The Faces & Challenges

Of Atopic Eczema
Leong kin fon

Pediatric Dermatologist ( GHKL )
kinfonleong@yahoo.com
Pediatric dermatology unit
Pediatric Institute , GHKL

Dr.Sabeera Begum
Dr.Ng Su yeen
Dr.Heah SS
Dr. Leong kin fon
Outline

1. What is atopic eczema & its pathogenesis ?


Atopic Eczema


Genes



Environment



Atopic Eczema


Genes



Environment



2 groups of Gene - endogenous
Atopic Eczema


Genes



Environment



Skin barrier defect
Immune
dysregulation
2 groups of Gene
2 Hypothesis



Inside Out
or
Outside In


Genes



Environment



Skin barrier defect
Outside In Hypothesis
Skin Epidermis , Dermis , Fat
In Eczema , our focus is Epidermis & upper dermis
The Main focus is Stratum corneum
The Outermost layer is Stratum Corneum
Stratum Corneum ( SC )

A Dry , Dying & Boring layer

BUT

Dynamic with multiple functions
A dying and drying layer with 11 functions
++ Defective SC in Atopic Eczema
In AD , prone to dryness & inflammation & Infection


6 weeks
basale to corneum
Subconsciously , gradual desquamation & thickness
maintained with minimal scaly surface
Undress 4 - 8 times per year
Brick & Cement Model
Stratum Corneum = Brick +Cement
Stratum Corneum = Brick +Cement
corneocyLe corneocyLe
corneocyLe corneocyLe
corneocyLe corneocyLe
corneocyLe corneocyLe
corneocyLe corneocyLe corneocyLe corneocyLe
!"#"$%
!"#"$%
!"#"$% !"#"$%
!
"
#
"
$
%

!
"
#
"
$
%

!
"
#
"
$
%

Stratum Corneum = spongebob + butter
Normal Stratum corneum
Normal Hydrated corneocytes
Stratum Corneum
Spongebob + Butter ( Lipid )
Healthy spongebob + butter
Healthy spongebob + butter
In Atopic Dermatitis
Dehydrated spongebob

Dehydrated
Xerotic
In Atopic Dermatitis
Dehydrated spongebob
+

Patchy Butter
( deficient of total lipid especially ceramide )
Unhealthy Stratum Corneum Barrier defect
Barrier defects in Atopic Dermatitis - 1
1. Lack of all intercellular lipid , especially ceramide
(i.e Ceramide / Cholesterol / Free fatty acid )

In lipid bilayer ! cement
In Atopic eczema! defective cement
In Atopic Eczema
Total quantity of lipid is reduced especially Ceramide
Barrier defects in Atopic Dermatitis - 1
1. Lack of all intercellular lipid , especially ceramide
(i.e Ceramide / Cholesterol / Free fatty acid )

Rationale :
Skin barrier repair cream with new features
A. physiological lipid
B. ceramide dominant replacement & repair
Moisturizer with combination

Humectant occlusion
occlusive
A. Non physiological
Vaseline , UngE
Aqueos cream ,
B. Physiological lipid
A. urea cream - 10
8. Clycerln 23
C. ropylene glycol
u. Sodlum CA
Barrier defects In Atopic Dermatitis - 2
1. Lack of all intercellular lipid , especially ceramide
( Ceramide / Cholesterol / Free fatty acid )

2. Lack of filaggrin & natural moisturizing factors
(Main contributor is fr degradation of filaggrin )


Stratum Corneum
Keratohyaline
granules
( Pro filaggrin )
packed
Filaggrin
Natural MF
Granular layer
Basal layer
Spinolosum
Epidermis
Barrier defects In Atopic Dermatitis - 2
1. Lack of all intercellular lipid , especially ceramide
( Ceramide / Cholesterol / Free fatty acid )

2. Lack of filaggrin & natural moisturizing factors
(Main contributor is fr degradation of filaggrin )

Rationale : Urea / Glycerin / Sodium PCA in cream
Moisturizer with combination

Humectant occlusion
occlusive
A. vasellne ,
8. ungL
C. Aqueos cream ,
u. hyslologlcal llpld
A. Urea cream 10%
B. Glycerin 25%
C. Propylene glycol
D. Sodium PCA
Barrier defects in Atopic Dermatitis ( 3 )
1. Lack of intercellular lipid , especially ceramide
( Ceramide / Cholesterol / Free fatty acid )

2. Lack of filaggrin & natural moisturizing factors
( main contributor is fr degradation of filaggrin )

3. Disrupted pH mantle & defective immune

Rationale :
Antiseptic / antibiotic
pH balance cream & cleanser
pH 5.5
pH 4.5 6
pH 7.35
pH 7.35
pH 7.35
pH 4.5 6
pH 7.35
pH 7.35
pH 7.35
pH 4.5 6
pH 7.35
pH 7.35
pH 7.35
acid mantle
Sharp pH Gradient Acid mantle


1. Desquamation
2. Healthy lipid bilayers & permeability barrier
3. Juicy home for non pathogenic bacteria
4. Yucky home for pathogenic bacteria
pH 4.5 6
Sharp pH Gradient ! Neutral / Alkaline in AD



pH 7
Disrupted pH Gradient ! Neutral / Alkaline in AD


1. Desquamation
2. Healthy lipid bilayers & permeability barrier
3. Juicy home for non pathogenic bacteria
4. Yucky home for pathogenic bacteria
Protease > inhibitor ++ desquamation & skin thinning

Reduction in lipid production & hydration barrier

> 90% of AE patients are colonized by Staphy
pH 7


Genes



Environment



Skin barrier defect
( Primary )
Immune
regulatory defect
Outside In Hypothesis


Genes



Environment



Skin barrier defect

( Primary )
Immune
regulatory defect
( Secondary )
Twin Tower & its Siblings 2011
2
nd
Hypothesis


Genes



Environment



Skin barrier defect
( Secondary )
Immune
dysregulation
Th 2 > Th 1
allergic response
IL 4 , 5 , 13
Inside Out hypothesis


Genes



Environment



Skin barrier defect
( Secondary )
Immune
regulatory defect
( Primary )
Namibia 2006


Genes



Environment



Skin barrier defect
Immune
regulatory defect
Inside Out Hypothesis
Outside In Hypothesis
Primary
?
Chicken & Eggs


Genes



Environment



Skin barrier defect
Immune
regulatory defect
Inside Out Theory Outside In Theory
Atopic Eczema = Endogenous eczema


Genes



Environment



Skin barrier defect
Immune
regulatory defect
Single parent risk is 20 40 %
Both parent risk is 40 80% OF ATOPY
Monozygotic twin > dizygotic twin
Kampung Kuantan
Kampung Kuantan 2011
1993 9.3
!"##$ &'()* +',** "-./0 1,2.3
+'* 4(56*-7 829.:* ;<=7 !)).* >?;@7 A< #.B.)-
ACC<DE "*3-*:F*, ACC<7 &(B*) @;;D@G;
Prevalence of atopic eczema in Msia children 2001
12.6% in 2001
Sarawak River 2004
Borneo Highlands 2008
Borneo Kids 2006
Atopic Eczema in Children
( West Malaysia VS East Malaysia )






Genetic + Environment
Johor Singapore Bridge 2011
Singapore 2011
Urbanized community has higher Prevalence


Atopic Eczema = Endogenous + Exogenous


Genes



Environment



Skin barrier defect
Immune
regulatory defect
Dynamic
Age / Activity / Climate etc


Itch Scratch Cycle

Triggering Factors vary with age / climate / education
Hot humid Sweating


Harsh Cleanser

Food allergy
Type 4 Allergy
Housedust mite

Bacteria Infection

infant toddler older children adolescent
Cape town , South Africa
Which one comes first
? Conclusion ?


Genes



Environment



Skin barrier defect
Immune
regulatory defect
Dynamic
Age / Activity / Climate etc
Chicken & Eggs


Genes



Environment



Skin barrier defect
Immune
regulatory defect
Inside Out Theory Outside In Theory
Chicken & Eggs Growth Hormone


Genes



Environment



Skin barrier defect
Immune
regulatory defect
Dynamic environment - Big 6
Chicken & Eggs Growth Hormone





Skin barrier defect
Immune
regulatory defect
Dynamic environment - Big 6
Chicken & Eggs Growth Hormone





Skin barrier defect
Immune
regulatory defect
Dynamic environment - Big 6
Multi factorial
disease
Atopic Eczema
Multi factorial
disease
Multi Faces
clinically
Atopic Eczema
Atopic Eczema 4 main components
Itch - Scratch

Gene

Dryness Inflammation

Environment

Infection

Itch Scratch inflammation Infection Cycle
Itch - Scratch

Gene

Dryness Inflammation

Environment

Infection

Ups and downs , improves after years
Chronic Itch Scratch Inflammation infection ! Psychosocial
Itch - Scratch

Gene

Dryness Inflammation

Environment

Infection

Argentina 2010
Multi factorial
disease
Multi Faces
clinically
Combination
approach
6 targets
Atopic Eczema
Itch Scratch inflammation Infection Cycle
Itch - Scratch

Gene

Dryness Inflammation

Environment

Infection

1st
Itch - Scratch

Gene

Dryness Inflammation

Environment

Infection

Emollient
Cleanser
2
nd

Itch - Scratch

Gene

Dryness Inflammation

Environment

Infection

Emollient
Cleanser
Steroid &
friends
3
rd

Itch - Scratch

Gene

Dryness Inflammation

Environment

Infection

Emollient
Cleanser
Steroid &
friends
Antibiotic &
antiseptic
4
th

Itch - Scratch

Gene

Dryness Inflammation

Environment

Infection

Emollient
Cleanser
Steroid &
friends
Antibiotic &
antiseptic
Combination
Recognize your groups of medication & their targets
For dryness
A. Emollient
For redness and inflammation
A. Steroid
B. Calcineurine inhibitor
C. Systemic steroid , Azathioprine ,cyclosporine , mycophenolate mofetil
D. UVBphototherapy
For infection
A. topical or oral antibiotic + antiseptic bath
For itchiness
A. Above treatment + Sedative Antihistamine + wet wrap + behavioural
5
th

Itch - Scratch

Gene

Dryness Inflammation

Environment

Infection

Emollient
Cleanser
Steroid &
friends
Antibiotic &
antiseptic
Combination
Modify
6
th
Gene therapy / Change parent ?
Itch - Scratch

Gene

Dryness Inflammation

Environment

Infection

Emollient
Cleanser
Steroid &
friends
Antibiotic &
antiseptic
Combination
Modify
Change parents
6
th
target : Chronic & Psychosocial ! Education
Itch - Scratch

Gene

Dryness Inflammation

Environment

Infection

LoLs of Lducauon

WhaL ls eczema
&
WhaL ls noL eczema

If Atopic eczema is = rambutan

Rambutan is converted into durian ,
polluted by opinion from family consultants i.e .
Aunties & Uncles
Misconception about Atopic eczema
1. AD is due to single causative agents .
Once detected & removed , AE is cured .
Misconception about Atopic eczema
1. AD is due to single causative agents .
Once detected & removed , AE is cured .
2. Keep shopping for a single magical cream ( Steroid / Emollient )
that can cure ( VS Combination approach )
Misconception about Atopic eczema
1. AD is due to single causative agents .
Once detected & removed , AE is cured .
2. Keep shopping for a single magical cream ( Steroid / Emollient )
that can cure ( VS Combination approach )
3. AE is caused by food allergy ( Cow , Goat ,Soy )
AE & Food allergy may co exist in 5% of all cases of atopic eczema
and food may acts as a triggering , but not causal role .
Rambutan is converted into durian ,
& managed as durian
LoLs of Lducauon
Moisturizer Itch
Steroid
&
friends
Anti
infective
Education
Modifying
environment
Balancing the 6 targets
Escalation Therapy

systemic and phototherapy

Wet wrap
Topical tacrolimus and higher strength steroid
Topical emollient / steroid / antihistamine / Education
Modify his environment
Borneo Kids 2005
Outline

1. What is atopic eczema & its pathogenesis ?
2. The Multiple Faces of Atopic eczema , how are they
generated ?

Outline

1. What is atopic eczema & its pathogenesis ?
2. The Multiple Faces of Atopic eczema
Visualize from
A. Its Morphology & progression

Recognize 3 Faces by its Morphology & progression
Morphology
Recognize 3 Faces by its Morphology & progression
Morphology

Acute
Sub acute
Chronic

Morphological progression of eczema
Acute subacute lichenified






Red weeping dry + less red dry , thick
pigmentary changes
Morphological progression in eczema
Acute subacute lichenified + Nodules






Papulovesicles dry + less red dry , thick
pigmentary changes
Morphological progression 2 ways
Acute subacute lichenified






Red weeping dry + less red dry , thick
pigmentary changes
Morphological progression overlaps
Acute subacute lichenified






Red weeping dry + less red dry , thick
pigmentary changes
If disease arrested early ( mild AD )
Acute subacute






Red weeping dry + less red Hypopigmentation
Hyperpigmentation
If disease relapses ++ ( moderate & severe AD )
Acute subacute lichenified






Red weeping dry + less red dry , thick
pigmentary changes
Prurigo Nodularis / Leucoderma
Prurigo Nodularis / Leucoderma
Bolivia 2010
My understanding was .

Year 1998 ( Pre derm era )

What is eczema ?
What is eczema ?
When I was a Junior doctor in Polyclinic?

Any skin lesion that is
Appears as Red + wet + itchy + Disappears with steroid .


What is eczema ?
when I was a Junior doctor in Polyclinic?

Any skin lesion that is
Red + wet + itchy + disappears with steroid .

Conclude it as
Steroid Responsive = eczema

What is eczema ?
when I was a Junior doctor in Polyclinic?

Any skin lesion that is
Red + wet + itchy + disappears with steroid .

Conclude it as
Steroid Responsive = eczema
Steroid dependant = severe eczema

What is eczema ?
when I was a Junior doctor in Polyclinic?

Any skin lesion that is
Red + wet + itchy + disappears with steroid .

Conclude it as
Steroid Responsive = eczema
Steroid dependant = severe eczema
Steroid Resistant er not eczema and refer
Eczema is
Red + Wet + Itchy
Stretch your imagination
Red + Wet + Itchy ( Gatal )

Year 2000

Post Derm Era
What is eczema
As a Dermatologist , you talk eczema
Inflammatory , pruritic skin disorder with
common pattern of clinical ( Morphology ) & histological
which correlates with the stage of the lesion .





What is eczema ,
As a Dermatologist , we talk eczema
Inflammatory , pruritic skin disorder with
common pattern of clinical ( Morphology ) & histological
which correlates with the stage of the lesion .


What the heaven is that .. Steroid anyway , right ?


Eczema & its 4 clues to lesional diagnosis
1
st
clue : Is the rash itch ?
Inflammatory , pruritic skin disorder with
common pattern of clinical ( morphology ) & histological
which correlates with the stage of the lesion .


Itch & eczema
Not all itchy skin lesion is eczema .
But if it does not itch & untreated before , it is
probably not eczema .
Top 3 Pruritic Dermatoses

Lczema , Scables , urucarla....
2
nd
clue : morphology & its evolution
Inflammatory , pruritic skin disorder with
common pattern of morphological & histological findings
which correlates with the stage of the lesion .


2
nd
clue : morphology & its evolution
Inflammatory , pruritic skin disorder with
common pattern of morphological & histological findings
which correlates with the stage of the lesion .


Lczema ls noL a slngle sLauc appearance
buL a dynamlc & progresslve slgn

Who is he ?
Who is he ?
Who is he ?
All of them are Barack Obama , but of
different stages of his life
so does eczema
Acute subacute chronic Obama
p
apuloveslcle
Vesicle ! erosion ! red scaly papules / plaque

1
sL
round
Vesicle ! erosion ! red scaly papules / plaque
1
st
round , 2
nd
round
Vesicle ! erosion ! ! ! lichenified plaque

1
st
round , 2
nd
round , 3
rd
, 4
th
..
Morphological progression in eczema
Acute subacute lichenified






Red weeping dry + less red dry , thick
pigmentary changes
3
rd
clue : morphological details
Inflammatory , pruritic skin disorder with
common pattern of morphological & histological findings
which correlates with the stage of the lesion .


Lczema , Lhe paLhologlcal level
ls aL epldermal leslon + upper dermls
Further clues : microscopic details
To appreciate eczema , in detail

1. Prominent epidermal surface changes
- superficial erosion / blister ( Acute )
- scaly surface ( Subacute )
- altered skin markings ( Chronic )
Thickening

2. ill defined margin
Epidermal changes with ill defined margin

Psoriasis Eczema
4
th
clue : Histological & its evolution
Inflammatory , pruritic skin disorder with
common pattern of morphological & histological findings
which correlates with the stage of the lesion .


4
th
clue : Histological & its evolution
Inflammatory , pruritic skin disorder with
common pattern of morphological & histological findings
which correlates with the stage of the lesion .


Histology , occasionally needed for diagnosis
Acute spongiotic dermatitis
Sub-acute
Chronic
Histology Morphology
Eczema & clinical definition
Inflammatory , pruritic skin disorder with
common pattern of morphological & histological findings
which correlates with the stage of the lesion .


Outline

1. What is atopic eczema & its pathogenesis ?
2. The Multiple Faces of Atopic eczema , how ?
Visualize from
A. Its Morphology & progression
B. Its Pattern & Distribution

3 Faces of Pattern based on age
( variation of skin thickness , exposure etc )
Infantile Toddler Adolescent / Adult
Morphology & Pattern

Acute
Subacute
Chronic


Infantile
Toddler
Adolescent

Morphology Pattern
3 3 = 9 Faces
ALoplc uermauus ~ Angry 8lrd
9 Basic Faces of AD
Case 1
12 month-old Malaysian boy with atopic eczema
since 6 month-old


Distribution
&
Pattern
Generalized
( ++ cheeks & extensors ; - ve palmoplantar & groin )
Distribution
&
Pattern

Morphology

Acute
eczema
Subacute
eczema
Subacute
ill defined dry scaly patches
Subacute to Chronic
dry lichenified

Acute
Sub acute
Chronic


Infantile
Toddler
Adolescent



Morphology Pattern
Moisturizer Itch
Steroid
&
friends
Anti
infective
Education
Modifying
environment
Moisturizer Itch
Steroid
&
friends
Anti
infective
Education
Modifying
environment
Bath , Emollients and Demo
Types & Preparation & adequate amount

Moisturizer with combination

Humectant occlusion
occlusive
A. Vaseline ,
B. UngE
C. Aqueos cream ,
D. liquid paraffin
A. Urea cream 10%
B. Glycerin 25%
C. Propylene glycol
D. lactic acid
Bath , Emollients and Demo
Types & Preparation & adequate amount

CREAM OINTMENT LOTION


Bath , Emollients and Demo
T Preparation & adequate amount

CREAM OINTMENT LOTION

Wet / Dry Dry Hairy


Bath , Emollients and Demo
Types , adequate amount and preparation


How much do we need per application for whole body ?
20g ( adult- male )

16g ( adult female )
10g ( > 4 year-old )
5 g ( infant < 1 year )
Finger tip units
Cost of moisturizers
Aqueous cream $ 17 ( 500 g )
Urea cream $ 65 ( 500 g )
Ung E $ 20 ( 500 g )
Vaseline $ 8 ( 500g )
Aqueous cream + 25% glycerin $21 ( 500g )
Physiogel $ 350 ( 500g )
Cetaphil
Ceradan $ 500 ( 500g)
Choice of moisturizer
Individualized recipe according to time and body parts

Good moisturizer and its features

Cost effective in large amount ( 500g / week )
Comfortable , easily applied on skin = pts preference
Effective
Safe , hypoallergenic , minimal irritation
1here ls no 'rlghL one for all
Evolution since ~ 10 years ago
Aqueous cream Urea 2 10 %
Vaseline 25% Glycerin
Ung Emulsificant Oint
Since ~ 10 years ago
Occlusion
Humectant
Cost & texture






Aqueous cream Urea 2 10 %
Vaseline 25% Glycerin
Ung Emulsificant Oint
Subsequent 10 years







Cetaphil Oilatum QV cream Physiogel Rosken
Ezzera Ceradan Atopiclair Organic & natural ++
Emollient & extra features in 2012

Humectant hypoallergenic Anti inflammation / Itch
Occlusive barrier repair cream & Physiological
Cost & Texture pH 5.5 Single daily application




Cetaphil Oilatum QV cream Physiogel Rosken
Ezzera Ceradan Atopiclair Organic & natural ++
l
Moisturizer Itch
Steroid
&
friends
Anti
infective
Education
Modifying
environment
Machu Pichu 2010
Case 2 :

4 year-old Malaysian Boy
with Atopic eczema since 7 month-old

Distribution
&
Pattern


Distribution
&
Pattern



Morphology


Subacute Red ill defined scaly patch
Chronic lichenified
Subacute + Lichenification + Prurigo nodules
Prurigo Papules & Nodules
Severe prurigo nodular eczema

Acute
Subacute
Chronic


Infantile
Toddlers
Adolescent




Morphology Pattern
Generalized
Flexural + +
Clinical implications & Challenges
For nodules ( recalcitrant )

1. Potent to Very Potent steroid
+/- Occlusion ( Wet bandage )
+/- systemic agents

2. Itch management
Class 1 : Hydrocortisone base / acetate

Class 3 : Mometasone furaoate
Betamethasone Valerate
Class 4 : Clobetasol proprionate
Betamethasone Dipropionate Oint
Prurigo Nodules
Class 2 : Clobetasone Butyrate
Desonide
Wet wrap
A. Maintain skin moisture
B. Prevent scratching
C. soothing for itchiness
D. Improves absorption
Avoid during infection
Malawi 2011
Case 3 : 4 year-old Malaysian boy with
atopic eczema

Acute
Subacute
Chronic


Infantile
Toddlers
Adolescent


Morphology Pattern
Flexural & its clinical implications ?
Flexural
1. Natural Occlusion irritant ( sweating ) , harsh cleanser
2. Thinner area physiologically
3. More prone to steroid side effects
Acute : ( Class 2 +/- Class 3 )
Maintenance : Need proactive therapy
Steroid +/- Calcineurine inhibitor + Emollient
Topical Steroid
A. The potency
B. The strategies
Steroid
Potency and degree of skin thickness


Ointment > Cream

Occlusion

Intralesional
Periorbital
Face
Flexures
Limbs
Hands and
Lichenified lesions
1% Hydrocortisone

Clobetasone

Mometasone
Fluticasone
Betamethasone

Clobetasol

x1
x300
x23
x100 Fluticasone
Location, location, location
Face, flexures, groin
1% hydrocortisone , Clobetasone

Limbs, trunk
betamethasone 1 in 8 / 1 in 4
Mometasone
Thick stubborn plaques or nodules on limbs
Betamethasone 1in 2
Dermovate for short period
Location, location, location
Topical Steroid
A. The potency
B. The strategies - Proactive or reactive
Reactive management of Atopic Dermatitis ~ Asthma

Subclinical inflammation
normal skln
Flare Flare Flare
C
l
i
n
i
c
a
l

s
c
o
r
e

Reactive management Proactive management
Early intervention as the flare starts
An intermittent application of anti-inflammatory

!"" $%&'()*+ ,*+- ../ 0*- ./ .121
8eacuve managemenL of ALoplc uermauus ~ AsLhma

Subclinical inflammation
normal skln
Flare Flare Flare
C
l
i
n
i
c
a
l

s
c
o
r
e

Reactive management Proactive management
Early intervention as the flare starts
An intermittent application of anti-inflammatory

!"" $%&'()*+ ,*+- ../ 0*- ./ .121
subclinical
inflammation
roacuve managemenL of ALoplc uermauus ~ AsLhma

Subclinical inflammation
normal skln
Flare Flare Flare
C
l
i
n
i
c
a
l

s
c
o
r
e

Reactive management Proactive management
Early intervention as the flare starts
An intermittent application of anti-inflammatory 2 -3 times / week

!"" $%&'()*+ ,*+- ../ 0*- ./ .121
For steroid phobia / atrophic sites
Tacrolimus / Pimecrolimus - A Calcineurin Inhibitor

Lmcacy
Moderate potent steroid ~ 0.1% Tacrolimus > Pimecrolimus
Clinical Indications
Steroid sparing agents for subacute & chronic eczematous lesions as Proactive treatment
Steroid phobia + expensive caretakers
Steroid atrophy
Thin areas ( face , periorbital )

Side effects
~ initial burning sensation , not weepy areas
- costly ( RM 100 - 150 / 10 g )
Licensed for > 2 years & off label use is not uncommon
Outline

1. What is atopic eczema & its pathogenesis ?
2. The Multiple Faces of Atopic eczema , how ?
Visualize from
A. Its Morphology & progression
B. Its Pattern & Distribution
C. Complications

9 Basic faces + More

Acute
Subacute
Chronic


Infantile
Toddler
Adolescent

Morphology Pattern

Complications

9 Basic Faces +++

Acute
Subacute
Chronic


Infantile
Toddler
Adolescent

Morphology Pattern

Infection


complication
Atopic eczema + clinical bacteria infection
'()* +,' -./(
'0)#12 )3./3%
Staph. aureus infection
Malawi 2011
Known case of Atopic eczema at 2 year-old
6 month-old
6 month-old
2 year-old
6 weeks
Recent flare has started about 6 weeks ago &
not responsive to her regular salvage regimen .
6 weeks
Balance the Triggering factors of Atopic eczema
1. Itch scratch
2. Hot , humid , Sweating
3. Bacteria
4. Dry , harsh soap& cleanser
5. Food Allergy
6. Housedust mite
8lg 6
ulsLrlbuuon
Pattern and local configuration
well defined annular & polycyclic

ill defined , red , scaly patches
ill defined red scaly
patches
crusted erosion
3 Morphologies or Faces identified
Ill defined scaly patches
Crusted Erosion
Well defined scaly patches with central clearing
3 Morphologies or Faces identified
Ill defined scaly patches
Crusted Erosion
Well defined scaly patches with central clearing
Are they progression of similar pathology

Or

2 in 1 ; 3 in 1
Fungal infection + eczema of varying stages
Annular & polycyclic with central clearing
Bring home message : Eczema + Tinea

Acute
Subacute
Chronic


Infantile
Toddler
Adolescent

Morphology Pattern
Suspect if

1. Not responsive to routine
treatment
2. Well defined margin
slowly migrating over wks
3. Annular / Polycyclic

New face

9 year-old Malaysian boy
Atopic eczema since 1 year-old
Case Study 6
Progression ( chronic relapsing )
red tall peak 1 -2 / year
Progression chronic relapsing
( low peaks in between )
Progression chronic relapsing
( highest peak since 2 weeks ago )
2 weeks
Distribution

Multiple discrete vesicles and
erosions

cluster around his extremities >
body

B. Local configuration
Lesions cluster at same stages - monomorphous
C. Morphology ( 1st )

ill defined , erythematous , dry scaly patches


Morphology New type for current flare

Multiple discrete erosions > vesicles
Details + Monitor the progression
1. Vesicles +/- umbilicated centre ( history > PE )
rogresslon
2. Discrete Superficial erosion

Multiple +/- coalesce
Hypopigmented macules
New Morphology in details
Vesicles / pustule
Superficial erosion & recovers without atrophy
Discrete , multiple +/- coalesce
Almost at same stages of evolution -
monomorphous
Bring home message : Eczema + HSV

Acute
Subacute
Chronic


Infantile
Toddler
Adolescent

Morphology Pattern
Suspect if

1. Not responsive to routine
treatment
2. Dual morphology :
Sudden onset of vesicles or
Punch out erosion
3. Fever , malaise
4. Tzanck smear / DFA
New face
Molluscum Contagiosum

Acute
Subacute
Chronic


Infantile
Toddler
Adolescent

Morphology Pattern

Central umbilicated papules
Pearly white in color
Discrete papule
Single or multiple
Each lesion lasts for 1 3
months
New face
Molluscum Contagiosum
Self Food restriction
.
Another faces : Extra cutaneous

Acute
Subacute
Chronic


Infantile
Toddler
Adolescent

Morphology Pattern


Failure to thrive
Hypoalbuminemia
Anaemia


New face
Contact irritant / Allergic dermatitis

Acute
Subacute
Chronic


Infantile
Toddler
Adolescent

Morphology Pattern


1. Well defined margin
2. Certain painted
pattern



New face
Toilet-seat contact dermatitis Round
Classic symmetrical eruption on the buttocks and posterior aspect of the thighs
Allergic contact dermatitis
rubber
9 faces + Complications = Multiple Faces

Acute
Subacute
Chronic


Infantile
Toddler
Adolescent

Infection
Scratch
Sweating
Food allergy
Misconception
Contact allergy
Irritant cleanser
Morphology Pattern Complications
17 year-old boy with chronic atopic eczema
Scratching sparing area
Morphology ! excoriated papules + linear
Itch spreads
Role of Sedative Antihistamine in AD
For its sedative effect

Itch mediators in eczema , is much more than histamine
All off label use in children < 18months , calculate the dose
according to body weight

Promethazine , Chlorpheniramine ,Hydroxyzine ,Diphenhyramine
9 faces + Complications = Multiple Faces

Acute
Subacute
Chronic


Infantile
Toddler
Adolescent

Infection
Scratch
Sweating
Food allergy
Misconception
Contact allergy
Irritant cleanser
Morphology Pattern Complications
Outline

1. What is atopic eczema & its pathogenesis ?
2. The Multiple Faces of Atopic eczema , how ?
Visualize from
A. Its Morphology & progression
B. Its Pattern & Distribution
C. Complications
D. Associated Features

9 faces + Complications = Multiple Faces

Acute
Subacute
Chronic


Infantile
Toddler
Adolescent

Infection
Scratch
Sweating
Food allergy
Misconception
Contact allergy
Irritant cleanser
Morphology Pattern Complications
Associated minor features
Pityriasis Alba
Dennie Morgan lines & Keratosis Pilaris
Multiple faces of combination
The faces of Lady Gaga @ burung Gagak
Practical Challenges
1. Recognizes its multifactorial ( not just food allergy ) & multi faces
2. Manage them with combination approach no single magical cream
3. Recognize that education is essential
4. Action plan ~ asthma
5. Steroid phobia VS dependent
6. Convince them that AD is a chronic relapsing diseases
but generally will get better
Singapore Triplet Tower 2011