Atopic Dermatitis Treatment:

from Conventional to Unconventional

Prof Ariyanto Harsono MD PhD SpA(K)

Atopic dermatitis is a disease that begin to arise at
the age of infants and children
 characterized by itching of the skin.
 chronic and relapsing
 inflammatory reaction
 based on hereditary factors and environmental
factors,
 the symptoms are chronic recurrent erythema,
papules, vesicles, crusting, and skuama.

Prof DR Dr Ariyanto Harsono SpA(K) 2

Atopic Dermatitis:

Itch that erupts

Not eruption that itches

Prof DR Dr Ariyanto Harsono SpA(K) 3

Prof DR Dr Ariyanto Harsono SpA(K) 4
Prof DR Dr Ariyanto Harsono SpA(K) 5
 IL-4, IL-5
IL-13
IgE

Prof DR Dr Ariyanto Harsono SpA(K) 6

 v

2 IL-4, IL-5
Super antigen IL-13
IgE
CD4+Th1 Cell
CD8+Th1 Cell
IFN-γ DTH 7
Prof DR Dr Ariyanto Harsono SpA(K)
 Spongious

Udem Infiltrasi
Eosinofil

Prof DR Dr Ariyanto Harsono SpA(K) 8

 Hanifin and Rajka criteria
Major criteria (minimal 3)

•Pruritus
•Characteristic Distribution and morphology of skin lesions
•Flexural Lichenification
•Facial and extensor Lichenification in babies and children
•Chronic
•History of family atopy

Prof DR Dr Ariyanto Harsono SpA(K) 9

 Hanifin and Rajka criteria
Major criteria (minimal 3)

•Pruritus
•Characteristic Distribution
and morphology of skin lesions
•Flexural Lichenification
•Facial and extensor
Lichenification in babies and children
•Kronik
Prof DR Dr Ariyanto Harsono SpA(K) 10
•History of family atopy
 Hanifin and Rajka criteria
Major criteria (minimal 3)
•Pruritus
•Characteristic Distribution
and morphology of skin lesions
•Flexural Lichenification
•Facial and extensor
Lichenification in babies and
children
•Kronik
Prof DR Dr Ariyanto Harsono SpA(K) 11
•History of family atopy
 Hanifin and Rajka criteria
Major criteria (minimal 3)

•Pruritus
•Characteristic Distribution
and morphology of skin lesions
•Flexural Lichenification
•Facial dan ekstensor pada bayi
dan anak
•Kronik
Prof DR Dr Ariyanto Harsono SpA(K) 12
•History of family atopy
 Kriteria
Hanifin and
Hanifin
Rajkaand
criteria
Rajka
Major criteria (minimal 3)

•Pruritus
•Characteristic Distribution
and morphology of skin lesions
•Flexural Lichenification
•Facial and extensor in babies
and children
•Chronic
Prof DR Dr Ariyanto Harsono SpA(K) 13
•History of family atopy
 Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris

•Xerosis
•Skin Test positive
•High IgE levels
•Early Onset of age
•Vulnerable of infections (Stafilokokus/herpes)
•Tend to nonspesific dermatitis
•Nipple eczema
•Cheilitis
•Recurrent Conjunctivitis
Prof DR Dr Ariyanto Harsono SpA(K) 14
 Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris

•Xerosis
•Skin Test positive
•High IgE levels
•Early Onset of age
•Vulnerable of infections (Stafilokokus/herpes)
•Tend to nonspesific dermatitis
•Nipple eczema
•Cheilitis
•Recurrent Conjunctivitis
Prof DR Dr Ariyanto Harsono SpA(K) 15
 Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris

•Xerosis
•Skin Test positive
•High IgE levels
•Early Onset of age
•Vulnerable of infections (Stafilokokus/herpes)
•Tend to nonspesific dermatitis
•Nipple eczema
•Cheilitis
•Recurrent Conjunctivitis
16
 Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris

•Xerosis
•Skin Test positive
•High IgE levels
•Early Onset of age
•Vulnerable of infections (Stafilokokus/herpes)
•Tend to nonspesific dermatitis
•Nipple eczema
•Cheilitis
•Recurrent Conjunctivitis
17
 Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris

•Xerosis
•Skin Test positive
•High IgE levels
•Early Onset of age
•Vulnerable of infections (Stafilokokus/herpes)
•Tend to nonspesific dermatitis
•Nipple eczema
•Cheilitis
•Recurrent Conjunctivitis
Prof DR Dr Ariyanto Harsono SpA(K) 18
 Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris

•Xerosis
•Skin Test positive
•High IgE levels
•Early Onset of age
•Vulnerable of infections (Stafilokokus/herpes)
•Tend to nonspesific dermatitis
•Nipple eczema
•Cheilitis
•Recurrent Conjunctivitis
Prof DR Dr Ariyanto Harsono SpA(K) 19
 Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris

•Xerosis
•Skin Test positive
•High IgE levels
•Early Onset of age
•Vulnerable of infections (Stafilokokus/herpes)
•Tend to nonspesific dermatitis
•Nipple eczema
•Cheilitis
•Recurrent Conjunctivitis
Prof DR Dr Ariyanto Harsono SpA(K) 20
 Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris

•Xerosis
•Skin Test positive
•High IgE levels
•Early Onset of age
•Vulnerable of infections (Stafilokokus/herpes)
•Tend to nonspesific dermatitis
•Nipple eczema
•Cheilitis
•Recurrent Conjunctivitis
Prof DR Dr Ariyanto Harsono SpA(K) 21
 Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris

•Xerosis
•Skin Test positive
•Vulnerable of infections (Stafilokokus/herpes)
•High IgE levels
•Early Onset of age
•Tend to nonspesific dermatitis
•Nipple eczema
•Cheilitis
•Recurrent Conjunctivitis
22
 Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris

•Xerosis
•Skin Test positive
•High IgE levels
•Early Onset of age
•Vulnerable of infections (Staphylococcus/herpes)
•Tend to nonspesific dermatitis
•Nipple eczema
•Cheilitis
•Recurrent Conjunctivitis
Prof DR Dr Ariyanto Harsono SpA(K) 23
 Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris

•Xerosis
•Skin Test positive
•High IgE levels
•Early Onset of age
•Vulnerable of infections (Stafilokokus/herpes)
•Tend to nonspesific dermatitis
•Nipple eczema
•Cheilitis
•Recurrent Conjunctivitis
Prof DR Dr Ariyanto Harsono SpA(K) 24
 Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris

•Xerosis
•Skin Test positive
•High IgE levels
•Early Onset of age
•Vulnerable of infections (Stafilokokus/herpes)
•Tend to nonspesific dermatitis
•Nipple eczema
•Cheilitis
•Recurrent Conjunctivitis
Prof DR Dr Ariyanto Harsono SpA(K) 25
 Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris

•Xerosis
•Skin Test positive
•High IgE levels
•Early Onset of age
•Vulnerable of infections
•Tend to nonspesific dermatitis
•Nipple eczema
•Cheilitis
•Recurrent Conjunctivitis
26
 Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris

•Xerosis
•Skin Test positive
•High IgE levels
•Early Onset of age
•Vulnerable of infections (Stafilokokus/herpes)
•Tend to nonspesific dermatitis
•Nipple eczema
•Cheilitis
•Recurrent Conjunctivitis
Prof DR Dr Ariyanto Harsono SpA(K) 27
 Hanifin and Rajka criteria

Minor criteria (minimal 3)

•Ichtyosis , palmar hyperlinearity, keratosis pilaris

•Xerosis
•Tes kulit positif
•Peningkatan IgE serum
•Onset usia muda
•Mudah infeksi kulit (Stafilokokus/herpes)
•Kecenderungan nonspesific dermatitis
•Nipple eczema
•Cheilitis
•Reccurent conjunctivitis
Prof DR Dr Ariyanto Harsono SpA(K) 28
 Kriteria
Hanifin and
Hanifin
Rajkaand
criteria
Rajka

Minor criteria
•Dennie Morgan infraorbital fold
•Keratoconus
•Anterior subcapsular cataract
•Orbital darkening
•Facial pallor/erythem
•Pityriasis alba
•Itch when sweating
•Wool intolerant /lipid solvent
•Perifollicular accentuation
•Food Intolerant
•Emotional and environmental influence
•White dermatographism Prof DR Dr Ariyanto Harsono SpA(K) 29
 Kriteria
Hanifin and
Hanifin
Rajkaand
criteria
Rajka

Minor criteria
•Dennie Morgan infraorbital fold
•Keratoconus
•Anterior subcapsular cataract
•Orbital darkening
•Facial pallor/erythem
•Pityriasis alba
•Itch when sweating
•Wool intolerant /lipid solvent
•Perifollicular accentuation
•Food Intolerant
•Emotional and environmental influence
•White dermatographism Prof DR Dr Ariyanto Harsono SpA(K) 30
 Hanifin and Rajka criteria

Minor criteria
•Dennie Morgan infraorbital fold
•Keratoconus
•Anterior subcapsular cataract
•Orbital darkening
•Facial pallor/erythem
•Pityriasis alba
•Itch when sweating
•Wool intolerant /lipid solvent
•Perifollicular accentuation
•Food Intolerant
•Emotional and environmental influence
•White dermatographism Prof DR Dr Ariyanto Harsono SpA(K) 31
 Hanifin and Rajka criteria

Minor criteria
•Dennie Morgan infraorbital fold
•Keratoconus
•Anterior subcapsular cataract
•Orbital darkening
•Facial pallor/erythem
•Pityriasis alba
•Itch when sweating
•Wool intolerant /lipid solvent
•Perifollicular accentuation
•Food Intolerant
•Emotional and environmental influence
•White dermatographism Prof DR Dr Ariyanto Harsono SpA(K) 32
 Hanifin and Rajka criteria

Minor criteria
•Dennie Morgan infraorbital fold
•Keratoconus
•Anterior subcapsular cataract
•Orbital darkening
•Facial pallor/erythem
•Pityriasis alba
•Itch when sweating
•Wool intolerant /lipid solvent
•Perifollicular accentuation
•Food Intolerant
•Emotional and environmental influence
•White dermatographism Prof DR Dr Ariyanto Harsono SpA(K) 33
 Kriteria
Hanifin and
Hanifin
Rajkaand
criteria
Rajka

Minor criteria
•Dennie Morgan infraorbital fold
•Keratoconus
•Anterior subcapsular cataract
•Orbital darkening
•Facial pallor/erythem
•Pityriasis alba
•Itch when sweating
•Wool intolerant /lipid solvent
•Perifollicular accentuation
•Food Intolerant
•Emotional and environmental influence
•White dermatographism Prof DR Dr Ariyanto Harsono SpA(K) 34
 Kriteria
Hanifin and
Hanifin
Rajkaand
criteria
Rajka

Minor criteria
•Dennie Morgan infraorbital fold
•Keratoconus
•Anterior subcapsular cataract
•Orbital darkening
•Facial pallor/erythem
•Pityriasis alba
•Itch when sweating
•Wool intolerant /lipid solvent
•Perifollicular accentuation
•Food Intolerant
•Emotional and environmental influence
•White dermatographism Prof DR Dr Ariyanto Harsono SpA(K) 35
 Kriteria
Hanifin and
Hanifin
Rajkaand
criteria
Rajka

Minor criteria
•Dennie Morgan infraorbital fold
•Keratoconus
•Anterior subcapsular cataract
•Orbital darkening
•Facial pallor/erythem
•Pityriasis alba
•Itch when sweating
•Wool intolerant /lipid solvent
•Perifollicular accentuation
•Food Intolerant
•Emotional and environmental influence
•White dermatographism Prof DR Dr Ariyanto Harsono SpA(K) 36
 Kriteria
Hanifin and
Hanifin
Rajkaand
criteria
Rajka

Minor criteria
•Dennie Morgan infraorbital fold
•Keratoconus
•Anterior subcapsular cataract
•Orbital darkening
•Facial pallor/erythem
•Pityriasis alba
•Itch when sweating
•Wool intolerant /lipid solvent
•Perifollicular accentuation
•Food Intolerant
•Emotional and environmental influence
•White dermatographism Prof DR Dr Ariyanto Harsono SpA(K) 37
 Kriteria
Hanifin and
Hanifin
Rajkaand
criteria
Rajka

Minor criteria
•Dennie Morgan infraorbital fold
•Keratoconus
•Anterior subcapsular cataract
•Orbital darkening
•Facial pallor/erythem
•Pityriasis alba
•Itch when sweating
•Wool intolerant /lipid solvent
•Perifollicular accentuation
•Food Intolerant
•Emotional and environmental influence
•White dermatographism Prof DR Dr Ariyanto Harsono SpA(K) 38
 Kriteria
Hanifin and
Hanifin
Rajkaand
criteria
Rajka

Minor criteria
•Dennie Morgan infraorbital fold
•Keratoconus
•Anterior subcapsular cataract
•Orbital darkening
•Facial pallor/erythem
•Pityriasis alba
•Itch when sweating
•Wool intolerant /lipid solvent
•Perifollicular accentuation
•Food Intolerant
•Emotional and environmental influence
•White dermatographism Prof DR Dr Ariyanto Harsono SpA(K) 39
 Hanifin and Rajka criteria

Minor criteria
•Dennie Morgan infraorbital fold
•Keratoconus
•Anterior subcapsular cataract
•Orbital darkening
•Facial pallor/erythem
•Pityriasis alba
•Itch when sweating
•Wool intolerant /lipid solvent
•Perifollicular accentuation
•Food Intolerant
•Emotional and environmental influence
•White dermatographism Prof DR Dr Ariyanto Harsono SpA(K) 40
Hanifin and Rajka criteria for baby
Kriteria
Major criteria(minimal
mayor (minimal2 2major)
mayor)

•History of family atopy

•Evidence of pruritic Dermatitis
•Dermatitis fasial, ekstensor, lichenification

Minor criteria (minimal 1 minor)

•Xerosis/ichtyosis/hyperlinear palm
•Perifollicular accentuation
•Chronic scalp scalling
•Periauricular fissures

Prof DR Dr Ariyanto Harsono SpA(K) 41

Hanifin and Rajka criteria for baby
Kriteria
Major criteria(minimal
mayor (minimal2 2major)
mayor)

•History of family atopy

•Evidence of pruritic Dermatitis
•Dermatitis fasial, ekstensor, lichenification

Minor criteria (minimal 1 minor)

•Xerosis/ichtyosis/hyperlinear palm
•Perifollicular accentuation
•Chronic scalp scalling
•Periauricular fissures

Prof DR Dr Ariyanto Harsono SpA(K) 42

Hanifin and Rajka criteria for baby
Kriteria
Major criteria(minimal
mayor (minimal2 2major)
mayor)

•History of family atopy

•Evidence of pruritic Dermatitis
•Dermatitis fasial, ekstensor, lichenification

Minor criteria(minimal 1 minor)

•Xerosis/ichtyosis/hyperlinear palm
•Perifollicular accentuation
•Chronic scalp scalling
•Periauricular fissures

Prof DR Dr Ariyanto Harsono SpA(K) 43

Hanifin and Rajka criteria for baby
Major criteria(minimal 2 major)

•History of family atopy

•Evidence of pruritic Dermatitis
•Dermatitis fasial, ekstensor, lichenification

Minor criteria (minimal 1 minor)

•Xerosis/ichtyosis/hyperlinear palm
•Perifollicular accentuation
•Chronic scalp scalling
•Periauricular fissures

Prof DR Dr Ariyanto Harsono SpA(K) 44

Hanifin criteria for children

Major criteria (minimal 3 major)

•Pruritus
•Characteristic Distribution and morphology of skin lesions
•Dermatitis fasial, ekstensor selama bayi dan awal usia anak
•Flexural lichenification dan linearity by adolescence
•Chronic Dermatitis

Minor criteria(minimal 1 minor)

•Xerosis/ichtyosis/hyperlinear palm/keratosis pilaris
•IgE reactivity
•Chronic scalp scalling
•Perifollicular accentuation
•Periauricular fissures
Prof DR Dr Ariyanto Harsono SpA(K) 45
Minor criteria(minimal 1 minor)
•Hand/foot dermatitis
•Cheilitis
•Vulnerable to infection (Herpes/Strep/S aureus)

Prof DR Dr Ariyanto Harsono SpA(K) 46

Minor criteria(minimal 1 minor)
•Hand/foot dermatitis
•Cheilitis
•Vulnerable to skin infetions (Herpes/Strep/S aureus)

Prof DR Dr Ariyanto Harsono SpA(K) 47

Minor criteria(minimal 1 minor)
•Hand/foot dermatitis
•Cheilitis
•Vulnerable to skin infetions (Herpes/Strep/S aureus)

Prof DR Dr Ariyanto Harsono SpA(K) 48

 Minor criteria(minimal 1 minor)
•Hand/foot dermatitis
•Cheilitis
•Vulnerable to skin infetions (Herpes/Strep/staphilococcus)

Prof DR Dr Ariyanto Harsono SpA(K) 49

Seborrhoic dermatitis

Prof DR Dr Ariyanto Harsono SpA(K) 50

Pompholix

Prof DR Dr Ariyanto Harsono SpA(K) 51

Prof DR Dr Ariyanto Harsono SpA(K) 52
Principle of Conventional Therapy

Target for skin

care

Target for anti

Eczema inflammatory
Prof DR Dr Ariyanto Harsono SpA(K) 53
 Education
 Hidration
Emolient
Moisturizer
Wet dressing
 Allergen/irritants avoidance
 Antihistamine
 Topical Steroid
Prof DR Dr Ariyanto Harsono SpA(K) 54
 Conventional Therapy
is not always safe

Topical steroid: cutaneous atrophy, striae, bruisability, telangiectasia

High-potency topical steroids can cause

systemic side effects in children.
Prof DR Dr Ariyanto Harsono SpA(K) 55
 New Treatment Strategy in AD
Mild Moderate Severe
Dry Itching and/or early sign of Flare
skin inflammation
Emolient

Mild to Moderate Potency Topical Steroids

Pimecrolimus
Tacrolimus
Oral Steroids

IVIG

Light treatment
Prof DR Dr Ariyanto Harsono SpA(K) 56
Cyclosporine, mycophenolate
 Arachidonic Acid (ARA)

Phospholiphase A

Cyccloxygenase Lipoxygenase
γ-linoleic acid

Leukotriene A

Prostaglandine Leukotriene B

TXA Leukotriene C
Prof DR Dr Ariyanto Harsono SpA(K) 57
Prostacyclin HETE,5-HETE, PAF
Use of IVIG

Macrophage Keratinocyte

Mechanism of Dr
Prof DR IVIG blocking
Ariyanto Harsono apoptosis via 58
Procaspase-8
SpA(K) pathway
Prof DR Dr Ariyanto Harsono 59
SpA(K)
 Thank you

Prof DR Dr Ariyanto Harsono 60

SpA(K)