SKIN ALLERGY DR. GRACE NS WARDHANA, SPKK

SKIN
      ALLERGY
Dr. Grace NS Wardhana, SpKK

ALLERGY ??

Allergic reaction:

- Vary from mild to harmful

- The tendency to develop allergies
 is often hereditary

Common Allergens:
- Airborne allergens:
 house dust mites, pollen (from weeds, grass &
 trees), molds, pets, cockroach
- Food allergens:
 cow’s milk, eggs, seafood, peanut and tree nut,
 soy, wheat
- Other allergens:
 insect stings, medicines, chemicals

Signs & Symptoms of Allergy:
- Vary from allergy to allergy and
 child to child

- Skin rash, itchy eyes, itchy & runny
 nose, sneezing, coughing, nasal
 congestion, throat tightness,
 difficulty breathing, and even shock
 (faintness or passing out)

ALLERGIC SKIN CONDITION
        - URTICARIA (HIVES)

  - ALLERGIC CONTACT DERMATITIS

- ATOPIC ECZEMA (ATOPIC DERMATITIS)

      - INSECT STING ALLERGY

         - DRUG ALLERGY

URTICARIA (HIVES)

… urticaria
- Red raised bumps or welts on the skin

- Can occur anywhere on the body

- ≤ 6 weeks: acute urticaria
  ≥ 6 weeks: chronic urticaria

- In some cases: accompanied by
  Angioedema (swelling in the deeper layers
  of the skin)

… urticaria
Common allergens:
       food
       medicines
       climate changes
       pets/animals
       pollen
       insect bites and stings
       infections
       stress
       exposure to the sun
       physical stimuli: pressure, cold, heat

… urticaria
- 15-25% of population: 1x urticaria

- Treatment:
   mild: won’t require treatment
   avoidance of the trigger
   antihistamine
   skin test

Allergic Contact Dermatitis

- Skin comes in direct contact
 with an allergen

- For instance: nickel, tatoo ink,
 cosmetics, diapers, etc

… allergic contact dermatitis

… allergic contact dermatitis

Atopic Eczema
             (Atopic Dermatitis)
Eczema (dermatitis):
    - a skin condition caused by
        inflammation of the skin
     - typically: itchy, red, dry, even
        cracked
     - can appear on any part of the body
     - it’s not contagious
     - it’s not allergy itself, but allergies can
        trigger eczema

…atopic eczema (atopic dermatitis)

Atopic Dermatitis (AD):
    - the most common of the many
         types of eczema
     -   “Atopic”: describes condition that
         occur when someone is overly sensitive to
         allergens in their environment
                 asthma, allergic rhinitis, AD
     -    common skin condition
     -    15-30% children, 10-20% adults
     -    incidence has increase 2-3 fold in the last
         30 yrs, possibly due to environmental and
         lifestyle changes

…atopic eczema

…atopic eczema (atopic dermatitis)

- AD in children:
    47,6% in their first year
    30% between ages 1-5

- The most children outgrow the
 condition, more recent studies:
 many continue to have relapses
 as teenagers and adults.

…atopic eczema

The cause:
interaction between
- environment
- immune system
- skin barrier dysfunction
- genetic (heredity)

…atopic eczema (atopic dermatitis)

Genetic factor:

- Atopic history (asthma, AD, allergic rhinitis)
      from both parents: 50-75 %
      from one of the parents: 30-50%

- An infant who has parent or sibling with AD,
  asthma or RA has a 60-80% chance of
  developing AD

- 80% of children with AD develop asthma or
  allergic rhinitis later in childhood

Skin barrier dysfunction in AD

Role of Food Allergen in AD

Atopic dermatitis and food allergy are co-
associated, but food allergy does not
cause atopic dermatitis

Foods may trigger exacerbations of atopic
dermatitis

Food allergy is more likely to play a role in
atopic dermatitis in infants and young
children with severe disease

Role of Food Allergen in AD
Foods should not be removed
from the diet of a child with
AD without determining a
specific clinical outcome and
a clear plan for reintroduction

   Foods should be re-
introduced within 3–4 weeks of
removal from the diet if no
clinical effect has been
observed

 An open food challenge is
the most appropriate way to
identify food as a trigger for
problematic atopic dermatitis

SIGNS & SYMPTOMS of ATOPIC DERMATITIS

- The main symptoms: ITCHING

- The itching can be severe and
 persistent, especially at night.
 Scratching the affected area
 causes a rash.
 The rash is red and patchy, and
 may be long-lasting (chronic) or
 come and go (recurring)

…atopic eczema (atopic dermatitis)

The usual location of the rash:

INFANT (ages 2 months – 2 years:
   - face      - neck
   - scalp     - arms
   - leg       - trunks

Atopic Dermatitis
in INFANT (2 months – 2 years)

Atopic Dermatitis
in INFANT (2 months – 2 years)

Atopic Dermatitis
             in INFANT (2 months – 2 years)

The rash is often crusted or oozes fluid

Atopic Dermatitis
in INFANT (2 months – 2 years)

…atopic eczema (atopic dermatitis)
..the usual location of the rash:

CHILDREN (ages 2 – 12 years) :

- In areas that bend: inside of the elbows, back of
  the knee
- Wrist
- Neck
- Arms & legs

May appear for the first time or may be a
continuitation of the infant phase

Atopic Dermatitis
in CHILDREN (2 – 12 years)

Atopic Dermatitis
       in CHILDREN (2 - 12 years)

Rubbing and scratching can
lead to infection

Atopic Dermatitis
in CHILDREN (2 - 12 years)

Atopic Dermatitis
in CHILDREN (2 - 12 years)

Atopic Dermatitis
in CHILDREN (2 - 12 years)

…atopic eczema (atopic dermatitis)
..the usual location of the rash:

ADOLESCENT & ADULTS:

- In areas that bend: inside of the elbows, back of
    the knee
-   Neck
-   Face
-   Arms & legs
-   Wrist

Adult-onset AD is rare, occurring in 9% to 14% of cases
Often improves as someone get older

Atopic Dermatitis
in INFANT (2 months – 2 years)

…atopic eczema (atopic dermatitis)

Skin diseases that mimic Atopic Dermatitis:

- Seborrhoic eczema
- Miliaria (prickly heat)

…skin disease that mimic AD

Seborrhoic Eczema:

skin has yellowish, oily, scaly patches on the scalp,
   face, and sometimes other parts of the body.

                                         Cradle cap

…skin disease that mimic AD
Miliaria
(prickly heat)

 Miliaria is a rash that
  develops in some people
  when they sweat more
  than usual. The rash is also
  sometimes called a sweat
  rash. It is not usually serious,
  but it can be itchy and
  uncomfortable.

 Miliaria is due to blockage
  of sweat ducts.

Skin conditions associated with AD:
      Dry skin (xerosis):                   Keratosis Pilaris:
-   due to skin barrier dysfunction   -   Rough bumps appear on the
-   lack of ceramide                      skin, mainly on the back and
                                          outer side of the upper arms.
-   dry skin is sensitive, easily
                                      -   May also appear on the thighs
    irrtitated, and itchy                 and buttocks

Skin conditions associated with AD:

    Atopic pleat or Dennie-                      Pityriasis alba:
         Morgan fold:                   -   Slightly scaly, round or oval, slightly
                                            white patches on the skin.
-   Reported in 60-8-0% patients
                                        -   More apparent in summer / after
-   Extra line on the lower eyelid          swimming
-   A distingusihing feature of AD or   -   Esp. in darker skinned children
    caused by rubbing the eye
                                        -   Incidence in AD children: 30-40%

Skin conditions associated with AD:

    Hyperlinear palmar :                             Cheilitis:
-    Many skin creases (lines) in the   -   Inflammation of the lips
     palms                              -   Cracks and scales on the lips

Skin conditions associated with AD:

     Periorbital eczema:             Hand and Feet Eczema
-   Eczema around the eyes       -    Eczema that affect the palms and
                                      the soles
-   Commonly caused and
                                 -    May develop tiny bubbles
    aggravated by rubbing and         (vesicles) which are intensely itchy
    scratching around the eyes

Skin conditions associated with AD:
      Skin infection
AD patients are more
predisposed to develop skin
infection. They are susceptible
to bacterial, viral and fungal
infection

…atopic eczema

Treatment:
    Avoiding dry skin

    One study has show that emollients may reduce
    the need for topical steroids by about 62%

Choosing the right emollient
-   No single emollient shown to superior

-   Not all of types emollients suit all people

-   The best emollient is one which the patient prefers
    because then they will use it more frequently.

-   Patients have a preference for one over the other based
    on lifestyle, cosmetic acceptability, personal choice,
    adverse reactions and cost

-   Cost is a major issue. Wide range of prices.

Choosing the right emollient

 Ceramide rich emollient more
 effective in blocking TEWL.

 Important to use ointments or thick
 creams containing high lipid
 content rather than watery ones.

Quantities of Emollient applied

 Use very liberally

 Explain that you cannot “overdose” as
  emollients do not contain any “active”
  drug

 Adults should expect to use about 1 x
  500 g tub each week a child 1 x 500 g
  every 2 weeks

Method of application

 Many times a day, 3 mins after
  bathing
 Avoid rubbing in (this causes irritation)
 Use light downward strokes to apply
 Should leave a thin film on skin surface

…atopic eczema

…treatment:
   - Avoiding irritants
   - Avoid excessive scrubbing &
     toweling
   - Avoid possible allergens
   - Controlling itching & scratching
   - Avoid becoming overheated

Avoid:
- Sodium lauryl sulphate (SLS)
- Methylparaben & propylparaben
- Propylene glycol stearate
- Sulfur
- Povidon iodine
- Heksaklorofen
- klorheksidin

…atopic eczema (atopic dermatitis)

Medicines:
    - Topical corticosteroids
    - Calcineurin inhibitors
    - Antihistamines
    - Oral corticosteroids
    - Cyclosporine
    - Interferon
    - Antibiotik / antiviral / antifungal if there
      is secondary infection

…atopic eczema (atopic dermatitis)

Topical corticosteroids         For a 3-6 month old child
                                   Entire face and neck – 1 FTU
                                   An entire arm and hand – 1 FTU
                                   An entire leg and foot – 1.5 FTUs
- First line treatment             The entire front of chest and abdomen – 1
                                    FTU
  and very effective               The entire back including buttocks – 1.5
                                    FTUs

- Using Finger Tip Unit (FTU)   For a 1-2 year old child
                                   Entire face and neck – 1.5 FTUs
  1 FTU = 0,5 g of cream           An entire arm and hand – 1.5 FTUs
                                   An entire leg and foot – 2 FTUs
                                   The entire front of chest and abdomen – 2
                                    FTUs
                                   The entire back including buttocks – 3 FTUs

…atopic eczema (atopic dermatitis)

Calcineurin inhibitor:
    - Pimecrolimus (Elidel®) & Tacrolimus
      (Protopic®)

    - The US FDA : caution when prescribing
      these medicines because of potential
      cancer risk.
      Only be used as directed, and only after
      trying other treatment options, are not
      approved for children younger than 2
      years of age

…atopic eczema (atopic dermatitis)

Coal Tar:
    - reduce itching
    - should not be used on skin that is very
      irritated

Antihistamines:
    - often used to treat itching and to help
      patient sleep when severe night
      itching is a problem

…atopic eczema (atopic dermatitis)

Oral Corticosteroids:
    - in severe cases
    - when the rash cover large areas

Cyclosporine & Interferon:
    - cytostatics
    - only used if other treatment is not
      succesful

Steroid Phobia

Insect Sting Allergy

- Can cause serious and even deadly reaction

- Insects: honeybee, yellow jackets, hornets,
  wasp, fire ants

- Symptoms: wheezing, trouble breathing,
  coughing, hoarseness, throat tightness,
  stomachache, vomiting, diarrhea, itchy-
  water-or swollen eyes, hives, red spots,
  swelling, and loss of conciousness

Insect Sting Allergy

Drug Allergy
     Drug allergies are a group of symptoms caused
     by an allergic reaction to a drug (medication).

The most common drug allergens:
    Antibiotics:
Penicillin
Sulfa drugs
Tetracycline
    Analgesics:
Codeine
Non-steroidal anti-inflammatory drugs (NSAIDs)
   Antiseizure:
Phenytoin
Carbamazepine

…drug allergy

Drug allergy symptoms

   Skin rash or hives
   Itchy skin
   Wheezing or other breathing problems
   Swelling of body parts
   Anaphylaxis, a life-threatening allergic
    reaction

Reactions can occur in any part of your
body.

…drug allergy

What is anaphylaxis?

 Anaphylaxis is a severe, life-threatening allergic reaction. This serious
  reaction happens within seconds to minutes after taking the drug.
  Patient may experience:
       Swelling of your body parts, with or without hives
       Light headedness or dizziness
       Sudden drop in your blood pressure, with or without loss of
consciousnes
       Shock, with damage to your internal organs

   Anaphylaxis requires emergency treatment to prevent death and
    damage to your internal organs.

   Treatment includes:
         Drugs (oxygen, adrenalin, antihistamine)
         Intravenous fluid

…drug allergy
Diagnosing Drug Allergy:

   When did you take the drug
   When did you stop the drug
   When did you problem begin
   What happened to you
   How long did your problem last
   What other prescription drugs did you take
   What other non-prescription drugs
   What health foods did you take
   What herbs did you take
   What minerals did you take
   What are the exact names
   What treatments did you get for the reaction

…drug allergy

Drug allergy treatment:
 For a mild reaction you may only have to stop
  the drug.

 For a more serious allergic drug reaction that is
  not life-threatening:
     Antihistamine
     to counteract the histamine released into
     your body during the reaction

     A non-steroidal anti-inflammatory drug or a
     corticosteroid : to reduce inflammation

…drug allergy

…drug allergy

Treating Allergy
There is no real cure for allergies, but it is possible to
relieve symptoms. The only real way to cope with them is
to reduce or eliminate exposure to allergens. That means
parents must educate their child early and often, not only
about the allergy itself, but also about what reaction they
will have if they consume or come into contact with the
allergen.

Informing any and all caregivers (childcare personnel,
teachers, extended family members, parents of your
child’s friends, etc) abut your child allergy is equally
important.

If reducing exposure to allergens isn’t possible or
ineffective, medications may be prescribed, including
antihistamines, corticosteroids, or epinephrine.

Thank You