Transcript skin barrier - Allergy New Zealand

Pauline Brown
Clinical Nurse Specialist Eczema/Allergies
Northland DHB
Child Health Centre
Debbie Rickard
Child Health Nurse Practitioner Candidate
Capital coast DHB
This session














What is eczema?
Who it affects and prevalence
Non-allergic triggers
Eczema and Atopy (allergy)
The skin barrier
Gene-environment interactions
Reasons for treatments
Costs and stresses on families
Pathophysiology of skin and eczema
Complications of eczema – bacteria, fungus, virus
Nurse led clinics Debbie
Basic Skin treatments/management concepts Debbie
Management infant/pre-school Pauline
Management in the school age/adolescent/adult – Debbie
What is eczema
Eczema is a chronic, inflammatory skin condition that is
characterised by
 Dryness
 Deep-seated itch
 Redness and inflammation
 Sometimes areas can be weepy or oozing
Incidence
 The incidence of eczema has increased steadily in
westernised countries, over the past 40 years (Cork et al
2006, p3 ISAAC study, lancet, 2006)
 It is believed that up to 1 in 4 children may be affected
and there is no cure. (Gold & Kemp, 2005)
 It affects around 30% of preschool-age children, 15% of
school-age children and 9% of adolescents
 60 % of the children will have onset before the age of 1
year (Krakowski, Pediatrics, 2008)
 Historically it is poorly understood and frequently
under treated.
Name Confusion?
 Eczema has been historically thought of as an allergic
disease hence the name Atopic Dermatitis
(inflammation of the skin due to allergies) (Cork et al,
Exchange, NES 2006)
 However, more recently it has been suggested that we
should be dividing the condition of ‘eczema’ into 2
terms
(Darsow etal European Task Force on Atopic Dermatitis, JEADV, 2010,
Ricci etal, Am J Clin Derm, 2009, Cork et al, Exchange, NES 2006)
Atopic - having allergic tendencies (extrinsic)
Non atopic – not having allergic tendencies
(intrinsic)
Eczema - Atopic
Atopy, or the tendency to be sensitised or allergic
 approximately 1/3rd of all individuals with eczema has
either;
 IgE (immediate hypersensitivity) (example hayfever, asthma, food
allergies)
or
 Cell-mediated (delayed type hypersensitivity). (example contact
dermatitis to nickel, dyes etc.)
 Cell mediated allergy does not show on skin prick testing
or RAST
(Cork et al 2006)
Eczema – Non Atopic
 2/3rds have non allergic eczema
 Trigger (things that irritate) factors include:
 Soap based products, body wash chemicals
 Heat, dry air or heating
 Stress and anxiety
 Woolly/rough clothes/fabrics
 Certain food chemicals or colourings/preservatives
(intolerances and not allergy)
 Some infections/bacterial, viral, fungal
 teething
However................
Regardless of the classification, it is
thought that the primary problem
is the skin barrier
Functions of the skin
Skin cells (keratinocytes) divide at the
bottom of the epidermis to make a
new supply of skin cells
The new cells mature as they move up
through the skin
At the top of the skin, the skin barrier
(stratum corneum) is formed
The barrier protects the body from the
environment and prevents the
penetration of irritants and allergens
The skin cells in the stratum corneum
are locked together by structures call
corneodesmosomes and the skin cells
are surrounded by lipid bi-layers.
(Cork et al, Exchange, NES 2006)
The skin barrier
The stratum corneum can be viewed
as a brick wall
Comparing skin cells to the bricks
and lipid lamellae to the cement
The wall is stabilised by passing iron
rods though the bricks which are
compared to the corneodesmosomes
The iron rods keeps the skin
together
In order to maintain a constant thick
barrier skin cells shed from the
surface of the skin
Malfunctioning
skin barrier
The skin cells in the stratum corneum are locked
together by structures call corneodesmosomes
and the skin cells are surrounded by lipid bilayers.
?Faulty genes break down the skin barrier's
binders or iron rods much faster than normal.
People with eczema have gaps in their lipids or
mortar.
This results in cracks all the way through the skin
barrier.
Irritants such as soap cause more break down
and the "brick wall" starts to fall apart.
A broken barrier lets allergens enter the skin
easily.
Germs and more irritants then lead to an eczema
flare
Management includes repairing the skin barrier
with moisturisers (more discussion later)
Why has the prevalence increased?
 The genes that predispose us to eczema has not
changed, but our environment has
 One theory - we are exposing our skin to more soaps
and surfactants such as bubble baths to wash babies
 Soap and surfactants shown to decrease the stratum
corneum by 40% (Cork et al Dermatol in Practice, 2002)
The rising prevalence of atopic eczema and
environmental trauma to the skin.
Cork et al. Dermat Pract 2002, 10, 22.
UK data
1960 - 1981
1995 - 2001
Personal use of soap -detergent
76 million £
453 million £
Water for personal washing
11 L /day
51 L/day
Increased skin barrier dysfunctions
Genes associated with strength of
skin barrier
 Chemicals called proteases break down




the corneodesmosomes (iron rods)
Normal skin has low levels of proteases so
skin barrier is thick
Non-allergic eczema has a change in the
gene which produces higher levels of
protease
Leads to premature break down of the
iron rods.
The lipid lamellae (cement) is also
incomplete
 Normal pH of the skin is 5.5
 Exposure to soap and surfactants ↑ 7.5 or higher
 The protease SCCE is pH sensitive
 50% increase in protease activity
 Equals greater breakdown of the skin barrier
 Increase penetration of irritants and allergens.
Aqueous Cream
 Contains surfactants
 Surfactants break down the skin barrier
 Aqueous cream was designed as a soap substitute for
eczema
 Widely used as a ‘leave on’ moisturiser
 Audit of children attending dermatology clinic showed
aqueous cream caused irritant reactions in > 50%
(Cork et al, Pharmaceutical J, 2003)
Genetic link
 If a child has one parent with atopic eczema – 20%
 If both parents have (or had) atopic eczema – 50%
Which leads us to the treatments
Our increasing knowledge and understanding of how
the skin barrier breaks down, reinforces the
importance of skin-barrier maintenance and repair
This is the first-line treatment →
Complete emollient (moisturiser)
regimes
nd
2
line of treatment
↓
Identification and avoidance of
irritants and allergens
rd
3
line of treatment
↓
Treatment of flares
The more attention paid to the first two
steps, the less often flares will occur
Loss of skin
barrier
Produces
more
Itch and
inflammation
Desire to
scratch
Moisturise
Creates
allergic
response
Steroids
Antibiotics
Immune system responds to
Bacterial invasion
Excoriation
occurs
Bathe
Cleanse
Primary/secondary
infection occurs
Triggers – micro-organisms
(staph. Aureus)
Eczema is no small itch
It is far more…… yet it is a disease that is
often minimized by health professionals
Consider The Impact Of Eczema
Overall it is the
commonest specific skin
disorder encountered –
yet very poorly
managed
Second commonest skin
disorder seen in
dermatologist office –
yet very poorly
managed
Major issues
 Physical symptoms
 Pruritus, skin discomfort, sleep disruption
 Emotional problems
 Stigma associated with the visibility of the disease
 Social dysfunction
 Loss of work, school, social activities
Financial Burden in Australia
 Approx. A$1142/year/per person for mild eczema
 Approx. A$6099/yr/person for severe eczema
 A$157Million/year per mild eczema population
 A$316.7 Million/year per severe eczema population
These figures do not include national expenditure on
subsidised medications

Annotation/Atopic eczema: Its social and financial costs; AS Kemp, Department of Immunology,
Royal Children’s Hospital, Parkville, Victoria, Australia - 1998
Major negative impact on the
quality of life (QoL)
 Since 1987 impact measured in a repeatable
standardised way;
 Dermatology Life Quality Index
 Children’s Dermatology Life Quality Index
 Skinex
 the impairment of the QoL and the psychological
wellbeing has been well documented
Br J Dermatol 2006; 155: 145-151
Recent study on monitoring ‘course of
life’ (CoL) impact on children with AD
 CoL refers to fulfilling age specific developmental tasks and
milestones
 Hampered CoL has been found in adults who have had;
 Childhood cancer
 End-stage renal failure
 Anorectal malformations
 Hirschsprung disease
 Esophageal atresia
 ...but this is 1st study on eczema
Paediatric Dermatology, Vol. 26 No. 1, 114-22, 2009
Study results
 117 patients, median age of 23.4 years
 508 control patients, median age 24.2 years
 Need for support was identified
 87% needed more information about treatment regimes
 85% wanted improvement of personal guidance and
advice of the physician during their treatments
 52% desired contact with fellow-sufferers
 68% felt they needed psychological support
CoL Results
 Compared mod eczema to severe eczema




Less friends in primary and secondary school
Spent less leisure time with friends
Fewer belonged to a group of friends
Less went to school dances
 Comparing severe eczema with healthy peers





Less were members of sports clubs during primary and
secondary years
70% felt shame around their peers
49% avoided intimacy
25% reason for missing school
24% did things on their own
Physical aspects
 90.7% experienced pain and itch
 69% sleeplessness
 60% fatique
 74% had increase in eczema when stressed
International Study Of Life with ATopic
Eczema (ISOLATE)
 Largest and most comprehensive study conducted
into the impact of eczema on patients' lives and
relationships
 Revealed the extent of the emotional suffering
caused by eczema. (2004)
Results
 55% either always or sometimes worried about the
next eczema flare
 51% always or sometimes unhappy/depressed
 86% avoid at least one type of everyday activity
during a flare-up
 43% fairly or very concerned about being seen in
public during a flare
 74% of patients and caregivers state that their
physicians have never discussed the emotional
impact that eczema has had on their lives
…..yet very poorly managed
Australian Study
Indicated that the family stress related
to the care of a child with moderate or
severe atopic dermatitis is
significantly greater than that of care
of children with insulin-dependent
diabetes mellitus. (Kemp, 1999)
…..yet very poorly managed
Patients and their families experience
considerable emotional distress, anxiety,
and embarrassment because of people’s
response to this illness. In fact, the
emotional scarring on both patient and
family members may outlast eczema's
physical effects.
Never underestimate the emotional
cost of eczema
 Single young mother
 1 year old
 Moderate – severe eczema and
receiving multiple and conflicting
advice
 Multiple food allergies –







conflicting advice
Multiple environmental allergies
No family living in same town
Mother studying
Minimal income
Sleepless nights
Irritable child during day
Difficult finding childcare due to
eczema