Atopic Dermatitis (Eczema) in Children

Definition

Atopic Dermatitis (AD) is an inflammatory skin reaction disease based on hereditary factors and enviromental factors, are chronic reccurent with symptoms are erythema, papules, vesicles, leprosy, squama and servere pruritus. If reccurent, Atopic dermatitis is usually accompanied by infections or allergies, psychological factors, or caused by chemicals or irritants. This disease is called atopic dermatitis, because as most sufferers by giving skin reactions based on Ig E and has tendency to suffer from asthma, rhinitis or both at a later date, known as the allergic march. Nevertheless, the term atopic dermatitis doesn’t always mean that the disease waqs based on the interaction of antigen with antybody. Another name for atopic dermatitis is atopic eczema, prurgo Besnier, and neurodermatitis.

Eczema can makes intolerable itching, inflammation, and sleep disorders. This disease affects about 10-20% of children. Typically the first episode befoe age 12 months and subsequent episodes will arise until a child is lost through a certain period. Most Children will recover from eczema before the of five years. A part of child will continue to have eczema until adulthood.

Etiology

There are several theories that can be associated with the etiology of AD:

1. Hereditary factors

Family history was found around 70% in all cases. In the control condition of atopic, Ig E production under the influence of a dominant gene or chromosome 11q13.

2. Imunologic

The increase of total Ig E antibodies and specific ig E in serum against antigens from food or by inhalation.

Various circumstances can exacerbate atopic dernatitis:

1. Emotional stress

2. Changes of temperature or humanity

3. Bacterila skin infection

4. Contact with substancees which are irritant clothing (especially wool)

5. Some children, food alergies can trigger atopic dermatitis.

How can food make Atopic Dermatitis?

Based on research of Double Blind Placebo Controlled Food Challenge (DBPCFC), almost 40% of infants and children with moderate and severe Atopic Dermatitis has history of food alergy. Infants an children with food allergies are generally accompanied by skin test (skin prick test) and positive specific. Ig E against various kinds of food. Despite this positive skin test to a particular food, doesn’t mean that the patient is allergic to those food, therefore, still needed a provocation test and elimination of these foods to determine for sure.

How can Inhaled Allergens make Atopic Dermatitis?

Inhaled allergens as a cause of Atopic Dermatitis (AD) can be throught contact, which can be proved by patch test, postive in 30-50% sufferer AD, or by inhalation. Postive reaction can be seen in house dust mite allergy, which one examination in vitro, 95% of AD patients contain specific Ig E postive to dust mite allergy compared to only 42% in patients with asthma ine USA. There should also be noted that AD can also be caused by other inhaled allergens such as domestic animal dander, mold or ragweed in countries with four seasons.

How relation between Allergic dermatitis and bacteria infection?

AD patients had a tendency to be accompanied by bacterial skin infection, usually Staphylococcus aureus, viruses and fungi. Staphylococcus can be found in 90% lesions of patients with AD and the number could reach 107 colony per cm square on the part of the lesions. Infections caused by staphylococcus bacteria will be released a toxin that works as a superantigen, activating macrophages and T lymphocytes, which then release histamine. Therefore, patients with AD with complicated infected by bacteria should be given a combination antibiotics against Staphylococcus and topical steroid drugs.

Histopathology

The appearance may look dependent on the course of the disease from a sufferer. In patients without skin lesions, the histopathological will have a mild hyperkeratosis, hyperplasia epiderm and mild inflammatory cell (lymphocytes) in the derm. In patients wich acute lesions, histopathological will have an intracellular edema (spongiosa) in the epiderm and intracellular edema.

If Chronic, the lesions will be lycenification, hystopatological will appear hyperplasia epiderm accompanied by the extension of the rete ridges, striking hyperkeratosis, and mild spongiosis. The number of Langerhans cells in the epidermis increases and mononuclear inflammatory cells in the derm is dominated by macrophages. Histopathological appearance of non-specific atopic dermatitis and in accordance with various other phases so the histopathological dermatitis is not used as parameter for diagnosis.

Clinical manifestations

Clinical Manifestations of atopic Dermatitis is itching, the presence of macular erythematous, chapel, or papulovesikel, which crusted eczematous area, lychenification and excoriations. Dryness of the skin and secondary infections. Based on the clinical appearance and age, Atopic dermatitis is divided into three types, namely:

A. Infant

Usually arisses at the age two months-two years. Generally begin as an itchy enough eritematous plaque on the check accompanied by development of intraepidermal vesicle which ruptured, then ruptured vesicle produces skin lesions with local damp crust. Predilection for the flexures, front and sides of the neck, eyelids, forehead, face, wrists, and dorsa of the feet and hands

B. Children

Usually arises at the age 4-10 years. The rash often appears and come back only on one several regions, especially the upper arm, elbow, or behind the front of the knee. Lesions are usually less eksudatif or not wet begin with a fairly itchy erythematous, scaly little chapel of infiltrates.

C. Adult

TYPE Acute
Poorly defined erythematous plaques, with or without scale Excoriations occur as a consequence of scratching and rubbing. Secondarily infected sites: pustules (usually follicular), crusts.
Chronic Lichenification a thickening of the skin with accentuation of skin markings, which results from repeated rubbing or scratching: diffusely lichenified areas; nodular lichenification (may be confused with prurigo nodularis)
Chronic Recurrent Papular and lichenified plaques, excoriations, pustules, erosions, dry and wet crusts, and cracks (fissures)
DISTRIBUTION Often generalized, with predilection for the flexures, front and sides of the neck, eyelids, forehead, face, wrists, and dorsa of feet and hands

1. Stigmata of atopic dermatitis: there are several clinical features and stigmata that occur in AD, namely: “WHITE DERMATOGRAPHISM” Scratches on the skin will cause redness AD patients within 10-15 second, followed by vasoconstrition that causes white line within the next 10-15 minutes. It is paradoxal vascular reactions of adaptation to changes in temperature in patients with AD. If AD had sufferer limb cold exposure, will be an accelerated cooling and heating deceleration compared with normal people.

2. Palm crease fold increment in the palm of the hand striking thought it is not typical sign for the AD.

3. Dennie Morgan lines or extra folds of skin under the eyes.

4. Buffed Nails Syndrome: nails look shiny because it’s always due to a sense of sangal itch scratched.

5. Allergic Shiner: is often found in patients with allergic disease due to repeated rubbing and scratching under the eye tissue with the consequents stimulation of melanocytes and increased melanin accumulation.

6. Hyperpigmentation: caused by continous scratching

7. Pilaris Keratotic: Dry skin, scaly, cracked and follicular hyperkeratotic

8. Delayed Blanch: injection of acetylcholine to patitient atopic mild erythema will delayed. This is caused by vasocontriction or increased capilarry permeability.

9. People with excessive sweating tend to sweat a lot so that AD increased pruritus

Diagnosis

A. Major Criterias (>3)

1. Pruritus

2. Typhical morphology and distribution:

- Infants and Children: the location most in face and extensor

3. Dernatitis are chronic recurrent

4. History of atopic patients or their families

B. Minor Criterias (>3)

1. Xerosis

2. Reactivation of the fast type skin test

3. Elevated levels of Ig E

4. Dermatitis on the mammary areola

5. Keilitis

6. Recurrent conjunctivitis

7. White dermographism/blanch delayed

Management