​Kembara Xtra - Medicine -Atopic Dermatitis

​Kembara Xtra - Medicine -Atopic Dermatitis 
Introduction 
A persistent, relapsing, inflammatory, and extremely itchy skin condition

More frequently than cases with a late onset, early-onset cases had concurrent allergen sensitivity.
May have a substantial impact on the patient's and their family's quality of life since repeated symptoms have an impact on lifestyle and mental health. Clinical phenotypical presentation is highly variable, suggesting complex pathogenesis.

Prevalence and incidence of disease 

 In the first six months of life, 45% of cases start, and 80-95% start before the age of five.
Before adolescence, 50–66% of afflicted children will experience a spontaneous remission.

 They might also experience a relapse of their childhood illness, mainly hand eczema, or late-onset dermatitis in adults.
Darker skinned people are more likely to be affected than white people, with a 60% incidence if one parent was previously afflicted and an 80% incidence if both parents were. The condition is 80% concordant in monozygotic twins.
Incidence
varies globally, but the inhabitants of all nations are impacted.
With Canada and Mexico as exceptions, the only reliable signal favors lower prevalence in rural than urban areas.
Nearly 20% of children and 10% of young people have this prevalence, which is still prevalent in later life. 2%

Pathophysiology and Etiology 
Atopic dermatitis is currently thought to be a systemic, Thelper cell-driven disease.
Changes to the stratum corneum cause transepidermal water loss and barrier function defects.
Interleukin-31 (IL-31) upregulation is thought to be a major factor in pruritus mediated by cytokines and neuropeptides rather than excessive histamine. Epidermal adhesion is reduced either as a result of (i) genetic mutation resulting in altered epidermal proteins or (ii) defect in immune regulation causing an altered inflammatory response.

Genetics: Epidermal and immune coding are likely implicated in the link recently discovered between atopic dermatitis (AD) and mutations in the filaggrin gene (FLG), which codes for a skin barrier protein.


Risk Elements 
The "itch-scratch cycle" (which boosts histamine release) Skin infections Emotional stress irritants in clothing and chemicals Extremely hot or cold climate Food allergy in youngsters (in some situations). Studies on whether breastfeeding reduces risk or increases risk come to conflicting conclusions.

 Exposure to tobacco smoke Repeated exposure to "hard" water, according to some data, may make the illness worse.
family history of allergic rhinitis, asthma, and atopy

Accompanying Conditions 

 Hyper-IgE syndrome (Job syndrome) - AD - Elevated IgE - Recurrent pyodermas - Decreased chemotaxis of mononuclear cells. Food sensitivity/allergy in many cases; strong association with asthma and allergic rhinitis.

Major symptoms must be present in order to diagnose AD. These symptoms include relapsing of the condition, family history, typical distribution, and morphology. The most common symptoms are itch (54%), dryness and scaling (19.6%), inflamed skin (7.2%), skin pain (8.2%), and sleep disturbance (11%)


clinical assessment 

skin symptoms are the main symptoms
Distribution of lesions: Infants have lesions on their trunk, face, and flexural surfaces, sparing the diaper; children have lesions on their antecubital and popliteal fossae; adults have lesions on their hands, foot, face, neck, upper chest, and genital regions.
The morphology of the lesions: Infants: erythema and papules; may also develop oozing, crusting vesicles; Children and adults: Chronic scratching and rubbing often results in lichenification and scaling (lichenification is uncommon in babies).
Associated symptoms include mild to moderate facial erythema.
- Infraorbital fold (Dennie sign/Morgan line) - Perioral pallor—Pityriasis alba (hypopigmented asymptomatic regions on the face and shoulders) —Atopic pleat —Dry skin developing into ichthyosis —Increased palmar linear lines
keratosis pilaris

Differential diagnoses include photosensitivity rashes, contact dermatitis (especially if only the face is affected), scabies, and seborrheic dermatitis (particularly in young children).
If only localized disease is present in adults, psoriasis or lichen simplex chronicus are possible diagnoses. Other rare pediatric disorders include ichthyosis vulgaris, Histiocytosis X, Wiskott-Aldrich syndrome, and ataxia-telangiectasia syndrome.

Laboratory Results 
Initial examinations (lab, imaging)
There is no diagnostic test.

Up to 80% of those with the condition have high serum IgE levels, however tests are rarely requested.
Eosinophilia frequently correlates with the severity of the illness.
The scoring system for atopic dermatitis (SCORAD), which includes points for area, intensity, and subjective symptoms.

Management 

Reduce flare-ups and regulate their frequency and intensity.
Steer clear of substances that can irritate you (such as wool and fragrances).
Minimize perspiration.
Taking a lukewarm (not hot) bath. Although there isn't any solid evidence to promote more frequent bathing, experts recommend at least twice weekly baths and post-bath skin care.

Don't use alkaline soaps. mildly acidic (pH 5-6) hypoallergenic cleansers that gently mechanically remove scale, crusts, and bacterial skin pollutants.
The sun may be beneficial.
• Increase the humidity in the home; • Minimize your interaction with water.

Avoid alcohol-containing lotions, and if your condition is particularly difficult to cure, look for a concomitant contact dermatitis.
Child Safety Considerations
Particularly in youngsters, prolonged use of powerful fluorinated corticosteroids may result in striae, hypopigmentation, or atrophy.

The First Line of Medicine
The mainstay of treatment, before any other intervention is taken into consideration, is frequent systemic lubrication with thick emollient creams (for example, Eucerin, Vaseline) over moist skin.
The "soak and seal" technique is advised.
0.5-1% topical hydrocortisone creams or ointments for infants and kids. The "fingertip unit [FTU]" dose should be used.
Adults should use topical corticosteroids with a higher potency in places besides their faces and skin folds.
For flare-ups, use short-term, higher strength corticosteroids; after that, reduce the dose to one that will control the dermatitis (creams are preferable).
Antihistamines for pruritus (10–25 mg of hydroxyzine before bed and as needed, for example).

Next Line
Topical immunomodulators for children older than two years old (tacrolimus or pimecrolimus). Regarding a possible cancer risk, the FDA has issued a black box warning (no increased incidence over the previous 15 years of clinical usage).
Combining plastic occlusion with topical medicine to increase absorption
Systemic steroids should be considered for 1 to 2 weeks in cases of severe AD (e.g., prednisone 2 mg/kg/day PO [max 80 mg/day] initially, tapered over 7 to 14 days). Oral steroids should be used extremely sparingly and are often saved for situations where immunotherapy is being evaluated.

Tricyclic doxepin used topically as a 5% cream may lessen pruritus.
At the first indication of a secondary skin infection, topical antibiotics should be applied right away. Modified Goeckerman regimen (tar and ultraviolet radiation).
Dupilumab, a biologic that targets IL-22, IL-17, and IFN-, has been given FDA approval to treat moderate-to-severe atopic dermatitis in adults and adolescents 12 to 17 years old. Phase 3 studies for kids aged 6 to 11 have just been finished, and they showed a significant improvement in QOL and symptom reduction. Together with topical corticosteroids, it is employed.


Problems to Refer 
Ophthalmology follow-up for cataract assessment if topical steroids were applied to the eyes for an extended period of time. Ophthalmology evaluation for chronic vernal conjunctivitis.
In the most severe cases and when the related mental health has an impact on quality of life, systemic immunotherapy (cyclosporine, azathioprine, methotrexate) should be taken into account.

Further Treatments 
Techniques to lessen the allergens from house mites (micropore filters on HVAC systems; impermeable mattress covers); Behavioral relaxation therapy to lessen scratching
Bleach baths may lessen staph colonization, but there isn't enough proof to say they're helpful for the condition.
Use 1/2 cup of regular home bleach (6% strength) in a full tub of water, soak for five to ten minutes, then pat the skin dry.


Healthcare Alternatives 

Probiotics may lessen the severity of the problem, hence minimizing the need for medicine. Evening primrose oil (which contains a high amount of fatty acids) may decrease prostaglandin synthesis and may accelerate the conversion of linoleic acid to omega-6 fatty acid.

Patient Follow-Up Monitoring
Check to be sure that the disturbance of the skin barrier has not led to the development of a secondary bacterial or fungal infection. Staphylococcus typically colonizes AD patients. Little evidence supports the normal use of antimicrobial therapies to minimize skin bacteria, but it is advised to cover Staphylococcus during clinical infection management.

Diet

Elimination trials may reveal particular "triggers" in specific patients.
According to conflicting beliefs, breastfeeding and maternal hypoallergenic diets may help certain newborns have less severe reactions.


90% of pediatric patients experience spontaneous remission by puberty due to their chronic condition, which declines with age.
Some people may still experience localized eczema, such as lichen simplex chronicus, eyelid dermatitis, or chronic hand or foot dermatitis.

Complications 
Patients with AD are more likely to develop cataracts. Skin infections (often caused by Staphylococcus aureus); occasionally subclinical
Eczema herpeticum, a generalized vesiculopustular eruption brought on by herpes simplex or vaccinia virus infection, can be quite unwell and necessitate hospitalization.
If fluorinated corticosteroids are applied to the face or skin folds, atrophy and/or striae may develop.
If extensive patches of skin are treated, especially if high-potency drugs and occlusion are used together, systemic absorption may happen.

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