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Moch Kurniawan

Defective skin barrier function

• Eczema is an inflammatory condition

of the skin

• In normal, healthy skin, the epidermis

acts as a protective barrier

• The stratum corneum consists of

dead skin cells held together by lipids

and proteins

• In eczema, the lipid layer is defective

causing:1

– Water loss

– Cracks in the outer layer of skin

(stratum corneum)

– Penetration of allergens and irritants

1. Cork MJ. (1997) The importance of skin barrier function. Journal of Dermatological Treatment (1997) 8, S7-13

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Allergy 2006: 61: 969–987

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www.eczemahelp.ca

*Robin Marks, Anne Plunkett, Kate Merlin, Nicole Jenner, Atlas of Common Skin Disease. Department of Dermatology, St Vincent’s

Hospital, Melbourne, Australia, 1999.

Prevalence of Atopic Dermatitis over all ages

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Color Textbook of Pediatric Dermatology, 4th Edition.

Infantile type Childhood type Adult type

Face, scalp, trunk, extensor surfaces

of extremities

Flexural folds of ext(antecubital, popliteal fossa)

neck, ankles

Upper arms, back, wrists, hands,

fingers, feet, toes

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Atopic eczema affects quality of life

Adapted from Jenner N et al. Australas J Dermatol 2004; 45(1): 16–22.

36

28

15

21

40

45

0 5 10 15 20 25 30 35 40 45 50

Spent >10 min/day applying treatments

Influenced the clothes they wore

Problems with treatment

Felt embarassed by their skin

Using 4 or more products

Itchy, sore, painful or stinging

Percentage of Patients (n = 85)

Therapeutic objectives for atopic dermatitis

Reduce signs and symptoms;

Prevent or reduce

recurrences

Provide long-term management by

preventing exacerbation;

Modify the course of the

disease

Dr C. Ellis et al British Journal of Dermatology 2003; 148 (Suppl. 63): 3–10

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The Consensus Conference on Pediatric Atopic Dermatitis

Role of Emollients

• Useful as first-line agents

• Ointment preferred over creams

• Frequent application recommended because of their short duration of action (6 hours)

General Measures

• Avoidance of irritating fabrics such as wool or synthetic in favor of cotton clothing

Topical Steroids

• Once or twice daily use of low- to medium-potencytopical steroids as first-line therapy for diseaseexacerbations

• Once controlled, topical steroids should be withdrawn or tapered to less potent or less frequent (twice weekly) application

• Steroids can be used safely if monitored appropriately

Oral Steroids

• Avoid use of systemic steroids because of their side effects

Topical non-steroidal immunosuppressive

therapies (eg, tacrolimus and pimecrolimus)

• Useful as intermittent, second-line therapy for moderate to severe AD (tacrolimus) or mild to moderate AD (pimecrolimus)

• Not approved for children less than 2 years of age

• Coordinated with sun protection because of concerns

Source: Eichenfield LF, Hanifin JM, Luger TA, et al. Consensus Conference on Pediatric Atopic Dermatitis. J Am Acad Dermatol. 2003;49:1088-1095.

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Cleansing

Moisturisation

Treatment

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Emollients

The most fundamental step in fighting atopic eczema is re-hydration

The principle mode of action of emollients is improving the depleted lipid barrier of

the skin thus reducing skin water loss

Reduce eczema flare ups and the need of topical steroids

Primary Care Dermatology Society & British Association of Dermatologists. Guidelines for the management of atopic eczema. October 2009. Cork MJ. (1997) The importance of skin barrier function. Journal of Dermatological Treatment (1997) 8, S7-13Prodigy – Quick Reference Guide. Emollients. [Online]. (URL www.prodigy.nhs.uk/Eczema-atopic). (Accessed 11 December 2006).

3 Stages of Emollient use in skin repair

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Emollients must be applied regularly and frequently…

• Every day, even when the skin looks clear

• In conjunction with other treatments during flare-ups

• Every 3-4 hours

• Helping patients to build emollient application into their daily routine can make it easier for them to adhere to

…and in the right quantities

• To get the most out of emollients, patients need to know how much they should use

• Illustrating how much emollient your patients should apply can be helpful

• Most pumps dispense approximately 4g

Adapted from Dunning G. Nursing Times 2005; 101 (4): 55-56

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Complete emollient therapy

• Giving patients a combination of different formulations and sizes can encourage themto use them regularly, frequently and in sufficient volume, for example:

– An ointment tub for use on severe areas or at night

– A large cream pump dispenser for daily moisturising and washing

– A smaller tube of cream or ointment for use when out and about

– A bath substitute as an alternative to cosmetic wash products

Prescribing emollients in sufficient volume

• 250-500g per week for children3

– Between 2-4 500g pump dispensers per month

• 600g per week for adults1

– 4 x 500g pump dispensers per month

• Pump dispensers are a good way to help patients:

– Use the correct volumes

– Reduce cross contamination

1. Primary Care Dermatology Society & British Association of Dermatologists. Guidelines for the management of

atopic eczema. October 2009.

3. NICE (2007) Clinical Guideline 57, London, December 2007

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Cleansing

Skin cleansing

• Ordinary soap can dry the skin and worsen itching.

• Ordinary soap contains sodium lauryl sulphate (SLS)which further aggravate and irritate skin.

• Ordinary soap can cause flare up and block theeffects of the treatment.

• The key to cleansing in children with atopicdermatitis is to be gentle due to the damaged,fragile stratum corneum.

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Skin cleansing

• Cleansing, with water, soap or a liquid cleanser, willaffect the moisture skin barrier

• Soap will bring about the greatest changes to thebarrier and increase skin pH

• Liquid facial cleansers are gentler, effecting lessdisruption of the barrier, with minimal change to skinpH, and can provide people with a cleanser that is acombination of surfactant classes, moisturizers andacidic pH in order to minimize disruption to the skinbarrier

Skin Therapy Letter • Editor: Dr. Stuart Maddin • Vol. 8 No. 3 • March 2003

Skin cleansing

• The dry skin of eczema is not caused by a lackof oil in the skin, but because the skin barrieris damaged, so that the skin cannot retainwater.

• This is why a skin regimen focused on bathing and moisturizing is your first defence against eczema flare-ups

www.eczemahelp.ca

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Skin cleansing

• Moisturising, mild pH-neutral or acidic cleansers should be used

• The use of bath oils free of fragrances and emulsifying agents is also recommended.

• Soaps and bubble baths should be avoided.

• Bathing time should not exceed 15 to 20 minutes

• Immediately after showering or bathing, a moisturiser should be applied.

http://skincare.dermis.net/content/e04erkrankt/e617/e620/index_eng.html

IRRITANTS

Sodium Lauryl Sulfate (SLS)

&

Sodium Laureth Sulfate (SLES)

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The skin's natural moisturizing factors are amino acids

The skin's natural moisturizing factors are amino acids

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Very mild and hypoallergenic. Weakly acidic, similar to the pH level of the

skin, leaving the skin without a taut feeling. Mild and gentle to the hair without leaving it

dry and coarse.

Amisoft is less irritant than SLS / SLES

0

1

2

3

0 1 2 3 4 5

Days

Re

ad

ing

Sodium LaurylSulfate

Amisoft

Water

A five day human patch testN=72 (age : 19-72, 30 men & 42 women)

Score Symptoms

0 No reaction

0.5 Slight erythema

1.0 Clear erythema &

hardening

2.0 Erythema &

vesiculation or

dryness

AJINOMOTO Co., Inc. AminoScience Lab. 2003.09.16.

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Prevention

•help soften the skin and lock in moisture

•should be applied after bathing and frequently throughout the day

Apply emollients and moisturizers

•If the results of the patch testing indicate an allergy, the patient should avoid all items that contain the allergen (substance causing the allergy)

Avoid allergens•The dermatologist will talk

about options for avoiding the substance(s) that is irritating the skin.

Avoid irritants

•If the patient wears gloves at work, it is important to realize that substances on the hands can get inside the gloves and irritate the skin, especially when more than one substance gets inside the gloves

Change work habits

Effective formulations for all types of skin

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www.eczemahelp.ca

The role of topical steroids• Topical steroids are widely used to relieve

acute symptoms and clear flare-ups

• They come as creams and ointments, and in a range of strengths

– So that patients can be given one that is ideal for the severity and location of their eczema

• Topical steroids should be applied to inflamed areas only and used twice a day at most

• They should be used sparingly and only for as long as is necessary to clear up the flare

– Fingertip units can be a useful way for patients to measure doses

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Prescribing topical steroids

• Topical steroids are usually prescribed using a step-wise approach:3

– Starting with the correct potency based on the severity of eczema

– Stepping down as the severity decreases

– Or stepping up as required

• The face and neck should normally only be treated with mild steroids – adverse effects are more likely in areas where the skin is thinner

3. NICE (2007) Clinical Guideline 57, London, December 2007

Akdis et al. J ALLERGY CLIN IMMUNOL JULY 2006

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DERMATOLOGY NURSING/December 2006/Vol. 18/No. 6

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