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ATOPIC DERMATITIS

CME Program Organized by IIHP 15th July 2012


Dr Chetna Deep Lamba Research Officer, CCRH Headquarters New Delhi

History
In 1925, Coca introduced the concept of atopy, meaning out of place or strange, to signify the hereditary tendency to develop allergies to food and inhalant substances. In 1933, Wise and Sulzberger introduced the concept of Atopic Dermatitis. AD is also known as atopic eczema, infantile eczema, flexural eczemza, disseminated neurodermatitis and prurigo diathsique.

Epidemiology
The prevalence of AD differs between countries/regions. In industrialized countries, the prevalence of AD has at least doubled in the last three decades, and it affects approximately 15-30% of children. Conversely, in developing countries it has been reported to be less than 10%.

In a 12-month study by the International Study of Asthma and Allergies in Childhood (ISAAC, phase 1), the prevalence of atopic eczema in 56 countries had been found to vary between 3-20.5%. As part of phase 1 of ISAAC study, more than 37000 children from India were studied at 14 different centers. All centers except Kottayam (Kerala) reported a 12-month period prevalence between 2.4% and 6% while Kottayam reported a prevalence of >9%.

Gender ratio has varied greatly between the studies though all have reported a male predominance. In 45% of children, the onset of AD occurs during the first 6 months of life. It occurs during the first year of life in 60% of patients and before the age of 5 years in at least 85% of affected individuals.

Pathogenesis

Diagnostic Criteria
Hanifin and Rajka for the first time proposed a systematic approach toward the standardization of the diagnosis of AD by incorporating three major/basic and 23 minor features. They suggested that a diagnosis of AD can be established if three of the major and three of the minor criteria are present.

Major/basic features
Pruritus Typical morphology and distribution: flexural lichenification or linearity in adults, facial and extensor involvement in infants and children Chronic or chronically relapsing dermatitis Personal or family history of atopy (asthma, AR, atopic dermatitis)

Minor or less-characteristic features


Xerosis Ichthyosis/palmar hyperlinearity/keratosis pilaris Immediate (type 1) skin test reactivity Elevated serum IgE Early age at onset Tendency toward cutaneous infections (esp. Staph. aureus and Herpes simplex)/impaired cell-mediated immunity Tendency toward nonspecific hand or foot dermatitis Nipple eczema Cheilitis Recurrent conjuntivitis

Dennie-Morgan infraorbital folds Keratoconus Anterior subcapsular cataracts Orbital darkening Facial pallor/facial erythema Pityriasis alba Anterior neck folds Itch when sweating Intolerance to wool or lipid solvents Perifollicular accentuation Food intolerance Course influenced by environmental/emotional factors White dermographism/delayed blanch No chemical marker for the diagnosis of atopic dermatitis is known.

UK Working Party diagnostic criteria


Must have: An itchy skin condition in the last 12 months Plus three or more of: History of involvement of skin creases History of a generally dry skin Personal history of asthma or hay fever( in children aged under 4 years, history of atopic disease in a first degree relative may be included) Visible flexural dermatitis

Itch-Scratch Cycle
Pruritis

Secondary changes

Scratch

Infantile AD
Onset: 1st year of life, but not until 2 months of age Eczema begins as erythma and scaling of cheeks Lesions may be papular or exudative Xerosis Incessant pruritus Itch-scratch cycle Lichenification is seldom seen in infancy Worse after immunization and viral infections Usual relapse in winter Infantile pattern disappears usually by the end of 2nd year of life

Childhood AD
Xerosis is often generalized Incessant pruritus Itch-scratch cycle Lesions are eczematous and exudative Excoriations and crusting are common affected Lichenification is characteristic

AD in adolescents and adults


In older patients, AD may occur as localized erythematous, scaly, papular, exudative or lichenified plaques Xerosis is prominent Itching occurs in paroxysms, often in response to heat, sweat, stress, evening or night AD triggered by acute emotional upsets Stress, anxiety and depression reduce the threshold at which itch is perceived Improvement occurs with time and dermatitis after middle life is uncommon

In general, these patients retain mild stigmata of the disease, such as dry skin, easy skin irritation, and itching in response to heat and perspiration. They remain susceptible to flare up of disease when exposed to specific allergen or environmental situation.

SCORAD
(SCORing Atopic Dermatitis)
A clinical tool for assessing the severity of atopic dermatitis as objectively as possible. In order to help physicians in the clinical evaluation of the severity of the disease, the European Task Force on Atopic Dermatitis has developed an easy to use scoring index, SCORAD (Scoring Atopic Dermatitis); it allows to assess as objectively as possible how seriously the patient is affected by defining the intensity of different parameters such as erythema, edema or lichenification. Subjective symptoms such as loss of sleep and pruritus are also taken into consideration.

The SCORAD index : Clinical evaluation


Extent criteria The rule of 9 before the age of 2 : cervical preponderance The rule of 9 in adults and older children Grading in practice : It is advisable to draw lesion spread directly on the evaluation sheet and then perform the calculation. Intensity criteria Erythema : stage 1 / stage 2 / stage 3 Edema / papulation : stage 1 / stage 2 / stage 3 Oozing / crusting : stage 1 / stage 2 / stage 3 Excoriation : stage 1 / stage 2 / stage 3 Lichenification : stage 1 / stage 2 / stage 3 Dryness (this is assessed in an area where there is no inflammation) Subjective symptoms The two most representative items concerning the quality of life of patients are : Pruritus Insomnia

The SCORAD index : Total score


How is it calculated ? A = SPREAD.../100 B = INTENSITY.../18 C = SUBJECTIVE SYMPTOMS.../20 SCORAD calculation: A/5 + 7.B/2 + C

Compute your SCORAD scores Patient ID : (3 char max.) Age : Below 20 months / Above 20 months Spread : Front Face : % Upper Limbs : % Trunk : % Hands* : % Lower Limbs: % Genitalia* : % Back Head : % Upper Limbs : % Trunk : % Lower Limbs : % * Adult only Intensity : Erythema : Edema : Oozing : Excoriation : Lichenification : Xerosis : Subjective signs : Pruritis : Insomnia :

Important references for literature on SCORAD


http://adserver.sante.univnantes.fr/Scorad.html http://www.rch.org.au/rchcpg/index.cfm? doc_id=9971 http://www.laboratoriosilesia.com/upfiles /sibi/D1007861.pdf

Disease severity assessed by SCORAD (scoring for AD) has been found to be mild in majority of Indian patients - 54%, 27% and 19% patients in Dhar et al.'s study had mild, moderate and severe disease.

Associated features and Complications


Cutaneous Dennie- Morgan fold A linear transverse fold just below the edge of the lower eyelids. Pityriasis alba-presents as poorly marginated, hypopigmented, slightly scaly patches on the cheeks, upper arms and trunk in young children. Vascular Headlight sign-Peri oral, perinasal and periorbital pallor. White dermographism-Blanching of the skin at the site of stroking with the blunt instrument. Ophthalmological abnormalities Up to 10% of patients with AD develop cataract.

Susceptibility to infections
More than 90% of chronic eczematous lesions contain Staphylococcus aureus, often in large numbers. Increased susceptibility to generalized herpes simplex infection as well as widespread vaccinia infection (eczema vaccinatum) and complicated varicella.

Differential Diagnosis
Seborrhic dermatitis- greasy, yellow scaly patches on scalp, nasolabial folds and eyebrows. Irritant or allergic contact dermatitiseczematous patches, papules and plaques, with/out weeping, crusting and vesicles. Scabies nocturnal itching with characteristic burrows on skin. Psoriasis-pink- red, silvery scaly patches. Auspitz Sign positive.

General Management
Bathe the child daily with lukewarm water. Dont use hot or warm water as it may make skin red and itchy. Avoid scratching. Apply lotions, moisturizer or creams immediately after bathing to prevent skin dryness. Apply cold compression on skin lesions. Avoid exposure to sudden temperature changes.

Prevention
Avoid getting overheated or sweating too much. Avoid synthetic clothes. If possible, dress the child in 100% cotton clothes. Avoid using harsh soaps and chemicals. Avoid environmental factors that trigger allergies (e.g., pollens, molds, mites, and animal dander) Be aware of food items that may cause eczema and avoid those food items.

Contd.
Keep childs bedroom and play areas free of dust mites. Use mild soaps for bathing the child and washing his/ her clothes. Dress the child in preferably in cotton clothing. Wool should be avoided as the fibres are irritating. The patient should be aware that emotional stress can be an important factor in causing exacerbation. In adults with AD, relaxation techniques may be useful.

In Japan, Itamura and Hosoya studied 17 patients with intractable atopic dermatitis. These patients had previously failed conventional dermatological drug therapy. They were then treated with individualized homeopathic medical therapy, in addition to conventional dermatology therapy. The studys followup period was 6 to 31 months. The efficacy of homeopathic treatment was measured by objective assessments of the skin condition and the patients' own assessments, using a 9 point scale similar to the Glasgow Homeopathic Outcome Scale, was used. Over 50% improvement was reported in overall impression and in their skin conditions by all patients, in itchiness by 15 of the patients, in sleep disturbance by 10 out of 13 patients, in satisfaction in daily life by nine out of 12, in fulfillment at work by seven out of 11 and in satisfaction with human relations by 10 out of 14.
(Itamura R, Hosoya R. Homeopathy. 2003: 92; 108-114.)

Research Updates

In an observational study, Witt and colleagues studied 225 children with atopic eczema. The children were treated with homeopathic medicine and were allowed to also use conventional dermatology drugs. They were followed for 24 months. The severity of eczema in these patients improved and the changes in severity assessment were of large effect size. Reductions in the use of conventional dermatology drugs were observed.
(Witt CM, et.al. Acta Dermato Venereol. 2009: 89(2); 182-183.)

Keil and colleagues from the Institute for Social Medicine, Epidemiology, and Health Economics in Berlin, Germany studied 118 children suffering from atopic eczema. 54 children were treated with homeopathic medicine and 64 children were treated with conventional dermatology drugs. Both groups were followed for a period of 12 months. Children in both groups had their eczema symptoms improve. Disease-related quality of life improved equally in both groups. However, improvement of eczema as observed by physicians was significantly greater in the homeopathic group (p<0.001).
(Keil T, et.al. Complement Ther Med. 2008: Feb; 16(1): 15-21.)

Homoeopathy in paediatric atopic diseases: long-term results in children with atopic dermatitis
Aim To study the socio-demographic features, the prescribed remedies and the outcome of atopic diseases in children treated with homeopathy at the Homeopathic Clinic of Lucca (Italy), and the long-term outcome of children suffering from atopic dermatitis (AD) after an approximate 8-year period (range 510 years). Methods Our data derive from an observational longitudinal study carried out on 213 children (38.6%) with atopic diseases out of 551 children consecutively examined from September 1998 to December 2008. We used the Glasgow Homeopathic Hospital Outcome Score to evaluate the results that were classified on the basis of a Likert scale.

Results Eighty-three (39%) children were affected by asthma, 51 (24%) by allergic rhinoconjunctivitis, 76 (36%) by AD and 3 (1%) by food intolerance. Followup patients were 104 (48.8%), and 65 (62.5%) of them reported a major improvement or resolution. The parents of paediatric patients suffering from AD, who had started homeopathic treatment at <4.9 years of age were invited to follow-up assessment 8 years later and 40 children (mean age 12.9) were examined; 28/40 (70%) had a complete disappearance of AD, 12/40 children (30.0%) were still affected by AD; 8/40 (20%) had asthma and 8/40 patients had, or developed, allergic rhinitis. Conclusion These preliminary results seem to confirm a positive therapeutic effect of homeopathy in atopic children. Furthermore, according to the data from the literature paediatric patients treated with homeopathy seem to show a reduced tendency to maintain AD and develop asthma (and allergic rhinitis) in adult age. (Elio Rossi, et al. Homeopathy. Volume 101, Issue 1, Pages 1-80 (January 2012) .Page 13-20)

Prospective observational study of 42 patients with atopic dermatitis treated with homeopathic medicines
Background Atopic dermatitis (AD) is a highly prevalent chronic inflammatory skin disease which usually develops during childhood. Despite being a condition frequently treated with homeopathy, the evidence is still insufficient to define homeopathic treatments efficacy and the best therapeutic strategies. Aims To evaluate the effectiveness of homeopathic treatment of AD in a general homeopathic practice setting.

Methods Patients spontaneously seeking homeopathic treatment meeting Hanifin and Rajkas criteria were prospectively treated. Severity of disease was evaluated by Rajka and Langelands score and a set of four Visual Analogue Scales (VAS) evaluating disease severity, itch, general and psychological wellbeing and quality of sleep. Assessed outcomes were: change in AD extension, change in VASs, and a categorical scale for global subjective perception of evolution. Results Forty two patients were eligible. Twenty-one had other atopic comorbidities and 28 (66.7%) were moderate or severe cases. Sixteen (38.1%) patients dropped out. Significant differences were found comparing first and last consultations in mean percentage (95%CI) of affected skin area, 21.1% (10.9; 31.4) versus 5.5% (1.3; 9.7) respectively, P = 0.002, and in the change or the four VASs: [mm (95%CI)] AD 31.1 (20.6; 41.7), P < 0.0001; Itch 35.0 (23.6; 46.4), P < 0.0001; General wellbeing 11.1 (1.2; 20.9), P < 0.0188, and Sleep 17.4 (5.0; 29.8), P < 0.0073.

Homeopathic aggravations were reported after 29.8% of prescriptions. Twelve individualized homeopathic medicines were prescribed; Sulphur accounted for 60% of cases with good treatment response. Conclusions This study suggests that in a general medical practice setting, homeopathic treatment could be regarded as an effective choice for patients with AD. (Jos Enrique Eizayaga et al. Homeopathy. Volume 101, Issue 1, Pages 1-80 (January 2012). Pages 21-27)

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