaie