Associate Professor Rohan Ameratunga
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1 Associate Professor Rohan Ameratunga Adult and Paediatric Clinical Immunologist and Allergist Auckland 16:30-17:25 WS #67: Managing Eczema 17:35-18:30 WS #79: Managing Eczema (Repeated)
2 Managing ECZEMA (an allergy perspective) A/Prof Rohan Ameratunga
3 Eczema introduction Long lasting inflammatory skin disorder Often begins in childhood Less commonly starts in adulthood- may have had it as a child. Pregnancy trigger after years of remission Associated with other atopic conditions Can have profound psychological effects
4 Eczema Case presentation 1 Miss KT aged 8 months Born at term Breast fed Solids introduced at 4 months Cows milk formula at 6 months
5 Eczema case presentation 3 F hx: Mother allergic rhinitis Immunizations up to date Normal growth and development No other medical problems Environment: Villa, cat, old carpet
6 Eczema case presentation 4 Physical findings: rash over face, limbs Infected, excoriated areas No abnormalities of other systems Normal height and weight
7 Eczema
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11 Pathogenesis of eczema Response of skin to scratching Genetically determined Associated with allergic march 50% have an allergic trigger Most cases improve Affects up to 20% children May be increasing in Asia and Africa 70% have a family history of allergies 80% monozygotic vs dizygotic twins
12 Pathogenesis Inversely linked to exposure of dogs Linked to exposure to hard water (CaCO3, double the risk adjusting for confounders) Vitamin D deficiency Outside in vs inside out hypothesis (skin barrier dysfunction vs immune system)
13 Fillagrin mutations R501X and 2282del4 Linked to childhood but not adult eczema Homozygous mutations- persistent eczema Higher rates of steroid use in homozygous mutations Spink5 codes LEKT1- inhibits skin chymotripsin Implicated in eczema Th17 and Th22 cells involved
14 Factors altering skin barrier Fillagrin Proteases eg chymotrypsin, arginase Protease inhibitors Proteins in tight junctions eg claudin
15 Interplay between genes and environment Profillagrin stored in keratohyaline granules Undergoes phosphorylation Generating fillagrin monomers Fillagrin metabolic products eg urocanic acid Pyrollidone carboxylic acid NMF Enzymes producing NMF defective eg arginase 1 Reduced tight junction proteins eg claudin1
16 Interplay between genes and environment
17 Interplay between genes and environment De Bendetto JID 2008
18 Immune response in eczema
19 Eczema triggers by age Trigger infant child adolescent adult Food +++ +/- - - Inhalant Type Malassezia +/ Staph Viral > Stress??
20 Trigger factors and eczema HEATING ITCHING SWEATING ALLERGY ALLERGY XEROSIS INFECTIONS IRRITANTS
21 Trigger factors and eczema HEATING ALLERGY ITCHING SCRATCHING SWEATING ALLERGY XEROSIS INFECTIONS IRRITANTS
22 Trigger factors and eczema HEATING ALLERGY ITCHING SCRATCHING ECZEMA SWEATING ALLERGY XEROSIS INFECTIONS IRRITANTS
23 Clinical features Age of person Acute vs chronic Complications infantile childhood adult erythema chronic changes lichenification bacterial infection viral and fungal inf pigmentary changes
24 Eczema in infants
25 Eczema in children
26 Eczema in adults
27 Differential diagnosis Seborrheic dermatitis Contact dermatitis Irritant dermatitis Psoriasis Scabies in infants- can affect face Immune deficiency Others
28 Psoriasis
29 Psoriasis
30 Psoriasis
31 Contact dermatitis
32 Contact dermatitis
33 Contact dermatitis
34 Contact dermatitis
35 Clinical evaluation History: age of onset progress triggers foods, contact complications treatments Other allergies Family history of atopy topical oral
36 Clinical evaluation Environmental hx carpeting, drapes lounge suite soft toys on bed pets, smokers, mould Feeding history breast feeding formula solids Growth and development
37 Diagnostic evaluation Skin testing foods inhalants SpIgE testing infants stopping antihistamines poor skin dermatographia Admission, food challenges
38 Specific IgE testing Food cut-off sensitivity specificity Egg 6.0 U/ml 61% 92% Milk 15 U/ml 51% 98% Peanut 15.0 U/ml 73% 92% Fish 19.5 U/ml 40% 99% Wheat > 100 U/ml PPV 60% Soy > 100 U/ml PPV < 50%
39 Complications
40 Complications
41 Complications
42 Complications
43 Complications
44 Complications
45 Complications
46 Complications
47 Complications
48 Mild eczema Use of emollients on a regular basis Use of topical steroids intermittently Antibiotics as required Antihistamines intermittently
49 Moderate- severe eczema: Individualised treatment Xerosis - soaps, excessive washing Infection- bacterial, fungal, viral Irritants - wool, chlorine, sand Sweating- heating, exercise Stress - heating Allergy - foods (eggs, milk, peanuts, wheat, soy) - contact/inhalants
50 Eczema treatment- Xerosis: skin hydration Emollients - avoid alcohol - apply 4-5x daily - SLS, lanolin sensitivity - Sorbelline - Vaseline Paraffin and occlusive dressings Creams vs ointments vs lotions Tar preparations Wet dressings - may need admission
51 Eczema treatment - skin hydration Baths Continuing debate! Soap substitute eg pinetarsol? Dry skin long baths Tepid pat skin dry apply emollient within 3 minutes shampoo Ketaconazole
52 Eczema treatment- Bleach baths NaOCl in bleach baths But pools have other forms of Cl eg Cl2, NaCl, Ca(OCl)2, Trichloro-isocyanuric acid, Sodium dichloroisocyanurate Pools 5-18% NaOCl Swimming pools: wash off Non chlorinated pools eg Ozone Sea baths are helpful but the sand irritates Bleach in the bath SLS? Avoid Janola
53 Eczema treatment- irritants Avoid wool contact with skin eg merino Double rinse after washing clothes Vaseline as a barrier at night
54 Eczema treatment - night time advice Avoid sweating - humidity control at night Keep Temp about 21C Loose fitting clothes Damp cloth at night for itching Ice pack Gloves Keep nails short Managing stress
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57 Eczema treatment - infections Infections bacterial mupirocin anti-staph viral acyclovir fungal Varicella immunization when well New non-live Zoster vaccine Antibiotics may be required for months
58 Eczema treatment - infections
59 Eczema treatment - infections
60 Presence of IgE antibodies to staphylococcal exotoxins on the skin of patients with atopic dermatitis. Evidence for a new group of allergens Leung DY, Harbeck R, Bina P, Reiser RF, Yang E, Norris DA, Hanifin JM, Sampson HA. J Clin Invest 1993 Sep;92(3): Method: 24/42 AD patients, identified multiple exotoxins from Staph cultured from AD patients SEA, SEB, TSST-1, ET 32/56 AD sera had IgE antibodies to these toxins These sera could trigger basophil histamine release Psoriasis pts had toxin secreting S aureus but no IgE antibodies
61 Staphylococcal colonization in atopic dermatitis and the effect of topical mupirocin therapy. Lever R, Hadley K, Downey D, Mackie R Br J Dermatol 1988 Aug;119(2): Method: DBPCRCT Patients: 49 Patients with AD. All patients had heavy colonization with S aureus. Method: Treated with topical mupirocin Results: Significant improvement in AD over the following 4 weeks
62 Eczema treatment - topical steroids Group I (mild) hydrocortisone Group II (moderate) triamcinolone Artistocort 0.05% clobetasone Eumovate 0.05% alcometasone Logaderm Group III (potent) 0.1% betamethasone Betnovate 0.05% betamethasone Cutivate 0.1% mometasone Elocon 0.1% hydrocortisone Locoid Group IV (v potent) 0.05% clobetasone Dermovate
63 Eczema treatment - topical steroids
64 Eczema treatment- calcineurin inhibitors Calcineurin inhibitors; Pimecrolimus cream NB Cancer risk 5yr study of infants 3-12 months. No increase in cancer or immunodeficiency Suggest- minimal effective dose avoid sunburn Tacrolimus more effective- overseas
65 Efficacy and safety of Tacrolimus ointment compared with that of hydrocortisone butyrate ointment in adult patients with AD Reitamo et al JACI 2002;109: Aim: To compare 0.03% Tac, 0.1% Tac and 0.1% HC butyrate in AD Method: DBPCRCT. 3 weeks multicentre Patients: 570 patients enrolled Results: 0.1% Tac similar to 0.1% HCbutyrate
66 Efficacy and safety of Tacrolimus ointment compared with that of hydrocortisone butyrate ointment in adult patients with AD Reitamo et al JACI 2002;109:547-55
67 Antihistamines May need twice daily treatment Larger doses may be needed Combinations of AH can be useful Some newer antihistamines can sedate Expense is a significant barrier for therapy Cetirizine and Loratadine now subsidised May need long term antihistmaines
68 Second line therapy Prednisone Methotrexate, Azathioprine, MMF Cyclosporin Phototherapy- narrowband UVB Immunotherapy- dust mites
69 Dust mites
70 Dust mites
71 The role of dust mites in eczema 24 adults and 24 children with eczema Randomised for dust mite prevention bed covers benzyltannate spray HEPA vacuum cleaning Significant reduction in dust mites Improvement in eczema with reduced mites Tan BT, Weald D, Strickland I & Friedman. Double blind controlled trial of housedust-mite allergen avoidance in atopic dermatitis Lancet 1996;347:15-18.
72 Effectiveness of occlusive bedding in the treatment of atopic dermatitis-a placebo-controlled trial of 12 months' duration. Holm L, Bengtsson A, van Hage-Hamsten M, Ohman S, Scheynius A. Allergy 2001 Feb;56(2):152-8 Method: 40 Adults RCT (22 avoidance, 18 placebo) Polyurethane covers for bedding Dust samples from beds at 3, 6 & 9 mo Exclusion:Pregnancy, Phototherapy, long term antibiotics, immunotherapy Outcomes: Clinical response SCORAD Labs- scd30, IgE, RAST HDM, Cat
73 Allergy to pets
74 Trigger factors and eczema HEATING ALLERGY ITCHING SCRATCHING ECZEMA SWEATING ALLERGY XEROSIS INFECTIONS IRRITANTS
75 Eczema case presentation 5 Gradual improvement in eczema over time. Pattern changed to involve the flexural areas As a teenager, Ms KT has dry skin Occasional flares of eczema with stress eg exams Easily controlled with topical steroids.
76 Teaching points: Eczema Scratching triggers eczema The distribution of eczema changes Food allergy can trigger eczema Trigger factors for itching must be eliminated Topical steroids are needed intermittently Antihistamines and antibiotics are needed
77 When to refer- Ped Soc guidelines Significant impact on lifestyle eg missing school Frequent infections Psychosocial impact eg bullying Persistent facial eczema Family requesting referral Presence of other allergies eg FA
78 Facial dermatitis
79 Scabies- infants Contact Irritant Malassezia Dust mites Seborrheic dermatitis Butterfly rash in SLE Stress Facial dermatitis
80 Hand dermatitis
81 Hand dermatitis As part of atopic dermatitis Contact Occupational eg latex Irritant eg sand in children, soaps Sucking fingers Psoriasis Fungal Staph infection Palmoplantar pustulosis- other dermatological
82 Scalp dermatitis-flaking
83 Scalp dermatitis-flaking Psoriasis Seborrheic dermatitis (incl eyebrows) Malassezia Reaction to hair dyes Reactions to shampoos Scabies
84 Eczema the future Biologics- dupilumab ILR antagonist 75% achieved 50% improvement Crisabole- topical agent PDE4 inhibitor Mild application site reactions only 1522: most patients improved No evidence of skin atrophy.
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Professor Rohan Ameratunga Clinical Immunologist and Allergist Auckland
Professor Rohan Ameratunga Clinical Immunologist and Allergist Auckland 16:30-17:25 WS #170: Eczema Management 17:35-18:30 WS #182: Eczema Management (Repeated) Managing ECZEMA A/Prof Rohan Ameratunga
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