SKIN

ALLERGY Dr. Grace NS Wardhana, SpKK

ALLERGY ??

Allergic reaction:

- Vary from mild to harmful

- The tendency to develop allergies

is often hereditary

Common Allergens:

- Airborne allergens:

house dust mites, pollen (from weeds, grass &

trees), molds, pets, cockroach

- Food allergens:

cow’s milk, eggs, seafood, peanut and tree nut,

soy, wheat

- Other allergens: insect stings, medicines, chemicals

Signs & Symptoms of Allergy:

- Vary from allergy to allergy and

child to child

- Skin rash, itchy eyes, itchy & runny

nose, sneezing, coughing, nasal

congestion, throat tightness,

difficulty breathing, and even shock

(faintness or passing out)

ALLERGIC SKIN CONDITION

- URTICARIA (HIVES)

- ALLERGIC CONTACT DERMATITIS

- ATOPIC ECZEMA (ATOPIC DERMATITIS)

- INSECT STING ALLERGY

- DRUG ALLERGY

URTICARIA (HIVES)

… urticaria

- Red raised bumps or welts on the skin

- Can occur anywhere on the body

- ≤ 6 weeks: acute urticaria

≥ 6 weeks: chronic urticaria

- In some cases: accompanied by Angioedema (swelling in the deeper layers of the skin)

… urticaria

Common allergens:

food

medicines

climate changes

pets/animals

pollen

insect bites and stings

infections

stress

exposure to the sun

physical stimuli: pressure, cold, heat

… urticaria

- 15-25% of population: 1x urticaria

- Treatment:

mild: won’t require treatment

avoidance of the trigger

antihistamine

skin test

Allergic Contact Dermatitis

- Skin comes in direct contact

with an allergen

- For instance: nickel, tatoo ink,

cosmetics, diapers, etc

… allergic contact dermatitis

… allergic contact dermatitis

Atopic Eczema

(Atopic Dermatitis)

Eczema (dermatitis):

- a skin condition caused by

inflammation of the skin

- typically: itchy, red, dry, even

cracked

- can appear on any part of the body

- it’s not contagious

- it’s not allergy itself, but allergies can

trigger eczema

…atopic eczema (atopic dermatitis)

Atopic Dermatitis (AD):

- the most common of the many

types of eczema

- “Atopic”: describes condition that

occur when someone is overly sensitive to

allergens in their environment

asthma, allergic rhinitis, AD

- common skin condition

- 15-30% children, 10-20% adults

- incidence has increase 2-3 fold in the last

30 yrs, possibly due to environmental and

lifestyle changes

…atopic eczema

…atopic eczema (atopic dermatitis)

- AD in children:

47,6% in their first year

30% between ages 1-5

- The most children outgrow the

condition, more recent studies:

many continue to have relapses

as teenagers and adults.

…atopic eczema

The cause:

interaction between

- environment

- immune system

- skin barrier dysfunction

- genetic (heredity)

…atopic eczema (atopic dermatitis)

Genetic factor:

- Atopic history (asthma, AD, allergic rhinitis)

from both parents: 50-75 %

from one of the parents: 30-50%

- An infant who has parent or sibling with AD, asthma or RA has a 60-80% chance of developing AD

- 80% of children with AD develop asthma or

allergic rhinitis later in childhood

Skin barrier dysfunction in AD

Role of Food Allergen in AD

Atopic dermatitis and food allergy are co-associated, but food allergy does not cause atopic dermatitis

Foods may trigger exacerbations of atopic dermatitis

Food allergy is more likely to play a role in atopic dermatitis in infants and young children with severe disease

Role of Food Allergen in AD

Foods should not be removed from the diet of a child with AD without determining a specific clinical outcome and a clear plan for reintroduction

Foods should be re-introduced within 3–4 weeks of removal from the diet if no clinical effect has been observed

An open food challenge is the most appropriate way to identify food as a trigger for problematic atopic dermatitis

SIGNS & SYMPTOMS of ATOPIC DERMATITIS

- The main symptoms: ITCHING

- The itching can be severe and persistent, especially at night.

Scratching the affected area causes a rash. The rash is red and patchy, and may be long-lasting (chronic) or come and go (recurring)

…atopic eczema (atopic dermatitis)

The usual location of the rash:

INFANT (ages 2 months – 2 years:

- face - neck

- scalp - arms

- leg - trunks

Atopic Dermatitis

in INFANT (2 months – 2 years)

Atopic Dermatitis

in INFANT (2 months – 2 years)

Atopic Dermatitis

in INFANT (2 months – 2 years)

The rash is often crusted or oozes fluid

Atopic Dermatitis

in INFANT (2 months – 2 years)

…atopic eczema (atopic dermatitis)

..the usual location of the rash:

CHILDREN (ages 2 – 12 years) :

- In areas that bend: inside of the elbows, back of the knee

- Wrist

- Neck

- Arms & legs

May appear for the first time or may be a continuitation of the infant phase

Atopic Dermatitis

in CHILDREN (2 – 12 years)

Atopic Dermatitis

in CHILDREN (2 - 12 years)

Rubbing and scratching can

lead to infection

Atopic Dermatitis

in CHILDREN (2 - 12 years)

Atopic Dermatitis

in CHILDREN (2 - 12 years)

Atopic Dermatitis

in CHILDREN (2 - 12 years)

…atopic eczema (atopic dermatitis)

..the usual location of the rash:

ADOLESCENT & ADULTS:

- In areas that bend: inside of the elbows, back of the knee

- Neck

- Face

- Arms & legs

- Wrist

Adult-onset AD is rare, occurring in 9% to 14% of cases

Often improves as someone get older

Atopic Dermatitis

in INFANT (2 months – 2 years)

…atopic eczema (atopic dermatitis)

Skin diseases that mimic Atopic Dermatitis:

- Seborrhoic eczema

- Miliaria (prickly heat)

Seborrhoic Eczema:

skin has yellowish, oily, scaly patches on the scalp, face, and sometimes other parts of the body.

…skin disease that mimic AD

Cradle cap

Miliaria (prickly heat) Miliaria is a rash that

develops in some people

when they sweat more

than usual. The rash is also

sometimes called a sweat

rash. It is not usually serious,

but it can be itchy and

uncomfortable.

Miliaria is due to blockage

of sweat ducts.

…skin disease that mimic AD

Skin conditions associated with AD:

Dry skin (xerosis): - due to skin barrier dysfunction

- lack of ceramide

- dry skin is sensitive, easily

irrtitated, and itchy

Keratosis Pilaris: - Rough bumps appear on the

skin, mainly on the back and

outer side of the upper arms.

- May also appear on the thighs

and buttocks

Skin conditions associated with AD:

Pityriasis alba: - Slightly scaly, round or oval, slightly

white patches on the skin.

- More apparent in summer / after

swimming

- Esp. in darker skinned children

- Incidence in AD children: 30-40%

Atopic pleat or Dennie-

Morgan fold: - Reported in 60-8-0% patients

- Extra line on the lower eyelid

- A distingusihing feature of AD or

caused by rubbing the eye

Skin conditions associated with AD:

Cheilitis: - Inflammation of the lips

- Cracks and scales on the lips

Hyperlinear palmar : - Many skin creases (lines) in the

palms

Skin conditions associated with AD:

Hand and Feet Eczema - Eczema that affect the palms and

the soles

- May develop tiny bubbles

(vesicles) which are intensely itchy

Periorbital eczema:

- Eczema around the eyes

- Commonly caused and

aggravated by rubbing and

scratching around the eyes

Skin conditions associated with AD:

Skin infection AD patients are more predisposed to develop skin

infection. They are susceptible

to bacterial, viral and fungal

infection

…atopic eczema

Treatment:

Avoiding dry skin

One study has show that emollients may reduce

the need for topical steroids by about 62%

- No single emollient shown to superior

- Not all of types emollients suit all people

- The best emollient is one which the patient prefers because then they will use it more frequently.

- Patients have a preference for one over the other based on lifestyle, cosmetic acceptability, personal choice, adverse reactions and cost

- Cost is a major issue. Wide range of prices.

Choosing the right emollient

Ceramide rich emollient more

effective in blocking TEWL.

Important to use ointments or thick

creams containing high lipid

content rather than watery ones.

Choosing the right emollient

Use very liberally Explain that you cannot “overdose” as

emollients do not contain any “active” drug

Adults should expect to use about 1 x

500 g tub each week a child 1 x 500 g every 2 weeks

Quantities of Emollient applied

Many times a day, 3 mins after

bathing

Avoid rubbing in (this causes irritation)

Use light downward strokes to apply

Should leave a thin film on skin surface

Method of application

…atopic eczema

…treatment:

- Avoiding irritants

- Avoid excessive scrubbing &

toweling

- Avoid possible allergens

- Controlling itching & scratching

- Avoid becoming overheated

Avoid:

- Sodium lauryl sulphate (SLS)

- Methylparaben & propylparaben

- Propylene glycol stearate

- Sulfur

- Povidon iodine

- Heksaklorofen

- klorheksidin

…atopic eczema (atopic dermatitis)

Medicines:

- Topical corticosteroids

- Calcineurin inhibitors

- Antihistamines

- Oral corticosteroids

- Cyclosporine

- Interferon

- Antibiotik / antiviral / antifungal if there

is secondary infection

…atopic eczema (atopic dermatitis)

Topical corticosteroids

- First line treatment

and very effective

- Using Finger Tip Unit (FTU)

1 FTU = 0,5 g of cream

For a 3-6 month old child

Entire face and neck – 1 FTU

An entire arm and hand – 1 FTU

An entire leg and foot – 1.5 FTUs

The entire front of chest and abdomen – 1

FTU

The entire back including buttocks – 1.5 FTUs

For a 1-2 year old child

Entire face and neck – 1.5 FTUs

An entire arm and hand – 1.5 FTUs

An entire leg and foot – 2 FTUs

The entire front of chest and abdomen – 2

FTUs

The entire back including buttocks – 3 FTUs

…atopic eczema (atopic dermatitis)

Calcineurin inhibitor: - Pimecrolimus (Elidel®) & Tacrolimus

(Protopic®)

- The US FDA : caution when prescribing

these medicines because of potential

cancer risk.

Only be used as directed, and only after

trying other treatment options, are not

approved for children younger than 2

years of age

…atopic eczema (atopic dermatitis)

Coal Tar:

- reduce itching

- should not be used on skin that is very

irritated

Antihistamines: - often used to treat itching and to help

patient sleep when severe night itching is a problem

…atopic eczema (atopic dermatitis)

Oral Corticosteroids:

- in severe cases

- when the rash cover large areas

Cyclosporine & Interferon:

- cytostatics

- only used if other treatment is not

succesful

Steroid Phobia

Insect Sting Allergy

- Can cause serious and even deadly reaction

- Insects: honeybee, yellow jackets, hornets, wasp, fire ants

- Symptoms: wheezing, trouble breathing, coughing, hoarseness, throat tightness, stomachache, vomiting, diarrhea, itchy-water-or swollen eyes, hives, red spots, swelling, and loss of conciousness

Insect Sting Allergy

Drug Allergy

Drug allergies are a group of symptoms caused by an allergic reaction to a drug (medication).

The most common drug allergens: Antibiotics:

Penicillin

Sulfa drugs

Tetracycline Analgesics:

Codeine

Non-steroidal anti-inflammatory drugs (NSAIDs)

Antiseizure: Phenytoin

Carbamazepine

…drug allergy

Drug allergy symptoms

Skin rash or hives

Itchy skin

Wheezing or other breathing problems

Swelling of body parts

Anaphylaxis, a life-threatening allergic reaction

Reactions can occur in any part of your body.

…drug allergy

What is anaphylaxis?

Anaphylaxis is a severe, life-threatening allergic reaction. This serious

reaction happens within seconds to minutes after taking the drug. Patient may experience:

Swelling of your body parts, with or without hives

Light headedness or dizziness

Sudden drop in your blood pressure, with or without loss of consciousnes

Shock, with damage to your internal organs

Anaphylaxis requires emergency treatment to prevent death and damage to your internal organs.

Treatment includes:

Drugs (oxygen, adrenalin, antihistamine)

Intravenous fluid

…drug allergy

Diagnosing Drug Allergy:

When did you take the drug

When did you stop the drug

When did you problem begin

What happened to you

How long did your problem last

What other prescription drugs did you take

What other non-prescription drugs

What health foods did you take

What herbs did you take

What minerals did you take

What are the exact names

What treatments did you get for the reaction

…drug allergy

Drug allergy treatment:

For a mild reaction you may only have to stop the drug.

For a more serious allergic drug reaction that is not life-threatening:

Antihistamine

to counteract the histamine released into

your body during the reaction

A non-steroidal anti-inflammatory drug or a

corticosteroid : to reduce inflammation

…drug allergy

…drug allergy

Treating Allergy

There is no real cure for allergies, but it is possible to relieve symptoms. The only real way to cope with them is to reduce or eliminate exposure to allergens. That means parents must educate their child early and often, not only about the allergy itself, but also about what reaction they will have if they consume or come into contact with the allergen.

Informing any and all caregivers (childcare personnel, teachers, extended family members, parents of your child’s friends, etc) abut your child allergy is equally important.

If reducing exposure to allergens isn’t possible or ineffective, medications may be prescribed, including antihistamines, corticosteroids, or epinephrine.

Thank You