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ECZEME/DERMATITE
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Terminologie Termenii de eczema/dermatita sunt
considerati sinonimi.
Termenul de dermatita este mai frecvent inliteratura anglo-americana, iar cel de eczemain cea francofona.
Etimologic, eczema deriva din limba greaca siinseamnaoparit .
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Eczema/dermatita= sindrom cutanat inflamator definit: Clinic: succesiune de modificari cutanate:
eritem, veziculatie, exsudatie, crustificare,descuamare si uneori lichenificare + prurit Histopatologic: spongioza, vezicule
spongiotice si infiltrat limfohistiocitarperivascular in dermul superior.
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Clinic
Sindrom clinic caracterizat prineritem, veziculaie, exudaie i
prurit
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eritem
papule
vezicule
pustule
exuda ! ie
cruste
scuame
ECZEM "
regresie
P R U R I T
vindecareprogresieEczem # cronic #
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Spongioza trasaturahistopatologica esentiala
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Vezicula spongiotica = veziculaclinic
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Eczeme
forme clinico-evolutive Eczem acut Eczem subacut
Eczem cronic
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Eczem # acut #
Eczem # subacut #
Eczem # cronic #
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ECZEM ! DE CONTACT CRONIC !
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Clasificarea eczemelor (dermatitelor) Dermatite exogene
Dermatita de contact Alergic (mecanism alergic) Iritativ (ortoergic ) - f r mecanism alergic
Eczeme (dermatite endogene Eczema (dermatita) atopic
Eczeme mixte (exo-endogene) Eczema numular Dishidroza, eczema dishidrozic Eczema (dermatita) de staz Eczema (dermatita) seboreic Eczema fisurar (craquel)
Eczema prin diseminare secundar
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I. Dermatite de contact iritative (f r
substrat alergic) Nu necesita expunere anterioara Zone afectate: locul contactului, extensie mica in jur
Susceptibilitate: universala Debutul leziunilor: rapid (ore de la expunere) Legatura cu expunerea: apar de la prima expunere
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II. Dermatite de contact alergice
Expunere anterioara este obligatorie Zone afectate: locul contactului, posibil si la distanta
Susceptibilitate: numai persoane sensibilizate Debutul leziunilor: lent (48 ore) Legatura cu expunerea: nu apar la prima expunere
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Dermatite de contact cu substrat alergic
Forme clinico-evolutive: acute subacute cronice
Teritorii limitate, sugernd contactul cu alergenul Diseminare:
hematogen transpiraie friciune
Forme clinice particulare: dermatite fotoalergice
dermatite de contact aeropurtate dermatite de contact pe cale sistemic
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Dermatita de contact alergic #
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D.C.A TANANTI
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Dermatita de contact alergic #-localiz #ri
! Cosmetice, deodorant,$ampon, lac de unghii! Gablon ! uri, nichel, crom! Agen ! i chimici,detergent, ciment! Plante
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Test epicutan (patch-test)
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Clasificarea eczemelor (dermatitelor) Dermatite exogene
Dermatita de contact Alergic (mecanism alergic) Iritativ (ortoergic ) - f r mecanism alergic
Eczeme (dermatite) endogene Eczema (dermatita) atopic
Eczeme mixte (exo-endogene) Eczema numular Dishidroza, eczema dishidrozic Eczema (dermatita) de staz Eczema (dermatita) seboreic Eczema fisurar (craquel)
Eczema prin diseminare secundar
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Eczema (dermatita) atopic Afec
iune cutanat
inflamatorie, cronic
, pruriginoas
, survenindla indivizi cu antecedente personale sau familiale de atopie
Prevalen variabil ( 0,5-20%), n continu cre tere, predominantla copii
Corela ie pozitiv a prevalenei cu nivelul socio-economic ridicat
i gradul de poluare "Ipoteza Igienei"( expunere insuficient la antigene bacteriene n copilrie n mediilefavorizate determin dezechilibru Th1/Th2,i manifestri de atopie)
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Imunitate celular # Dezechilibru Th1/Th2
Citokine proinflamatorii
Piele uscat #,deficit al secre ! iei
de sebum $i sudoare,prag redus de prurit
Blocaj al receptorilorbeta-adrenergici
Alergii alimentare$i de mediu
Nivel ridicat de IgE
Predispozi ! ie imunologic # ereditar #
Tip de personalitate: Astenic #, stres emo ! ional
ECZEMA ATOPIC "
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Stigmate de atopie
Pliuri Dennie-Morgan Halou periorbital
Dermografism alb Hiperliniaritate palmar #
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Eczema atopic #
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Lichen simplexcronic
(Neurodermit #)
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ECZEM " ERITRODERMIC "
ECZEMA HERPETICUM
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Criteriile de diagnostic Hanifin-Rajka CRITERII MINORE ( 3 DIN 23)
Xeroz cutanat Ichtioz/hiperlinairitate palmar/keratosis pilaris Reacii cutanate de hipersensibilitate imediat ( tipI) IgE seric crescut Debut n copilrie Tendin la infecii cutanate, aprare imun mediat celular
sczut Tendin la dermatite nespecifice palmo-platare Eczem perimamelonar
Cheilit Conjunctivit recurent Pliuri Dennie-Morgan Keratoconus Cataract subcapsular anterioar Hiperpigmentare periocular Paloare facial/ eritem Pitiriazis alba
Riduri anterocervicale Prurit asociat transpiraiei Intoleran la ln i detergeni Accentuare perifiolicular Intolerane alimentare Evoluie influenat de factori d emediu i emoionali Dermografism alb
CRITERII MAJORE(3 DIN 4)
" Prurit" Leziuni cutanate cumorfologie $i localizaretipic# " Dermatit # cronic # saurecidivant # " Antecedente personalesau familiale de atopie
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Criteriile Hanifin-Rajka
Prea complicate Utilizeaza date de laborator
Nu au fost niciodata validate in populatie Stabilite prin consens de experti
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Criteriile britanice de diagnostic a
dermatitei atopice Afectiune cutanata pruriginoasa
+
minimum 3 dintre urmatoarele: istoric de eruptie in zone flexurale istoric personal de astm sau febra de fan istoric de xeroza cutanata
debut sub varsta de 2 ani dermatita flexurala vizibilaSensibilitate: 74%; Specificitate: 99% (Romania)
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Criterii de diagnostic al DAconsensul Academiei Americane de Dermatologie 2001
CRITERII ESENIALE : prezente obligatoriu, cnd sunt ndeplinitecomplet, sunt sufiiente pentru diagnostic Prurit Leziuni eczematoase: morfologie tipic, specific vrstei Afectare facial, cervical i a suprafeelor de extensie la sugari i copii Leziuni flexurare prezente sau n antecedente la aduli/orice vrst Evoluie cronic, recidivant
CRITERII IMPORTANTE: prezente n majoritatea cazurilor, susindiagnosticul Debut precoce Atopie (IgE) crescut Xeroz cutanat CRITERII ASOCIATE, sugestive pentru diagnostic
Keratosis pilaris/ hiperlinearitate palmar R spuns vasomotor atipic Accentuare perifolicular, lichenificare/ prurigo Modificri perioculare/periorbitale Leziuni periorale/periauriculare
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Clasificarea eczemelor (dermatitelor) Dermatite exogene
Dermatita de contact Alergic (mecanism alergic) Iritativ (ortoergic ) - f r mecanism alergic
Eczeme (dermatite) endogene Eczema (dermatita) atopic
Eczeme mixte (exo-endogene) Eczema numular Dishidroza, eczema dishidrozic Eczema (dermatita) de staz Eczema (dermatita) seboreic Eczema fisurar (craquel) Eczema prin diseminare secundar
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Eczem # numular #
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Eczem # dishidrozic #
DISHIDROZ "
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ECZEM " SEBOREIC "
ECZEMASEBOREIC "
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Eczema de staz # (varicoasa)
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Clasificarea dermatocorticoizilor
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Necesarul de dermatocorticoid
- thefingertip unit (FTU) - A finger tip unit (FTU) is definedas the amount of ointment,cream or other semi-solid dosageform expressed from a tube witha 5mm diameter nozzle,appliedfrom the distal skin-crease to thetip of the index finger of anadult.
One FTU is enough to treat anarea of skin twice the size of theflat of an adult's hand with the
fingers together, i.e. ahandprint .
Finlay et al. Lancet, 1989
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2 FTU = 1g topic = 4palme= 4%
din suprafata corpului One handprint is 0.8% (i.e.approximately 1%) of the totalbody surface area, and one FTUcovers approximately two
handprints. As two FTUs are approximatelyequivalent to 1g of topicalapplication, theRule of Hand states that4 hand areas = 2FTU = 1g .
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Efecte adverse specifice ale corticoizilor
topici Efecte locale Atrofie cutanat, striuri,
telangiectazii Purpur steroid Ulceraii , pseudoescare Acnee steroid Hipertricoz Dermatit perioral Hiperpigmentare Hipopigmentare Alergii de contact Favorizarea infeciilor
Efecte sistemice Inhibiia axei hipotalamo-
hipofizo-cortico-suprarenalian Sindrom Cushing Hirsutism Vergeturi, purpur Acnee steroid Hipertensiune Hiperglicemie Galucom ntrzierea creterii la copii
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Traditional stepwise managementparadigm
Step 1: Dry skin only
Step 2: Mild to moderate AD
Step 3: Moderate to severe AD
Step 4: Recalcitrant, severe AD
Basic treatment: skin hydration, emollients,avoidance of irritants, identification and
addressing of specific trigger factors
Lowmid potency TCS or TCI*
(TCI if moderate AD not adequatelyresponsive or intolerant to TCS)
Midhigh potency TCS or TCI*(TCI if not adequately responsive
or intolerant to TCS)
Systemic therapy (e.g.ciclosporin A) or UV therapy
1. Akdis C, et al . Allergy 2006; 61:969987.2. Wollenberg A, et al. J Dtsch Dermatol Ges 2009; 7:117121.
* Over the age of 2 years. AD = atopic dermatitis; TCS = topicalcorticosteroid; TCI = topical calcineurin inhibitor
Many acute flares can be treated successfully using the stepwisetreatment paradigm 2 However, repeatedly recurrent flares constitute a frustrating and
frequent problem for both patient and physician 2
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