When conventional therapy fails to treat atopic dermatitis

Prof DR Dr Ariyanto Harsono SpA(K)

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Atopic dermatitis is a disease that began to arise at the age of infants and children,

chronic and relapsing characterized by itching of the skin.inflammatory reactionbased on hereditary factors and environmental

factors,the symptoms are chronic recurrent erythema,

papules, vesicles, crusting, and skuama.

2Prof DR Dr Ariyanto Harsono SpA(K)

Atopic Dermatitis:

Itch that erupts Not eruption that itches


EducationHidration

EmolientMoisturizerWet dressing

Allergen/irritants avoidanceAntihistamineTopical Steroid


Conventional Therapy is not always safe

Topical steroid: cutaneous atrophy, striae, bruisability, telangiectasia

High-potency topical steroids can cause systemic side effects in children.


IgE

IL-4, IL-5IL-13


IgE

IL-4, IL-5IL-13

v

2

CD4+Th1 Cell

IFN-

CD8+Th1 Cell

DTH

Super antigen

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Spongious

InfiltrasiEosinofil

Udem


Kriteria Hanifin and Rajka

Kriteria mayor (minimal 3)

•Pruritus

•Characteristic Distribution and morphology of skin lesions

•Flexural Lichenification

•Facial and extensor Lichenification in babies and children

•Chronic

•History of family atopy




•Pruritus

•Characteristic Distribution

and morphology of skin lesions


•Facial and extensor

Lichenification in babies and children

•Kronik

•History of family atopy

•Riwayat atopi dan keluarga atopi




•Pruritus




•Facial and extensor

Lichenification in babies and

children

•Kronik

•History of family atopy13Prof DR Dr Ariyanto Harsono SpA(K)



•Pruritus




•Facial and extensor Lichenification

in babies and children

•Kronik

•History of family atopy 14Prof DR Dr Ariyanto Harsono SpA(K)



•Pruritus




•Facial and extensor in babies

and children

•Chronic

•History of family atopy15Prof DR Dr Ariyanto Harsono SpA(K)


Kriteria minor (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Stafilokokus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis





•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Skin Test positive•High IgE levels•Early Onset of age•Vulnerable of infections (Staphylococcus/herpes)•Tend to nonspesific dermatitis•Nipple eczema•Cheilitis•Recurrent Conjunctivitis



•Ichtyosis , palmar hyperlinearity, keratosis pilaris•Xerosis•Tes kulit positif•Peningkatan IgE serum•Onset usia muda•Mudah infeksi kulit (Stafilokokus/herpes)•Kecenderungan nonspesific dermatitis•Nipple eczema•Cheilitis•Reccurent conjunctivitis



Kriteria minor

•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism 24Prof DR Dr Ariyanto Harsono SpA(K)


Kriteria minor


•Dennie Morgan infraorbital fold•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythem•Pityriasis alba•Itch when sweating•Wool intolerant /lipid solvent•Perifollicular accentuation•Food Intolerant•Emotional and environmental influence •White dermatographism


Kriteria minor



Kriteria Hanifin and Rajka pada bayi

Kriteria mayor (minimal 2 mayor)

•History of family atopy•Evidence of pruritic Dermatitis•Dermatitis fasial, ekstensor, likenifikasi

Kriteria minor (minimal 1 minor)

•Xerosis/ichtyosis/hyperlinear palm•Perifollicular accentuation•Chronic scalp scalling•Periauricular fissures




•History of family atopy•Evidence of pruritic Dermatitis•Dermatitis fasial, ekstensor, lichenification




Kriteria Hanifin pada anak


•Pruritus•Characteristic Distribution and morphology of skin lesions•Dermatitis fasial, ekstensor selama bayi dan awal usia anak•Flexural lichenification dan linearity by adolescence•Chronic Dermatitis

Kriteria minor (minimal 1 minor)•Xerosis/ichtyosis/hyperlinear palm/keratosis pilaris

•IgE reactivity•Chronic scalp scalling•Perifollicular accentuation•Periauricular fissures 36Prof DR Dr Ariyanto Harsono SpA(K)


•Hand/foot dermatitis•Cheilitis•Kepekaan infeksi kulit (Herpes/Strep/S aureus)



•Hand/foot dermatitis•Cheilitis•Vulnerable of skin infetions (Herpes/Strep/S aureus)



•Hand/foot dermatitis•Cheilitis•Vulnerable of skin infetions (Herpes/Strep/staphilococcus)



Seborrhoic dermatitis

http://content.nejm.org/content/vol352/issue22/images/large/09f3.jpeg


Pompholix

Principle of Conventional Therapy

Eczema

Target for skin care

Target for anti inflammatory


Mild Moderate Severe

Mild to Moderate Potency Topical Steroids

Pimecrolimus

Tacrolimus

Oral Steroids

Cyclosporine, mycophenolate

Light treatment

New Treatment Strategy in AD

Emolient

Dry skin

Itching and/or early sign of inflammation

Flare


IVIG

Results: Anti-inflammatory activity

Stimutex-As + Saccharide Isomerate shows a significant anti-inflammatory activity when compared with control.

The anti-inflammatory activity of Stimutex-As + Saccharide Isomerate is equivalent to Dexamethasone, a moderately potent steroid.

*

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Saccharide Isomerate: Moisture Retention Efficacy

There were less moisture lost with saccharide isomerate compared to urea and glycerin at all humidity levels.

Saccharide Isomerate

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• Saccharide isomerate regulates and retains moisture in the skin at all humidity levels.

• The efficacy of saccharide isomerate has been tested and proven to be superior to urea and glycerin.


Safety Profile

• There were no serious adverse events reported except for 2 cases of erythema which were treated with topical steroids.


Arachidonic Acid (ARA)

Phospholiphase A

Cyccloxygenase Lipoxygenase

Prostaglandine

TXA

Prostacyclin

Leukotriene A

Leukotriene B

Leukotriene C

-linoleic acid

HETE,5-HETE, PAF50Prof DR Dr Ariyanto Harsono SpA(K)

Mechanism of IVIG blocking apoptosis via Procaspase-8 pathway

Macrophage Keratinocyte


Use of IVIG


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Thank you

When conventional therapy fails to treat atopic dermatitis

Education

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