異位性皮膚炎：概述、診斷與治療

Diagnosis of Eczema ... EU Guidelines for Atopic-Eczema-Part2 · Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in ... Areyouahealthcareprofessional? Theinformationinthiswebsiteisintendedonlyforhealthcareprofessionals.Byenteringthissite,youareconfirmingthatyouareahealthcareprofessional. EnterSite ✕ Areyoualaboratoryprofessional? Theinformationinthiswebsiteisintendedonlyforlaboratoryprofessionals.Byenteringthissite,youareconfirmingthatyouarealaboratoryprofessional. EnterSite ✕ Allergy AllergyOverview RespiratoryAllergies RespiratoryAllergiesOverview AllergicRhinitis IndoorAllergies FoodAllergies FoodAllergiesOverview Cow'sMilkAllergy EggAllergy PeanutAllergy TreeNutAllergy FishAllergy ShellfishAllergy WheatAllergy SoyAllergy AtopicDermatitis Urticaria PetAllergy VenomAllergy DrugAllergy LatexAllergy ChronicOtitisMedia Mastocytosis Asthma AutoimmuneDisease AutoimmuneDiseaseOverview AntiphospholipidSyndrome ConnectiveTissueDiseases GastrointestinalDiseases RheumatoidArthritis AutoimmuneThyroidDisease Vasculitis HowtoTest HowtoTestOverview AllergyTestingOptions AutoimmunityTestingOptions ResourceCenter AllergenEncyclopedia ContactUs Home Allergy AtopicDermatitis     AtopicDermatitis:Overview,Diagnosis,andTreatment Triggers Diagnosis Management PracticeParameters TestingInformation AboutAtopicDermatitis Eczemaisacomplexinflammatoryskindiseasethatpresentsclinicallywithawidespectrumofsymptoms.1Eczemaisanonspecifictermsynonymouswithdermatitisthatisoftenusedtorefertoatopicdermatitis(AD),themostcommontypeofeczema.Alsoknownasallergiceczemaoratopiceczema,itaffectsabout20percentofchildrenandupto3percentoftheadultpopulationworldwide.2 ADusuallystartsinearlychildhoodandisoftentheinitialstepintheatopicmarch.3 Skinbarrierdysfunctionineczemamayleadtobothfoodandaeroallergensenteringthroughtheimpairedbarrier,initiatingimmunologicalreactionsandinflammation.1,3 Childrenwithearly-onseteczemaarethreetimesmorelikelytodevelopallergensensitizationbytheageoftwo.3FoodreactionscanbeeitherimmunoglobulinE(IgE)mediatedornon-IgEmediated(e.g.,dermatitisherpetiformis).4 Asthemarchcontinues,childrenareatincreasedrisktodevelopallergicrhinitisorasthmalaterinlife. 3,5-7 Themajorityof infantsandyoungchildrenwitheczemahaveanunderlyingallergythatcontributestodiseaseseverity.3,11 SpecificIgEbloodtestingcanhelpyouidentifytheseallergensandprovideapersonalizedmanagementplan. 300%morelikely Childrenwithearly-onseteczemaarethreetimesmorelikelytodevelopallergensensitizationbytheageoftwo.3 Whenclinicallyassessingpatientswithatopiceczema,healthcareprovidersshouldseektoidentify potentialtriggerfactors, including:17 Irritants(e.g.,soaps,detergents,toiletries,andwool) Contactallergens Heat Perspiration Cigarettesmoke Foodallergens Aeroallergens Emotionalstress Chemicals  Cleaningsolutions Eczemahasseveral aggravatingfactorsandtriggers,suchasheat,perspiration,emotionalstress,andexposuretocertainchemicals,cigarettesmoke,orcleaningsolutions. Atopicdermatitisdiagnosis:Testingfordifferentialdiagnosis Atopicdermatitisisacomplexdiseasethatoftendevelopsinconnectionwithotherconditions,suchasasthmaandrhinitis.GuidelinesadvisethatdiagnosingADstartswithaphysicalexamination.Duringthatevaluation,itmayhelptoemployanallergy-focusedpatienthistory.1,12 Thefindingsofthisallergy-focusedpatienthistorymayalsosuggestthatthenextbeststepistoorderspecificIgEtests.SpecificIgEbloodtestingandskin-pricktesting(SPT)canhelpyouruleinorruleout allergensensitization,whichmaygiveyoutheabilitytocorrectlydiagnoseandimproveclinicalmanagement.15,16SpecificIgEbloodtestingcanbeperformedirrespectiveofskincondition,whereasSPTmaynotbeapplicableduetotheskinconditionofanADpatient. Whoshouldbetested? Withupto70percentofinfantsandyoungchildrenwitheczemahavinganunderlyingallergythatcontributestodiseaseseverity,13,14healthcareproviderscanusespecificIgEtestingtoenhancethediagnosticprocessandpinpointthoseallergens.Thespecificinformationgleanedfromtestresultscanalsobeusedtodevelopapersonalizedtreatmentplan.   Thesymptomthreshold Upto80percentofpatientswithallergiesaresensitizedtomorethanoneallergen.18Theeffectiscumulative:Anindividualpatientmayhaveanumberoftriggers,which,combined,mayleadtosymptoms.19,20Theallergensymptomthresholdisthepointatwhichthecumulativeallergenloadleadstosymptoms.19,20 × DiagnosisofEczema Regulartreatmentwithemollientsandtopicalsteroidspm Eczemapoorlycontrolled Eczemawellcontrolled Allergytestingunlikelytobehelpful   ReviewcomplianceandifnecessarymodifytreatmentasperNICEguidelines Allergytestingunlikelytobehelpful   Treatmentoptimizedeczemastillpoorlycontrolled Takeadetailedallergyhistory: •Isthereapersonal/familyhxofeczema,asthmaorhayfever? •Wastheeczemaearlyonsetand/orisitsevere? Ifno Allergytestingunlikelytobehelpful Ifyes Ifyes Ifyes Ifnoimprovement,refertodermatologicalassessment StepuptreatmentasperNICEguidelines Regulartreatmentwithemollientsandtopicalsteroidspm Eczemapoorlycontrolled ReviewcomplianceandifnecessarymodifytreatmentasperNICEguidelines Treatmentoptimizedeczemastillpoorlycontrolled Takeadetailedallergyhistory: •Isthereapersonal/familyhxofeczema,asthmaorhayfever? •Wastheeczemaearlyonsetand/orisitsevere? Ifyes Cananytriggersbeidentified? •Food,aero-allergens,skinproducts,etc Ifyes FeaturesofanlgE-mediatedreaction:rapidonsetonexposuretoallergen:reproducible;smallamountstriggerreactions Considerallergytesting:specific-lgE(andtotallgE)orskinpricktests. Featuresofanon-lgEmediatedreaction:delayedonsetofsymptomsdelayedfollowingexposuretoallergen;smallamountsofallergenmaybetolerated Ifno Ifyes Ifconfirmed,adviseonallergenavoidancemeasures   Considerexclusionoffoodsfor4-6weeksand,ifsymptomsimprove,subsequentchallengetoconfirmdiagnosis Considercontactallergicdermatitisespeciallyifeczemapredominantlyonhandsoreyelids   Long-termdietaryexclusioninchildrenmayneeddieteticassessment Stillpoorcontrol: Refertodermatologist   Refertodermatologistfor patchtesting   FeaturesofanlgE-mediatedreaction:rapidonsetonexposuretoallergen:reproducible;smallamountstriggerreactions ClicktoViewAlgorithm Atopicdermatitisandqualityoflife Atopicdermatitis(AD)posesasignificantburdenonnotonlyhealthcareresources,butalsothequalityoflifeofyourpatientsandtheircaregivers.1 ChildrenwithADhaveaworsequalityoflifethanchildrenwithasthma,diabetes,orepilepsy.8 Eczemamayresultinschoolabsenteeism,activityavoidance,andsocialisolation.9 Childrensufferingfromeczema,andtheirparents,canloseuptotwohoursofsleeppernight.10 Commonallergens SpecificIgEserologicaltestsaidinthediagnosisofallergicdisease.Assuch,anyonepresentingwitheczemaorotherallergysymptomsisacandidateforspecificIgEtesting.Herearecommonallergensthatcanadduptosymptoms:17 Animaldander Egg Fish Housedustmites Milk Peanut Pollen Shellfish Soybean Treenuts Wheat TestingConfidence TestingIncreasesDiagnosticConfidence Addingdiagnostictestingtoaidinadifferentialdiagnosishasbeenshowntoincreaseconfidenceindiagnosisto90percent.i,ii Conventionally,adiagnosisofallergicorautoimmunediseasereliesonthecasehistoryandaphysicalexamination.However,addingdiagnostictestingtoaidinadifferentialdiagnosishasbeenshowntoincreaseconfidenceindiagnosis.i,ii Diagnostictestingcanalsohelptoimprovethepatient’squalityoflifeandproductivity,reducecostsassociatedwithabsenteeism,andoptimizeuseofmedication,inadditiontodecreasingunscheduledhealthcarevisits.iii,iv  i.Duran-TauleriaE,VignatiG,GuedanMJ,etal.TheutilityofspecificimmunoglobulinEmeasurementsinprimarycare.Allergy.2004;59(Suppl78):35-41. ii.NiggemannB,NilssonM,FriedrichsF.PaediatricallergydiagnosisinprimarycareisimprovedbyinvitroallergenspecificIgEtesting.PediatrAllergyImmunol.2008;19:325-331 iii.WelshN,etal.TheBenefitsofSpecificImmunoglobulinETestinginthePrimaryCareSetting.JAmPharmAssoc.2006;46:627. iv.SzeinbachSL,WilliamsB,MuntendamP,etal.Identificationofallergicdiseaseamongusersofantihistamines.JManagCarePharm.2004;10(3):234-238 Learnmoreabouttesting.   AllergyTestingOptions Getscientificinformationonmorethan550allergens. AllergenEncyclopedia Managementandcareforpatients withatopicdermatitis Skindisorders,includingatopicdermatitis(eczema)andurticaria(wheals)arecommonlyseenbyhealthcareprovidersandmanagingpatientswiththeseconditionscanoftenbechallenging.Resultsfromstudieshavedemonstratedthatatopicdermatitisandurticariahaveaprofoundlynegativeimpactonhealth-relatedqualityoflive(HRQoL),particularlyimpactingsocialfunctioningandpsychologicalwell-being.Andmanypatientswithoneorbothconditionsreportproblemsattributabletotheirskininfacetsofeverydaylifeincludinghomemanagement,personalcare,mobility,sleep,rest,school,andwork.21,22 Themanagementofskinallergiesconsistsofthreemajorcategoriesoftreatment:21,22 1.Allergenavoidanceandenvironmentalcontrolmethods 2.Pharmocologictherapy 3.Immunotherapy Guidelinessuggestdevelopingatreatmentplanwithintensityofmanagementbasedondiseaseseverityandfluctuationfromacuteflarestoperiodsofdiseasecontrol.Theprimaryelementsoftheskincareplanincludehydration,topicalanti-inflammatorymedications,andantibacterialmeasures.23,24 Practiceparametersandguidelines foratopicdermatitis: Atopicdermatitis:Apracticeparameterupdate2013 Consensus-basedEuropeanguidelinesfortreatmentofatopiceczema(atopicdermatitis)inadultsandchildren:Part1 Consensus-basedEuropeanguidelinesfortreatmentofatopiceczema(atopicdermatitis)inadultsandchildren:Part2 ReadPatientCaseStudies References   Pawankar R,HolgateS,CanonicaG,atel.WorldAllergyOrganization.WhiteBookonAllergy(WAO).2011.http://www.worldallergy.org/UserFiles/file/WAO-White-Book-on-Allergy_web.pdf.AccessedDecember2017.  KayJ, Gawkrodger DJ,MortimerMJ,JaronAG.Theprevalenceofchildhoodatopiceczemainageneralpopulation. JAm Acad Dermatol. 1994;30(1):35-39.   BantzSK,ZhuZ,ZhengT.TheAtopicMarch:ProgressionfromAtopicDermatitistoAllergicRhinitisandAsthma. JClinCellImmunol. 2014;5(2):202.   Spergel JM. Nonimmunoglobulin e-mediatedimmunereactionstofoods.AllergyAsthmaClinImmunol.2006;2(2):78-85.  VanDerHulstAE, Klip H,BrandPL.Riskofdevelopingasthmainyoungchildrenwithatopiceczema:asystematicreview. JAllergyClinImmunol.2007;120(3):565-569.   GustafssonD, Sjöberg O, Foucard Tetal.Developmentofallergiesandasthmaininfantsandyoungchildrenwithatopicdermatitis―aprospectivefollow-upto7yearsofage. Allergy.2000;55(3):240-245.   Kulig M, Bergmann R,TackeU,etal.Long-lastingsensitizationtofoodduringthefirsttwoyearsprecedesallergicairwaydisease.TheMASStudyGroup,Germany. Pediatr AllergyImmunol.1998;9(2):61-67 BeattiePE,Lewis-Jones MS.A comparativestudyofimpairmentofqualityoflifeinchildrenwithskindiseaseandchildrenwithotherchronicchildhooddiseases. BrJDermatol.2006;155(1):145-151 Lewis-JonesS:Qualityoflifeandchildhoodatopicdermatitis:themiseryoflivingwithchildhoodeczema. IntJClin Pract. 2006;60:984-992.  ReidP,Lewis-JonesMS.Sleepdifficultiesandtheirmanagementinpreschoolerswithatopiceczema. ClinExpDermatol.1995;20(1):38-41.   EuropeanAcademyofAllergyandClinicalImmunology;GlobalAtlasofAllergicRhinitisandChronicRhinosinusitis,2015.http://www.eaaci.org/globalatlas/ENT_Atlas_web.pdf.AccessedJanuary2018.  SmithHE, Hogger C, Lallemant C,etal.Isstructuredallergyhistory sufficient whenassessingpatientswithasthmaandrhinitisingeneralpractice?JAllergyClinImmunol. 2009;123:646-650. Spergel JM.AmJClinDermatol. 2008;9:233-44. Eigenmann PA,etal.Prevalenceof IgE-mediatedfoodallergyamongchildrenwithatopicdermatitis. Pediatrics. 1998;101:E8.   Duran-Tauleria E, Vignati G, Guedan MJ,etal.TheutilityofspecificimmunoglobulinEmeasurementsinprimarycare.Allergy.2004;59(Suppl78):35-41. NiggemannB,NilssonM,FriedrichsF. Paediatric allergydiagnosisinprimarycareisimprovedbyinvitroallergenspecific IgE testing. Pediatr AllergyImmunol. 2008;19:325-331. NHSEczema;www.nhs.uk/conditions/eczema-(atopic)/pages/causes.aspx;lastaccessedOctober2017. Lewis-JonesS, Mugglestone MA,GuidelineDevelopmentGroup(2007)Managementofatopiceczemainchildrenagedupto12years:summaryofNICEguidance.BMJ335(7632):1263-1264 Ciprandi G, Alesina R,ArianoR,etal.Characteristicsofpatientswithallergicpolysensitization:thePOLISMAILstudy. EurAnnAllergyClinImmunol.  2008;40(3):77-83.   EgglestonPA.Controlofenvironmentalallergensasatherapeuticapproach. lmmunol AllergyClinNorthAm. 2003;23(3):533-547. LifschitzC.TheImpactofAtopicDermatitisonQualityofLife. Ann Nutr Metab. 2015;66(suppl1):34–40  O'DonnellBF,etal.Theimpactofchronicurticariaonthequalityoflife. BrJDermatol.1997Feb;136(2):197-201. LeBovidge Jetal.Multidisciplinaryinterventionsinthemanagementofatopicdermatitis.JAllergyClinImmunol. 2016Aug;138(2):325-34. Deacock SJ.Anapproachtothepatientwithurticaria. ClinExpImmunol. 2008Aug;153(2):151-61.