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Lecture notes, cheat sheets
Dermatovenerology. Atopic dermatitis (most important)
Directory / Lecture notes, cheat sheets Table of contents (expand) LECTURE No. 3. Atopic dermatitis Atopic dermatitis (or diffuse neurodermatitis, endogenous eczema, constitutional eczema, diathetic prurigo) is a hereditary chronic disease of the whole body with a predominant skin lesion, which is characterized by polyvalent hypersensitivity and eosinophilia in the peripheral blood. Etiology and pathogenesis. Atopic dermatitis is a multifactorial disease. The model of multifactorial inheritance in the form of a polygenic system with a threshold defect is currently considered the most accurate. Thus, hereditary predisposition to atopic diseases is realized under the influence of provoking environmental factors. The inferiority of the immune response contributes to increased susceptibility to various skin infections (viral, bacterial and mycotic). Superantigens of bacterial origin are of great importance. An important role in the pathogenesis of atopic dermatitis is played by the inferiority of the skin barrier associated with a violation of the synthesis of ceramides: the skin of patients loses water, becoming dry and more permeable to various allergens or irritants that fall on it. The peculiarities of the psycho-emotional status of patients are of great importance. Characteristic features of introversion, depressiveness, tension and anxiety. Changes in the reactivity of the autonomic nervous system. There is a pronounced change in the reactivity of the vessels and the pilomotor apparatus, which is dynamic in nature in accordance with the severity of the disease. Children who had manifestations of atopic dermatitis at an early age represent a risk group for the development of atopic bronchial asthma and allergic rhinitis. Diagnostics. To make the correct diagnosis, basic and additional diagnostic criteria are used. The criteria proposed at the First International Symposium on Atopic Dermatitis are used as a basis. Main criteria. 1. Itching. The severity and perception of itching can be different. As a rule, itching is more disturbing in the evening and at night. This is due to the natural biological rhythm. 2. Typical morphology and localization of lesions: 1) in childhood: damage to the face, extensor surface of the limbs, torso; 2) in adults: rough skin with an accentuated pattern (lichenification) on the flexion surfaces of the limbs. 3. Family or individual history of atopy: bronchial asthma, allergic rhinoconjunctivitis, urticaria, atopic dermatitis, eczema, allergic dermatitis. 4. The onset of the disease in childhood. In most cases, the first manifestation of atopic dermatitis occurs in infancy. Often this is due to the introduction of complementary foods, the appointment of antibiotics for some reason, climate change. 5. Chronic relapsing course with exacerbations in the spring and autumn-winter seasons. This characteristic feature of the disease usually appears no earlier than 3-4 years of age. A continuous off-season course of the disease is possible. Additional criteria. 1. Xeroderma. 2. Ichthyosis. 3. Palmar hyperlinearity. 4. Follicular keratosis. 5. Increased level of immunoglobulin E in blood serum. 6. Tendency to staphyloderma. 7. Tendency to nonspecific dermatitis of the hands and feet. 8. Dermatitis of the breast nipples. 9. Cheilitis. 10. Keratoconus. 11. Anterior subcapsular cataract. 12. Recurrent conjunctivitis. 13. Darkening of the skin of the periorbital region. 14. Denny-Morgan infraorbital fold. 15. Paleness or erythema of the face. 16. White pityriasis. 17. Itching when sweating. 18. Perifollicular seals. 19. Food hypersensitivity. 20. White dermographism. Clinic. Age periodization. Atopic dermatitis usually manifests itself quite early - in the first year of life, although its later manifestation is possible. The duration of the course and the timing of remissions vary significantly. The disease can continue into old age, but more often its activity subsides significantly with age. There are three types of atopic dermatitis: 1) recovery up to 2 years (most common); 2) pronounced manifestation up to 2 years with subsequent remissions; 3) continuous flow. Currently, there is an increase in the third type of flow. At an early age, due to the imperfection of various regulatory systems of the child, various age-related dysfunctions, the effect of external provoking factors is much stronger. This may explain the decrease in the number of patients in older age groups. In a deteriorating environmental situation, the role of external factors is increasingly increasing. These include exposure to atmospheric pollution and professional aggressive factors, increased contact with allergens. Psychological stress is also significant. Atopic dermatitis proceeds, chronically recurring. Clinical manifestations of the disease change with the age of patients. During the course of the disease, long-term remissions are possible. The clinical picture of atopic dermatitis in children aged 2 months to 2 years has its own characteristics. Therefore, the infant stage of the disease is distinguished, which is characterized by an acute and subacute inflammatory nature of lesions with a tendency to exudative changes and a certain localization - on the face, and with a widespread lesion - on the extensor surfaces of the extremities, less often on the skin of the body. In the vast majority of cases, there is a clear connection with alimentary irritants. Initial changes usually appear on the cheeks, less often on the outer surfaces of the legs and other areas. Possible disseminated skin lesions. The lesions are located primarily on the cheeks, in addition to the nasolabial triangle, the unaffected skin of which is sharply demarcated from the lesions on the cheeks. The presence of rashes on the skin of the nasolabial triangle in a patient with atopic dermatitis at this age indicates a very severe course of the disease. Primary are erythematooedema and erythematosquamous foci. With a more acute course, papulovesicles, cracks, weeping, and crusts develop. Severe pruritus is characteristic (uncontrolled scratching during the day and during sleep, multiple excoriations). An early sign of atopic dermatitis may be milky crusts (the appearance on the skin of the scalp of oily brownish crusts, relatively tightly soldered to the reddened skin underlying them). By the end of the first - the beginning of the second year of life, exudative phenomena usually decrease. Infiltration and peeling of the foci are intensifying. Lichenoid papules and mild lichenification appear. Perhaps the appearance of follicular or pruriginous papules, rarely - urticaria elements. In the future, complete involution of rashes or a gradual change in morphology and localization with the development of a clinical picture characteristic of the second age period is possible. The second age period (childhood stage) covers the age from 3 years to puberty. It is characterized by a chronically relapsing course that often depends on the season (exacerbation of the disease in spring and autumn). Periods of severe relapse may be followed by prolonged remissions, during which children feel practically healthy. Exudative phenomena decrease, pruriginous papules, excoriations predominate, and a tendency to lichenification, which increases with age. Eczema-like manifestations tend to be clustered, most often appearing on the forearms and lower legs, resembling plaque eczema or eczematids. Often there are difficult-to-treat erythematosquamous rashes around the eyes and mouth. At this stage, typical lichenified plaques can also be present in the elbows, popliteal fossae, and on the back of the neck. The characteristic manifestations of this period also include dyschromia, which is especially noticeable in the upper back. With the development of vegetovascular dystonia, a grayish pallor of the skin appears. By the end of the second period, the formation of changes typical of atopic dermatitis on the face is already possible: pigmentation on the eyelids (especially the lower ones), a deep crease on the lower eyelid (Denny-Morgan symptom, especially characteristic of the exacerbation phase), in some patients thinning of the outer third of the eyebrows. In most cases, atopic cheilitis is formed, which is characterized by damage to the red border of the lips and skin. The process is most intense in the region of the corners of the mouth. Part of the red border adjacent to the oral mucosa remains unaffected. The process never passes to the oral mucosa. Erythema is typical with fairly clear boundaries, slight swelling of the skin and the red border of the lips is possible. After subsiding of acute inflammatory phenomena, lichenification of the lips is formed. The red border is infiltrated, flaky, on its surface there are multiple thin radial grooves. After the exacerbation of the disease subsides, infiltration and small cracks in the corners of the mouth may persist for a long time. The third age period (adult stage) is characterized by a lesser tendency to acute inflammatory reactions and a less noticeable reaction to allergic stimuli. Patients mainly complain of pruritus. Clinically, lichenified lesions, excoriations, and lichenoid papules are most characteristic. Eczema-like reactions are observed mainly during periods of exacerbation of the disease. Severe dryness of the skin, persistent white dermographism, and a sharply enhanced pilomotor reflex are characteristic. Age periodization of the disease is not observed in all patients. Atopic dermatitis is characterized by a polymorphic clinical picture, including eczematous, lichenoid and pruriginous manifestations. Based on the predominance of certain rashes, a number of such clinical forms of the disease in adults can be distinguished, such as: 1) lichenoid (diffuse) form: dryness and dyschromia of the skin, biopsy pruritus, severe lichenification, a large number of lichenoid papules (hypertrophied triangular and rhombic skin fields); 2) eczema-like (exudative) form: most characteristic of the initial manifestations of the disease, but in adults, the clinical picture of the disease may have a predominance of skin changes such as plaque eczema, eczematis and eczema of the hands; 3) prurigo-like form: characterized by a large number of pruriginous papules, hemorrhagic crusts, excoriations. Among the dermatological complications of atopic dermatitis, the first place is occupied by the addition of a secondary bacterial infection. In cases where staphylococcal infection predominates, they speak of pustulization. If the complication of the disease is due mainly to streptococci, impetiginization develops. Often develops sensitization to streptococci and eczematization of foci of streptoderma. With prolonged existence of inflammatory changes in the skin, dermatogenic lymphadenopathy develops. Lymph nodes can be significantly enlarged and of a dense consistency, which leads to diagnostic errors. Treatment. Therapeutic measures for atopic dermatitis include active treatment in the acute phase, as well as constant strict adherence to the regimen and diet, general and external treatment, and climatic therapy. Before starting therapy, it is necessary to conduct a clinical and laboratory examination, to identify factors that provoke an exacerbation of the disease. For the successful treatment of atopic dermatitis, the detection and control of risk factors that cause an exacerbation of the disease (triggers - alimentary, psychogenic, meteorological, infectious and other factors) are very important. The exclusion of such factors greatly facilitates the course of the disease (sometimes to complete remission), prevents the need for hospitalization and reduces the need for drug therapy. In the infantile phase, nutritional factors usually come to the fore. Identification of such factors is possible with sufficient activity of the child's parents (careful keeping of a food diary). In the future, the role of food allergens is somewhat reduced. Patients with atopic dermatitis should avoid foods rich in histamine (fermented cheeses, dried sausages, sauerkraut, tomatoes). Among non-food allergens and irritants, dermatophagoid mites, animal hair, and pollen occupy a significant place. Colds and respiratory viral infections can exacerbate atopic dermatitis. At the first symptoms of a cold, it is necessary to start taking hyposensitizing drugs. In young children, such nutritional factors as enzymatic deficiency and functional disorders are of great importance. It is advisable for such patients to prescribe enzymatic preparations, to recommend treatment at gastrointestinal resorts. With dysbacteriosis, intestinal infections, a targeted correction is also carried out. With mild exacerbations of the disease, you can limit yourself to the appointment of antihistamines. Most often, blockers of the H1-receptors of histamine of the new generation (cetirizine, loratadine) are used, which do not have a sedative side effect. Preparations of this group reduce the body's response to histamine, reducing spasms of smooth muscles caused by histamine, reduce capillary permeability, and prevent the development of tissue edema caused by histamine. Under the influence of these drugs, the toxicity of histamine decreases. Along with the antihistamine action, the drugs of this group also have other pharmacological properties. For moderate exacerbations of the disease, in most cases it is advisable to begin therapy with intravenous infusions of solutions of aminophylline (2,4% solution - 10 ml) and magnesium sulfate (25% solution - 10 ml) in 200-400 ml of isotonic sodium chloride solution ( daily, 6-10 infusions per course). In the lichenoid form of the disease, it is advisable to include atarax or antihistamines with a sedative effect in therapy. For an eczema-like form of the disease, atarax or cinnarizine is added to therapy (2 tablets 3 times a day for 7-10 days, then 1 tablet 3 times a day). It is also possible to prescribe antihistamines that have a sedative effect. External therapy is carried out according to the usual rules - taking into account the severity and characteristics of inflammation in the skin. The most commonly used creams and pastes containing antipruritic and anti-inflammatory substances. Naftalan oil, ASD, wood tar are often used. To enhance the antipruritic action, phenol, trimecaine, diphenhydramine are added. In the presence of an acute inflammatory reaction of the skin with weeping, lotions and wet-drying dressings with astringent antimicrobial agents are used. With the complication of the disease by the addition of a secondary infection, stronger antimicrobial agents are added to the external agents. Externally, for mild to moderate exacerbations of atopic dermatitis, short courses of topical steroids and topical calcineurin inhibitors are used. External use of drugs containing glucocorticosteroids in atopic dermatitis is based on their anti-inflammatory, epidermostatic, coreostatic, anti-allergic, local anesthetic actions. In case of severe exacerbation of the process, it is advisable to carry out a short course of treatment with glucocorticosteroid hormones. The drug betamethasone is used. The maximum daily dose of the drug is 3-5 mg with gradual withdrawal after achieving a clinical effect. The maximum duration of therapy is 14 days. For severe exacerbations of atopic dermatitis, it is also possible to use cyclosporine A (daily dose 3-5 mg per 1 kg of patient body weight). Most patients in the acute phase require psychotropic medications. A long course of itchy dermatosis often provokes the appearance of significant general neurotic symptoms. The first indication for prescribing drugs that inhibit the function of cortico-subcortical centers is persistent night sleep disorders and general irritability of patients. For persistent sleep disturbances, sleeping pills are prescribed. To relieve excitability and tension, small doses of atarax are recommended (25-75 mg per day in separate dosages during the day and at night), a drug that has a pronounced sedative, as well as antihistamine and antipruritic effect. The use of physical factors in therapy should be strictly individual. It is necessary to take into account the forms of the disease, the severity of the condition, the phase of the disease, the presence of complications and concomitant diseases. In the phase of stabilization and regression, as well as as a prophylactic, general ultraviolet irradiation is used. Prevention. Preventive measures should be aimed at preventing relapses and severe complicated course of atopic dermatitis, as well as preventing the occurrence of the disease in risk groups. Author: Sitkalieva E.V. << Back: Parasitic dermatoses (Scabies. Lice) >> Forward: Viral dermatoses (Herpes viral infections. Human papillomavirus infection. Molluscum contagiosum)
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