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INTRODUCTION
Atopic Dermatitis (AD) is a chronically relapsing skin disease that occurs
most commonly during early infancy and childhood It is fre!uently associated
"ith a#normalities in skin #arrier function$ allergen sensiti%ation$ and recurrent
skin infections& Atopy is defined as an inherited tendency to produce
immunoglo#ulin ' (Ig') anti#odies in response to minute amounts of common
enironmental proteins such as pollen$ house dust mites$ and food allergens &$
Dermatitis deries from the *reek +derma$, "hich means skin$ and +itis$, "hich
means inflammation
Atopic Dermatitis (AD) affects a#out one-fifth of all indiiduals during their
lifetime$ #ut the prealence of the disease aries greatly throughout the "orld In
seeral industrialised countries$ the prealence increased su#stantially #et"een
&./0 and 000 so much that many refer to as the +allergic epidemic, 1o"eer$
current indications point to ec%ema symptoms haing leelled off or een haing
decreased in some countries "ith a formerly ery high prealence$ such as the
United 2ingdom and Ne" 3ealand
This indicates that the allergic diseaseepidemic is not increasing continually "orld"ide Neertheless$ AD remains a
serious health concern$ and in many countries$ particularly in the deeloping
"orld$ the disease is still ery much on the rise
The appearance of the indiidual skin lesion in AD does not differ from
other ec%emas such as contact ec%ema In it4s acute form$ ec%ema is characterised
#y a liely red infiltrate "ith oedema$ esicles$ oo%ing$ and crusting5
lichenification$ e6coriations$ papules$ and nodules dominate the su#acute and
chronic form Accordingly$ the diagnostic approach #uilds upon other
characteristics such as the distri#ution of the ec%ema as "ell as associated features
of the patient&$
The most "idely used diagnostic criteria for AD "ere deeloped #y 1anifin
and Ra7ka in &.80 and "ere later reised #y the American Academy of
Dermatology This set of criteria is primarily useful in clinical practice5 another
set of diagnostic !uestions "idely used in epidemiological research "as
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deeloped #y the U2 9orking :arty in &..; The seerity of ec%ema can #e
graded according to seeral scoring systems such as <coring Atopic Dermatitis
(<CORAD) and 'c%ema Area and <eerity Inde6 ('A<I)=$;
Rapidly deeloping symptoms (type-& reactions) caused #y allergens in
allergic diseases can #e easily diagnosed "ith detailed anamnesis$ skin tests
and>or specific Ig' leel measurements 1o"eer$ diagnostic approaches are
rather comple6 in late onset reactions$ such as AD& Immediate-type
hypersensitiity is usually diagnosed #y skin prick tests (<:Ts) or #y
measurement of serum-specific Ig' The disadantage of <:T is the need for thediscontinuation of topical steroid and antihistamine treatment$ "hich can lead to a
"orsening of the pree6isting AD In addition$ the re!uirement of intact skin
cannot al"ays #e fulfilled5 this is especially true in childhood$ "hen AD lesions
are commonly locali%ed on the olar side of the forearms "here <:T is usually
performed In contrast$ specific Ig' measurement has no such limitations=$/
Delayed$ allergen-specific T-cell reactions also play an important role in the
pathogenesis of AD$ #ut since it is not possi#le to detect these reactions using tests
of immediate-type hypersensitiity$ a different kind of test needs to #e used in
their diagnosis The patch test is a standard method used for testing of delayed-
type hypersensitiity reactions to contact allergens? The atopy patch test (A:T)
poses its modification$ "hich is performed "ith allergens also kno"n to elicit
immediate-type hypersensitiity reactions@$8$. In the diagnosis of food allergy$
A:T can increase the diagnostic #enefit of <:T and>or specific Ig' measurement$
een if it is often necessary to erify results #y a dou#le-#lind$ place#o-controlledfood challenge <ensitiity and specificity of A:T aries depending on the type of
food allergen@$8 In this paper$ it has #een reported a case of atopic dermatitis in
adult that has #een treated "ith moisturi%er$ topical corticosteroid$ sistemic
antihistamin and "ere done skin prick test and atopy patch test to identified
triggering factors
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CA<' R':ORT
A &. years old girl came to dermatoenereology outpatient clinic at dr
<aiful An"ar *eneral 1ospital on <eptem#er &?th 0&/$ "ith chief complaint red
patches on #oth of her arms and legs and also itchy mostly at night since = "eeks
#efore admission and got "orse in the last = days irstly$ it appeared like small
red pimples and felt itch on her #oth arms and started to spread on her #oth legs
<he said that it happened after she ate meat#alls and tongkol fish = "eeks ago
<he keep scratching it all day long #ut the itch got "orsen at night <he appliedinerson on the itch part of her #ody #ut not regularly and sho"ed no
improement
rom the history of the past illness$ she had the same symptoms like this
since she "as a child (the patient forgot "hen e6cactly) <ometimes got #etter #y
it self #ut sometimes she has to go to general practitioners (*:) to get some
medication The *: said that she had allergies <he usually use inersonB and
olie oil for her o"n medication #ut not regularly The redness patch sometimes
dissapear #ut sometimes not According to the patient$ the itch #egan to appeared
eerytime she eats meat#all and tongkol fish$ that is "hy she tried to aoid it <he
also felt itch and had runny nose or snee%ing eerytime she helps her mother to
clean the house or "hen the "eather is cold ut if she has runny nose or snee%ing
in the morning$ it "ill #ecome seldom or gone if she "ears "arm cloth or "hen
it4s already noon <he used to had "heals "hen she "as a child and appeared
"hen the "eather is cold ut she neer e6perienced it again since she "as in 7unior high school <he had "hite and dry patches on her face "hen she "as a
child$ sometimes she had it no" #ut not as often as "hen she "as a child
(tratak4en) <ometimes she had itch on #oth of her eyes and only fe" times on her
nipples <he "as the third and the last child
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rom family history of atopy$ her mother has the same ec%ema on #oth of
her arms and legs <he usually felt it "hen the "eather is cold 1er first #rother
has the same ec%ema 1er second sister has asthma ut all of her si#ling already
married and lie "ith their o"n family
In patient daily enironment$ the patient use cotton mattres #ut not cleaned
eery month$ only change the sheeth eery "eeks <he use dettolB soap for
eeryday usage 1er skin is ery dry #ut she uses hand and #ody lotion t"ice
daily <he sleeps on a #ed #unk 1er father hae pets like some chickens and
#irds There are a lot of "ild cats "andering arround her house and sometimessleeps on her doormat or on her kitchen <he "orks as a administration on an
electricity housing supplier "arehouse in alang <he "orks from 8 am until /
pm eeryday e6cept on <unday
rom dermatological e6amination$ on her face sho"ed no perior#ital
darkening (igure &A) On her trunk$ upper right arm$ upper and lo"er left arm$
upper and lo"er legs$ sho"ed multiple hyperpigmented patches "ith ill defined
#order$ irregular shape$ aried in si%es (igure &$ D$ $ *$ 1$ I) On her right
lo"er arms sho"ed multiple erythematous papules "ith ill defined #order$ round
shape$ si%e E -=mm (igure &') On her dorsal feet sho"ed multipleϕ
hyperpigmented pla!ue "ith "ell defined #order$ "ell defined$ aried in si%es$
some coered "ith "hite-yello"ish rough scale (igure &F)
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igure & A There "ere no perior#ital darkening$ face palor$ Dannie organ fold nor pityriasis
al#a
igure & On her trunk and her #ack <ho"ed multiple hyperpigmented patches "ith ill defined #order$ irregular shape$ aried in si%es (green arro") C No lession
5
1A
1B 1C
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igure & orm her left upper and lo"er arm D <ho"ed multiple hyperpigmented patches "ith illdefined #order$ irregular shape$ aried in si%es (green arro") ' <ho"ed erythematous papules$
multiple$ round shape$"ith ill defined #order$ si%e E -=mm (green arro")ϕ
igure & On her left upper and lo"er arm <ho"ed multiple hyperpigmented patches "ithirregular shape$ aried in si%es$ ill defined #order (green arro") * <ho"ed multiple
hyperpigmented patches "ith irregular shape$ aried in si%es$ ill defined #order (green arro")
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1E1D
1 1G
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igure & On her #oth upper and lo"er legs 1 <ho"ed multiple hyperpigmented papules "ith illdifined #order$ round shape$ aried in si%es I <ho"ed multiple hyperpigmented macules "ith ill
defined #order$ irregular shape$ and aried in si%es
igure & On her dorsal feet F <ho"ed multiple hyperpigmented pla!ue "ith defined #order$aried in si%es$ some coered "ith "hite-yello"ish rough scale
7
1H 1I
1J
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igure & On her hands 2 G H <ho"ed no lession
rom general e6amination$ the patient "as compos mentis and looks "ell
her #lood pressure "as &0>80 mm1*$ pulse rate 806>mnt$ respiratory rate
06>mnt$ and her a6ilar temperature =@$= C 1er Ig' serum leel "as eleated
(&&. IU>mH)
The patient "as diagnosed as AD$ made clinicaly #ased on history taking
and physical e6amination rom 1anifin and Ra7ka criteria$ on ma7or sign "ere
found pruritus$ typical morphology and distri#ution$ tendency to"ard chronic or
chronically relapsing dermatitis$ personal or family history of atopic disease J
asthma$ allergic rhinitis$ AD On minor sign "as found drynes on her skin$
eleated serum immunoglo#ulin '$ early age onset$ tendency to"ard non spesific
hand or foot dermatitis$ history of nipple ec%ema$ recurrent con7unctiitis$
pityriasis al#a and food intolerance 1er <CORAD "as /$. and include
moderate AD
Ta#le & <CORAD or score for AD
Spread (K) (K) (K) (K) (K) (K) Total
ront ace 0 Upper
torso 0
Arm right
and left 0
*ene
Talia
0
Heg right n
left &8
Ho"er torso
ack 1ead 0 Upper
torso 0
Arm right
and left .
Heg right n
left &8
Ho"er torso
;.>/
Intensity ---------- -------- --------- ---------- ---------- -------------
'rythe
ma &
'dema 0 Oo%ing 0 '6coria
tion &
Hichenificat
ion &
Lerosis
@/>
Subjective
sign
---------- -------- --------- ---------- --------- -------------
:ruritus
@
Insomnia @
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Total score /$.
The patient "as gien moisturi%er cream$ deso6ymethasone ointment
t"ice daily$ loratadine &0 mg once daily$ also education a#out the disease$ ho" to
maintain the moisture of the skin$ and ho" to aoid the triggers so the patient can
make the e6acer#ation less happen The patient came #ack after &; days for the
follo" up and sho"ed "ith a good result 1er <CORAD score "as ; categori%ed
as mild AD
igure A G ollo" up after &; days There "ere no lession
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igure C G D ollo" up after &; days On the trunk and #ack sho"ed multiple hyperpigmented
patches "ith irregular shape$ aried in si%es$ ill defined #order
igure ' and ollo" up after &; days On the #oth legs sho"ed multiple hyperpigmented patches "ith irregular shape$ aried in si%es$ ill defined #order
igure * ollo" up after &; days The lession #efore "as gone Dryness (M)
The patient "as educated to identify the triggering factor of her disease #y
doing skin prick test and atopy patch test irstly$ she "as e6plained a#out the
procedure$ the function of the test$ and also the side effect that might could
happend during or after the test :atient "as told not to drink any drugs that can
decrease the prutitus such as loratadin$ cold or flue medication that sold on oer
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the counter store$ and the patient didn4t take any oral corticosteroid Also there
"asn4t any flare during the test$ or else the test can4t #e done ecause the patient
"as under & years old and didn4t accompanied #y her mother$ then she "as told
to come#ack later again "ith her mother for hospital policy on signing informed
concent On Decem#er &;th 0&/$ she came to do the skin prick test irst "e
make sure that the ollar area "ere free from any lession$ the patient didn4t hae
any flares and did all the instruction #efore After that the mother4s patient signed
an informed concent for skin prick test
irstly "e do the dermographism in the patient and if the result "asnegatie then "e can do the skin prick test (igure =) Then "e do the aseptic on
the upper right arm near the ollar area using alchohol and dra" & for histamin
dihydrocloride (&mg>mH) as a positie control$ for coca as a negatie control
9e put a drop of histamin using the cap of the steril lancet and use the steril lancet
to prick the droplet & mm into the skin "ithout any #leeding 9e do the same "ith
coca as a negatie control After &/ minutes there "ill #e reaction on num#er &
"hich as a positie control it "ill appeared as a "heal$ in this case the "heal
diameters "as ;$80 mm (MMM) and the negatie control didn4t appear at allϕ
(igure ;A and ;)
igure = Dermographism (green circle) ;A Num#er & "as histamin dihydrochloride (&mg>mH)
(green arro") and num#er "as coca (red arro") ; After &/ minutes appeared "heal onnum#er &"ith ;$80mm (red arro")ϕ
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After that$ "e continued "ith other allergen e6tracts such as dog4s hair
(num#er ;)$ chicken feather (num#er /)$ house dust (num#er ?)$ ra" cotton
(kapuk) (num#er @)$ yeast (ragi) (num#er 8)$ mullet fish (ikan #andeng) (num#er
.)$ pindang fish (num#er &0)$ cra# (num#er &&)$ "heat flour (num#er &)$ co"4s
meat (num#er &=)$ chocolate (num#er &;)$ co# fish (ikan tongkol) (num#er &/)$
pinapple (num#er &?)$ #anana (num#er &@)$ peanuts (num#er &8)$ co"4s milk
(num#er &.)$ chicken4s meat (num#er 0)$ shrimp (num#er &)$ orange (num#er
)$ chicken egg "hites (num#er =)$ chicken egg yolk (num#er ;)$ duck egg
"hite (num#er /)$ duck egg yolk (num#er ?)$ goat4s meat (num#er @)$ tempe
(num#er 8)$ and papaya (num#er .) 9ith the same techni!ue "e use all
alergens on the patient4s right and left fore arm After &/ minutes the reaction can
#e seen and interperated rom all alergens only house dust mite (num#er ?) "as
positie "ith diameter ;$?/ mm (MM) On cra# allergen e6tract (num#er &&) alsoϕ
appeared "heal "ith diameters $ mm #ut not consider as a positie reactionϕ
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igure ;C dra"n on ollar area for preperation of allergen e6tract prick test D G ' A drop
different allergen "as gien and pricked on eery num#er <ho"ed "heal on num#er ? ( ;$?/ϕ
mm)(red arro" and red circle) and && ( $ mm) after &/ minutes * <ho"ed no "healϕ
After skin prick test "as done$ the patient came #ack on Decem#er &?th 0&/
to do the atopy patch test irstly "e make sure that the #ack area "ere free from
any lession$ the patient didn4t hae any flares and did all the instruction #efore
The patient "ere e6plained once again a#out the function of the test$ the
procedures$ and the side effect that could happen during or after the test After that
the patient agreed and signed an informed concent for atopy patch test 9e do the
asepsis on the #ack of the patient using alchohol s"a# y using the prick skin
allergens "e applied it on the finn cham#er "ith si%e 8 mm "ith a filter paper in
it$ then aplied it on the patient #ack using "hite tape 9e identified eery alergens
and "rite it on the "hite tape "ith num#ers la#el according to the num#ers that
"ritten on the skin prick test allergens (igure /A G /)
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igure /A <ho"ed the #ack of the patient "ere clear from any lession / The finn cham#ers"ere apllied on the #ack "ith the "hite tape after applying prick test allergens and then la#elled #y
the se!uence num#er of prick allergens
After la#elled #y the the se!unce num#er of prick allergens$ "e apllied
another "hite tape to ensure that the finn cham#ers "ere sttached firmly to the
patient #ack (igure /C) 9e educated the patient to did not do actiities that are
too heay that could make her s"eats too much 9e also told the patient not to
drink any medication$ not to applied anything that can make the tape came off$
and if she felt itch it means that the allergens are giing reaction #ut if it she felt
#urning sensation or pain sensation then she can take off the "hite tape The
reading of the A:T reactions are read after ;8$ and @ hours
igure /C The atopy patch test "ere applied "ith another "hite tape to ensure the finn cham#er attached firmly
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After ;8 hours "e took off the "hite tape and all of the fin cham#ers to see
the reaction The reading started &/ minutes after "e took off the atopy patch On
the left part "ere seen no reaction on the control "hich is coca (num#er ) and
erythematous papules on histamin allergen (num#er &) "ith interpretation MM
Also seen erythematous papules on num#er ; (dog4s hair)$ num#er ? (house dust)$
num#er &0 (pindang fish)$ and num#er & ("heat flour) (figure /D and /')
igure /D G ' :ositie MM on num#er &$ ;$ ?$ &0$ & <ho"ed fe" erithematous papules (redarro")
On the right side of the #ack seen fe" erithematous papules on num#er &8
(peanuts)$ &. (co"4s milk)$ & (shrimp)$ (orange)$ @ (goat4s meat)$ and 8
(tempe) "ith interpretation "ere MM (igure / and /*)
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igure / G * :ositie MM on num#er &8$ &.$ &$ $ @$8 <ho"ed fe" erithematous papules(red arro")
After @ hours$ the reading only seen on num#er &$ ;$ ?$ $8 "ith some
erithematous papules and the interpretation "as MMM Num#er and @ sho"ed
less papules and erythema$ the interpretation "as M (igure /1 and /I)
igure /1 G /I <ho"ed many spreading erythematous papules on num#er &$ ;$ ?$ and 8$interpretation MMM and num#er @ interpretation M (red arro")
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The patient "as educated a#out the positie findings on prick test and
atopy patch test <he also told to aoid the trigering factors that already kno"n
from the tests such as dog4s hair$ house dust$ and tempe
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Ta#le Result of <:T and A:T
No Allergens A:T ;8 hr A:T @ hr <:T
& 1istamin &mg>mH MM MMM MMM(;$80mm)
Coca (control) - - -
; dog4s hair $/ mg>ml MM MMM -
/ chicken feather $/ mg>ml - - -
? house dust / mg>ml MM MMM MM(;$?/mm)
@ ra" cotton / mg>ml - - -
8 east & mg>ml - - -
. mullet fish (#andeng) mg>ml - - -
&0 pindang fish mg>ml MM - -
&& Cra# mg>ml - - -
& "heat flour & mg>ml MM - -
&= co"4s meat mg>ml - - -
&; chocolate & mg>ml - - -
&/ co# fish (tongkol) mg>ml - - -
&? :inapple & mg>ml - - -
&@ anana & mg>ml - - -&8 :eanuts & mg>ml - - -
&. Co"4s milk & mg>ml - - -
0 chicken4s meat mg>ml - - -
& shrimp mg>ml - - -
Orange - M -
= chicken egg "hites & mg>ml - - -
; chicken egg yolk & mg>ml - - -
/ duck egg "hite & mg>ml - - -
? duck egg yolk & mg>ml - - -
@ goat4s meat mg>ml - M -
8 tempe & mg>ml - MMM -
. :apaya & mg>ml - - -
DI<CU<<ION
The appearance of the indiidual skin lesion in AD does not differ from
other ec%emas such as contact ec%ema In its acute form$ ec%ema is characteri%ed
#y a liely red infiltrate "ith oedema$ esicles$ oo%ing$ and crusting5
lichenification$ e6coriations$ papules$ and nodules dominate the su#acute and
chronic form Accordingly$ the diagnostic approach #uilds upon other
characteristics such as the distri#ution of the ec%ema as "ell as associated features
of the patient The typical patient "ith AD is a person "ith an early onset of itchy
ec%ema localised at typical sites such as the fle6ures of the el#o"s and knees in an
atopic patient or in a person "ith a familial predisposition to atopic disease The
most "idely used diagnostic criteria for atopic dermatitis "ere deeloped #y
1anifin and Ra7ka in &.80 and "ere later reised #y the American Academy of
Dermatology (igure ?)&$
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igure ? 1anifin Ra7ka criteria for AD
In this case the patient "as diagnosed as AD$ made clinicaly #ased on
history taking and physical e6amination rom 1anifin and Ra7ka criteria$ on
ma7or sign "ere found pruritus$ typical morphology and distri#ution$ tendency
to"ard chronic or chronically relapsing dermatitis$ personal or family history of
atopic disease J asthma$ allergic rhinitis$ AD On minor sign "as found dryness on
her skin$ eleated serum immunoglo#ulin '$ early age onset$ tendency to"ard non
specific hand or foot dermatitis$ history of nipple ec%ema$ recurrent con7unctiitis$
pityriasis al#a and food intolerance
Ha#oratory testing is not needed in the routine ealuation and treatment of
uncomplicated AD <erum Ig' leels are eleated in appro6imately @080K of
AD patients& This is associated "ith sensiti%ation against inhalant and food
allergens and>or concomitant allergic rhinitis and asthma In contrast$ 0=0K of
AD patients hae normal serum Ig' leels This su#type of AD has a lack of Ig'
sensiti%ation against inhalant or food allergens 1o"eer$ some of these patients
may possess Ig' sensiti%ation against micro#ial antigens such as S. aureus to6ins$
and Candida albicans or Malassezia sympodialis can #e detected As "ell$ some
of these patients sho" positie reactions using the atopy patch test despite
negatie immediate skin tests& 9e measure the patient Ig' leel #y #lood test and
sho"ed high Ig' leel "hich is &&. UI>ml
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Atopic Dermatitis (AD) is not cura#le$ and many patients "ill e6perience a
chronic course of the disease Accordingly$ the treatment of AD aims to minimi%e
the num#er of e6acer#ations of the disease$ so-called flares$ second$ reduce the
duration and degree of the flare$ if flare occurs The first aim relates primarily to
preention5 the second aim relates to treatment :reention is #est attained #y
trying to reduce the dryness of the skin$ primarily ia daily use of skin
moisturi%ing creams or emollients along "ith aoidance of specific and unspecific
irritants such as allergens and noncotton clothing 9hen dryness is reduced$ the
desire to scratch "ill lessen and the risk of skin infection "ill decrease Aoiding
long$ hot #aths further preents skin dryness$#ut "hen a #ath is taken$ an
emollient should #e applied directly after it to secure a moist epidermis and
augment the skin #arrier function&$
Reducing the flare is "arranted "hen actual ec%ema occurs or "hen mild
intermittent ec%ema "orsens anagement of an ec%ema e6acer#ation re!uires
medical treatment often in the form of corticosteroid creams Topical
corticosteroids are the mainstay of the treatment for moderate to seere AD$ #oth
in children and adults ost patients #enefit from treatment "ith mild to moderate
corticosteroid preparations$ "hereas only a small su#set those "ith seere disease
needs potent preparations5 ery strong preparations are rarely needed ild and
moderate corticosteroid creams are resered for children$ "hile adults can #e
treated "ith stronger preparations In this case "e gae emolient to the patient$
due to dryness of her skin and #ecause the outcome of these patients <CORAD
are moderate leel$ then "e gie a moderate potency corticosteroid preparations
Oral antihistamines are recommended for itching #ut hae no effect on the
actiity of the ec%ema Non-sedating antihistamines should #e used$ #ut "hen
night-time itching interferes "ith sleep$ sedating antihistamines are
recommended In this case "e use loratadin due to the the patient4s heay
actiity
<coring Atopic Dermatitis (<CORAD) is a clinical tool used to assess the
e6tent and seerity of ec%ema Dermatologists may use this tool #efore and after
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treatment to determine "hether the treatment has #een effectie The scoring
include = measuring irst is area to determine e6tent$ the sites affected #y ec%ema
are shaded on a dra"ing of a #ody The rule of . is used to calculate the affected
area (A) as a percentage of the "hole #ody <econd is intensity$ A representatie
area of ec%ema is selected In this area$ the intensity of each of the follo"ing signs
is assessed as none (0)$ mild (&)$ moderate () or seere (=)
• Redness
• <"elling
• Oo%ing > crusting
• <cratch marks
• <kin thickening (lichenification)
• Dryness (this is assessed in an area "here there is no inflammation)
The intensity scores are added together to gie PP (ma6imum &8) And the third is
su#7ectie symptoms ie$ itch and sleeplessness$ are each scored #y the patient or
relatie using a isual analogue scale "here 0 is no itch (or no sleeplessness) and
&0 is the "orst imagina#le itch (or sleeplessness) These scores are added to gie
PCP (ma6imum 0)= In this case "e measure the <CORAD "ith result /$. and
categori%ed as moderate atopic dermatitis
The prick test is usually the most conenient test method for detecting
immunoglo#ulin ' (Ig')-mediated allergy/ <eeral re!uirements are adocated to
reach an ideal prick test <ome of them are controling the efect of medication
Antihistamines of the so-called third generation$ e6tensiely used no"adays$
a#olish the immediate reactiity of the skin usually for &= days This concerns
cetiri%ine$ loratadine$ fe6ofenadine$ e#astine$ mi%olastine$ and the ne"comers
desloratadine and leocetiri%ine :rick testing can #e performed = days after
stopping treatment Honger "ash-out periods are needed "ith ketotifen (&/ days)
and astemi%ole (; "eeks) Oral methylprednisolone more than 8 mg daily and
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e!uialent doses of other corticosteroids may also "eaken the immediate
reactiity of the skin Other drugs such as non-steroidal anti-inflammatory drugs
as "ell as topical application of corticosteroids do not affect prick test results
significantly/ In this case "e educated the patient to aoid ussage of antihistamin
drugs$ cold or flue medication that sold on oer the counter store$ and the patient
didn4t take any oral corticosteroid
Harge num#ers of commercial prick test allergens are aaila#le5 self-made
allergens can also #e used Drops of allergen solutions are applied to the olar
aspect of the forearm or to the upper part of the #ack The fle6ures of the el#o"smust #e aoided$ #ecause this may gie rise to not easily reada#le reactions$ either
positie or negatie Other skin sites are not conenient as "ell An important
point concerns the distance #et"een the indiidual prick tests These are applied
ideally =/ cm apart to aoid oerlapping of reactions at reading If such a
distance is not respected$ difficulties in correct reading are o#ious and no definite
conclusions can #e dra"n This mistake in technology happens too often$ een
among "ell-trained clinicians 9hen drops of allergen solutions are applied to the
skin$ they are pierced "ith a special lancet Aller#iopoint is a stainless steel lancet
(lengthJ && mm5 penetration angle ;/Q5 presenting itself as a #lister of ten sterile
disposa#le lancets) :uncture is made #y gentle pressure5 some authors$ "hen
puncturing$ e6ert a slight rotation moement to ensure #etter penetration of the
allergen No #leeding may occur/
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igure @ :rick testing (a) :rick test lancets5 (#) :ositie prick test to late6J positie and negatiecontrols?
:rick testing of allergens needs the concomitant use of controls$ positie and
negatie 1istamine chlorhydrate solution (&-&0 mg>ml) to measure direct
reactiity to histamine <aline and>or the ehicle of the allergens is used as a
negatie control/ In this case "e use histamin & mg>ml as a positie control and
coca as a negatie control
After &/ min$ the allergen and control droplets are "iped off "ith soft
paper tissue Conentional time reading is &/0 min$ as "e are ealuating an
immunological immediatetype & reaction Reading prick test reactions needs
careful ealuation and interpretation$ taking into account seeral parameters of
prime importance The negatie control ought to #e negatie5 if positie$ it raises
!uestions a#out the reading of allergen prick tests Its main interest is therefore to
detect false-positie reactions/ In this case the coca4s reading "as negatie and
the histamin4s reading "as positie (MMM)
Reading and interprating prick test should #e measure carefully These are
some parameters that should #e notice on reading prick testJ
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9heal and flare reactions to positie controls$ "hich appear around the piercing
usually in minutes$ are measured in terms of diameters and surface areas
Allergen prick test results are usually e6pressed as the mean of the longest
diameter of the "heal and the largest diameter perpendicular to it
Reactions greater than = mm and at least half of that produced #y histamine are
regarded as positie Reactions smaller than those produced #y histamine may not
#e clinically significant
If the patient has dermographism (factitious urticaria)$ skin piercing produces
usually small (& mm) "heals$ "hich may make the interpretation of the results
ery difficult/
There is a clear-cut difference in terms of readings #et"een patch testing
and prick testing :atch testing is a codified procedure that does not imply any
control$ "hereas prick testing is inaria#ly su#mitted to controls either positie or
negatie in order to achiee correct interpretation of the results The final goal in
prick testing is to assess (either past or current) the releance The practical means
to conclude +likely$, +possi#le$, +dou#tful$, or +not traced, releance/ In this
case the result "as positie MM on house dust #ecouse the diameter "as more than
= mm or at least more than half of the positie control (;$80mm) "hich is
;$?/mm
Atopic patch test (A:T) can #e used as a diagnostic tool in characteri%ing
patients "ith allergen triggered AD@$8$. <hankar 2$ Chakraarthi studied a#out
A:T using prick test allergens in aluminium patch test cham#ers8 The antigens
are loaded in aluminium patch test cham#ers "ith filter paper using the dropper
proided #y the manufacturer A drop from the dropper "as appro6imately &>&?
ml The test site "as upper #ack The antigens used "ere dust mitesJ D. farinae,
D. pteronyssinus$ pollens of Cynodon dactylon and Parthenium hysterophorus$
foods like rice$ "heat$ milk$ egg and dog and cat epithelia8 The reading "as taken
after ;8 and @ hours and interpretation and *rading of A:T reaction "as done
according to the guidelines #y 'uropean task force on AD consensus (igure
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8)@$8$. After ;8 hours$ "ere seen erythematous papules on num#er ; (dog4s hair)$
num#er ? (house dust)$ num#er &0 (pindang fish)$ and num#er & ("heat flour)
And also after @ hours$ the reading only seen on num#er &$ ;$ ?$ $8 "ith some
erithematous papules and the interpretation "as MMM Num#er and @ the
interpretation "as M
igure 8 *rading A:T reactions@
inn Cham#er is a round aluminum patch test deice "hich proides good
occlusion #ecause of the cham#er design The 8 mm inner diameter proides a /0
mm area and a#out 0 SH olume The outer diameter is && mm and the distance
#et"een the cham#ers is 0 mm Apart from standard 8 mm (inner diameter) inn
Cham#ersB$ large & mm (inner diameter) inn Cham#ers can #e purchased (00
strips of one cham#er) These are of special interest "hen using the A:T or
li!uid allergens$ place a filter paper disk in the cham#er$ and apply one drop of
li!uid$ 7ust sufficient to soak the disk :etrolatum patches can #e made up a fe"
hours in adance5 li!uid patches should #e made up at the last minute ? In this case
"e use finn cham#er 8 mm si%e due to lack of the si%e & mm 9e also use filter
paper disk to apply the allergens and immediately applied to the #ack area
Dust mites are considered to #e the most important triggering agent for AD
In a study conducted in Croaotia #y 2ul7anac et al, on Dermatophagoides
pteronyssinus "ith A:T and concluded that A:T may detect the trigger factor in
AD patients@ According to Tur7amaa et al$ and "erfel et all$ among the allergens
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found to #e releant in atopic ec%ema$ food allergens (mostly in children) and
aeroallergens are the most important&0$&& 'nironmental su#stances like
aeroallergens produce flares in some patients "ith atopic ec%ema oreoer
aeroallergen aoidance$ especially "ith regard to house dust mites$ can result in
marked improement of skin lesions An epicutaneous patch test$ A:T$ "ith type &
allergens kno"n to elicit Ig'-mediated reactions$ and the ealuation of
ec%ematous skin lesions after ;@ h can #e used as a diagnostic tool in
characteri%ing patients "ith aeroallergen and food-triggered A' Atopy patch
testing (A:T) has #een inestigated as a potential tool to identify foods "hich
may cause late-type symptoms such as e6acer#ation of AD&
Another study done #y irosla Necas$ a#out A:T using aeroallergen
prick testing$ using histamin &0mg>ml as a positie control and salone solution as
a negatie control The allergens "ere applied to the patients4 #acks during the
remission of atopic dermatitis The first reading "as made after ;8 hours and the
second after @ hours The ealuation of the reactions "as made according to the
'TAD group recommendations$ sho"ed the most common allergen "ere house
dust mite allergens (&8K)$ follo"ed #y grass and plant pollen (&0;K) and dog
allergens (8K)&= rom this case$ positie result on hause dust found on #oth test$
<:T and A:T eside that$ it has positie result on dog4s hair allergen and tempe
(MMM) and "eak reasult on orange (M)
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<UAR
9e reported a case of a &. years old girl "ith atopic dermatitis "ho
presented #y chief complaint red patches on #oth of her arms and legs since =
"eeks ago and got "orse in the last = days rom history taking and clinical
appearence fit to hanifin and ra7ka criteria for atopic dermatitis <CORAD "as
used as seerity score "ith the alue of /$. The therapy "as gien$ emolient$
deso6ymethasone ointment t"ice daily$ loratadine &0 mg once daily$ also
education a#out the disease The patient is also done skin prick test and atopy
patch test to identify the triggering factors of her disease The result of the <:T"as house dust mite (MM) and also for the A:T are positie on dog4s hair$ house
dust$ and tempe :atient then aducated a#out the result and to aoid the triggerring
factors
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R''R'NC'<
& Heung $ 'ichenfield H$G ogunie"ic% AD (Atopic 'c%ema) In J
it%patrick4s Dermatology In *eneral edicine$ 8th edition$ edited #y
*oldsmith HA$ 2at% <I$ *ilchrest A$ :aller A<$ Heffel DF$ and 9olff 2$
0&5 p &?/-&8
Thomsen < ADJ Natural 1istory$ Diagnosis$ and Treatment ISRN llergy$
0&;$ article ID =/;/0 pJ &-@
3. Hiska $ *utoa $ :an%ner :$ rodska : The Clinical Releance of
arious 1ypersensitiity Tests in :atients "ith AD as Assessed #y Their
1istory$ <CORAD Changes$ and Num#er of Days "ith Need of Anti-
Inflammatory Treatment Pediatric llergy, Immunology, nd Pulmonology0&/5 8 ()J pJ8@-.&
; 1anifin F$ Thurston $ Omoto $ Cherill R$et all$ The ec%ema area and
seerity inde6 ('A<I)J assessment of relia#ility in AD$ !"perimental
Dermatology$ 00& ol &0$ no &$ pp &&&8
/ Hachapelle F$ ai#ach I1 The etodology Of Open (Non-:rick) Testing$
:rick Testing$ And It4s ariants In J :atch Testing And :rick Testing$ A
:ractical *uide$ nd edition$ edited #y Hachapelle F$ ai#ach I1$ 00.5
pJ&;&-/&
? Hachapelle F$ ai#ach I1 :atch Testing etodology In J :atch Testing
And :rick Testing$ A :ractical *uide$ nd edition$ edited #y Hachapelle F$
ai#ach I1$ 00.5 pJ==-?@
@ Darso" U$ Ring F The Atopy :atch Test In AD InJ :atch Testing And :rick
Testing$ A :ractical *uide$ nd edition$ edited #y Hachapelle F$ ai#ach
I1$ 00.5 pJ &&-?
8 <hankar 2$ Chakraarthi Atopic :atch testing Indian # Dermatol
$enereol %eprol $ 0085 pJ;?@-@0
. Cudo"ska $ 2ac%marski Atopy :atch Test In The Diagnosis Of ood
Allergy In Children 9ith Atopic 'c%ema Dermatitis <yndrome Roczni&i
&ademii Medyczne' ( )ialymsto&u.00/5pJ ?&- ?@
&0 Tur7anmaa 2$ Darso" U$ Niggemann= $ Ranc 2$ anto/ T$ 9erfel? T
:resent status of the atopy patch test Allergy 00?J ?&J &=@@&=8;
&& 9erfel T$ allmer-9e#er $ 'igenmann :A$ Niggemann $ Ranc $
Tur7anmaa $ 9orm 'c%ematous reactions to food in atopic ec%ema
Allergy 00@J ?J @=@8
& ToniV RF$ Hipo%eniV F Role and <ignificance of Atopy :atch Test cta
Dermatao*enerol Croat +-5&8(&)J=8-//
13. Necas Atopy :atch Testing "ith air#orne allergens cta
Dermato*enerologica 0&=5J=.-;