I- CONSTITUTIONAL ECZEMA – ATOPIC DERMATITIS:
1- Definition:
- Atopic dermatitis refers to all skin manifestations that occur in a subject genetically predisposed to the development of other atopic conditions: asthma, rhinitis, conjunctivitis. (1 manifestations of atopic hypersensitivity)
- It is the most common dermatosis in children
- Its prevalence is increasing 5% (1960) to 15 – 20% currently
- It starts in 60-70% of cases before 6 months (30 to 40 before 3 months), average age – 8 months
2- Physiopathology:
- Genetic and immunological factors
– Atopy is a personal and/or family tendency to produce Ac (IgE) when exposed to protein allergens (mites, hair, animal saliva, pollen, food…)
Allergen , Irritating,Surinfection,Stress Two types of atopic Dermatitis:
– Extrinsic atopic dermatitis or allergic: High blood hyper IgE and igE
– Intrinsic or non-allergic atopic dermatitis: no hyperlgE and has a lower risk of asthma
- Constituent or induced abnormalities of the epidermal barrier (deficit in fillagrin, increased insensitive water losses, abnormalities of surface skin lipids)
3- Clinical aspect:
- Eczema is a superficial inflammation of the skin accompanied by pruritus, and characterized by a polymorphic rash:
Erythema, vesicles, crusts, dander and forming crumbled closets.
Manual scraping is often preceded by equivalent movements as early as the 2nd month: friction, agitation, twitching
Location:
0 —- 2 years old
- Convex areas of the face: scalp, forehead, cheeks, chin (sparing the nose and peribuccal area).
- Ear lobule, sub and retro-ear crack.
- Thumb sucked.
- Face of limb extension or bending.
After 2 years
- Less affected face (retro-ear furrows, lips, peribuccal)
- bends (poplity creases, bends of the elbows).
- interfessional folds
- Hands, neck, back of feet, ankles.
- Very pruriginal lichened placard.
4- Diagnostic criteria:
A- after Hanifin JM, Rajka G. Diagnostic features of atopy dermatitis. Acta Derm Venereol (Stockh) 1980; (suppl. 92) : 44-7).
Three major criteria and at least three minor criteria are required for diagnosis.
a- Major criteria:
- Pruritus
- typical morphology and distribution
- lichenification of bends or linear appearance in adults,
- facial and extended faces in children and infants
- chronic or recurrent dermatosis
- personal or family history of atopy (asthma, allergic rhinitis, atopic dermatitis).
b- Minor criteria:
- xerosis;
- ichthyose/hyper-linearity palmaarity/pilar keratosis;
- skin reactions of immediate hypersensitivity (type 1);
- rise of hypereosinophilia serum IgE
- start at an early age
- tendency to skin infections (particularly golden Staphylococcus or Herpes simplex) in relation to impaired cell-mediated immunity;
- nipple eczema;
- cheilites;
- recurrent conjunctivitis;
- lower sub palpebral fold (Dennie-Morgan sign);
- keratocons;
- anterior sub capsular cataract;
- sub-orbital pigmentation;
- facial pallor/facial rash;
- pityriasis alba, dartres, eczema
- folds at the anterior part of the neck;
- pruritus to perspiration;
- intolerance to wool and lipid solvents;
- perifolocular aggravation;
- food intolerance
- changes influenced by the environment and/or emotional factors;
- white dermographism.
B- UK Working Party atopic dermatitis criteria:
- Mandatory criterion
Pruriginous dermatosis or parents reporting that the child is scratching or rubbing.
- associated with at least 3 following criteria
- personal history of bending folds (anteccubital pits, poplities, anterior sides of the ankles, neck) and/or cheeks in children under 10 years of age;
- personal history of asthma or allergic rhinitis (or atopic disease in a first-degree parent in children under 4 years of age);
- a history of diffuse skin xerose in the previous year;
- eczema reaching the cheeks, forehead or convexity of the limbs in children under 4 years of age;
- skin signs before the age of 2 (usable criteria for a child over 4 years of age).
Intensity and evolutionary monitoring of DA
5- Differential diagnosis:
In infants:
- Infantile seborrheic dermatitis, Leiner erythrodermia moussous:
Early start (first week of life)
Relatively limited contours
Location to seborrheic areas (scalp, seat, creases)
Lack of pruritus
Healing around 6 months
- Infant Gale
- Langerhansian Histiocytosis
In adults:
- Contact eczema
- Hematodermia
- Toxidermia
6- Evolution:
- By thrusts
- Trigger/aggravating factors: pneumallergens, trophallergens, psychological trauma, infectious, irritation…
- DA may disappear completely or persist into adulthood
- Resurgence in adolescence is possible
- Asthma develops around 3 years of age
7- Complications:
- Bacterial overinfection: impetiginization
- Viral overinfection
– Kaposi- Juliusberg syndrome – high fever herpetic infection, AEG
– Molluscum contagiosum
- Contact dermatitis at the topicals
8- Allergological balance:
- Skin tests Prick
- The dosage of total serique IgE
- The atopy patch-tests: cow's milk, flour, wheat, egg being evaluated
- Diagnostic Food Eviction Plan
- TPO (Oral Provocation Test
These tests are reserved for severe DAs and DAs with signs of food, respiratory or contact allergy
9- Prevention:
- Dietary
- Breastfeeding
- slow diversification
Introduce foods containing peanut oil, egg, fish and exotic fruits after one year
- Aeroallergenic:
- Mites: plush toys curtains, carpet
—-Cover of polyurethane mattresses
- Mold
- Pet hair and saliva
10- Treatment:
- Fighting inflammation:
- Dermocorticoids: Class II for trunk and limbs (Diprosone®) or III for face and seat (Tridésonit®)
- When pushing it is better to hit hard and not long!
- Counterindictation of general corticosteroid therapy (constant side effects, not effective short ttt)
- Tacrolimus locally: Protopic® gel: 1appl x2/pdt six weeks then maintenance ttt two appl per week to avoid relapse
- Infection control
- Maximum lukewarm bath with antiseptic foaming solution: septivon®
- Active general antibiotic therapy on staphylococcus
- Fighting dry skin
- Overgras bread, syndet: liquid cleansing gel without soap.
- Emollient cream
- Spa Cure: Roche Posay, Avène, St Gervais
- EXCEPTIONAL TREATMENT
- UVBTL01 phototherapy from 7-8 years old
- Ciclosporin in adults
hygienic-dietary advice
- Avoid wool or synthetic garments directly in contact with the skin (wearing cotton underwear)
- Cutting the nails (wearing mouffles, if intense pruritus)
- Avoid softeners and, if possible, replace laundry with glitter Marseille soap
- Humidify the apartment
- Avoiding people with herpes
- Vaccinations: controlling BCG outside of flare-ups
- Therapeutic education: New approach to atopic dermatitis. Its main objective is to improve the therapeutic alliance between the caregiver, the carer and his entourage to allow optimal care. Therapeutic education increases the effectiveness of treatment on pruritus and sleep. It appears to be beneficial in understanding the disease and managing it
CONTACT II-ECZEMA:
1- Physiopathology:
- Delayed hypersensitivity reaction to cell mediation
- 2 phases:
- Awareness: asymptomatic, a few days to several years.
Trigger
Topic already sensitized – 24 to 48 hours before
2- Clinical aspect:
- Erythematous phase
- Vesicular phase
- Oozing phase
- Desquamative phase
Pruritus
Crumbled-edged placards
topographical form:
- Face, genitals: edema
- Hand and feet: enshrined vesicles
symptomatic form:
- Nummular Eczema
- dysidrosis
photo-allergic form:
Face, upper and inf members
3- Differential diagnoses:
Irritation dermitis
| Contact ecrema | Irritarion dermatitis | |
| Skin lesions | Crumbled edges | Net edges |
| Topography | Overflows contact aone | limited to contact area |
| Symptomatology | Pruritus | Burn |
| Epidemiology | Reaches some sensitized topics | Reaches the majority of subjects |
| Histology | Spongiosis exocytosis | Epidermal necrosis |
| Epieutanés test | Positive | Negative |
- Other pruriginous vesicular dermatoses:
– Mycoses (dermatophyties, candidiasis)
– Herpes, shingles
– Gale
- Other eczemas:
– Atopic Dermatitis
– Varicose eczema
– Dysidiroic eczema
- Facial edema:
– Erysipelas
Zona
– Quincke's edema
– Insect bite
– Lupus, dermatomyositis
4- Etiology:
- Questioning
- Initial topography
- Trigger Circumstance
- Chronology
- Local treatments used
- Clinical review
- Topography
- Skin epips: patch tests
The test patches:
- Away from the eczema flare-up, corticosteroid therapy, anti-histamine ttt
- Play at 48 and 72 hours
- European standard battery (23 substances)
- Products brought in
- Specialized batteries (hairdressing, painting…)
- Photopatchs tests
- Relevance of tests
Causes identified:
- Occupational allergens, the most common occupational diseases compensated
- Start at the hands, improve during the holidays
- Building trade
- Hairdressing
- Health profession
- Topical medicine
- Cosmetic
- Clothing products
- Photo-allergens
- Metals: nickel /
5- Evolution, complications:
- If the allergen is removed: healing
- If persistent, think about corticosteroid allergies
- Otherwise:
- Superinfection
- Erythrodermia
- Socio-professional impact
6- Treatment:
- Eviction of the allergen sometimes difficult because ubiquitous
- Eviction list to be handed over to patients
- Thinking about cross-allergies
- Corticosteroid Class II, no indication of systemic corticosteroid
- If overinfection: antibiotic therapy 7 days without delaying treatment with dermocorticoids
- Occupational eczema: work stoppage, skin tests, occupational illness declaration in collaboration with occupational doctor
- Prevention: gloves, protective clothing
- No possibility of desensitization
Dr. Bariout's Course – Faculty of Constantine