Hudbarrieren og fugtighedscremer PO-SCORAD

dsr.dk

Hudbarrieren og fugtighedscremer PO-SCORAD

Hudbarrieren og fugtighedscremer

PO-SCORAD

Mette Deleuran

Ledende overlæge, dr.med.


Hudens funktioner

• Fysisk barriere mod varme, kulde stråling, mekanisk

traume, mikroorganismer og kemikalier

• Sensorisk organ (smerte, temperatur, tryk, vibration og

kløe)

• Temperaturregulation (autonome nervesystem)

• Væske- og elektrolytbalance

• Socio-seksuel kommunikation

• Immunologiske og metaboliske funktioner


Celletyper i normal epidermis

• Keratinocytter:

- 85 % epidermis celler

- Laver keratin

- 3 ugers livscyklus

• Langerhans celler

- Fra knoglemarv

- Antigenpræsenterende

celler

- Dendritisk celler der

hjælper med at aktivere

immunsystemet

• Melanocytter:

- Pigmentceller i

stratum basale.

- Beskytter keratinocytternes

kerner mod skadelige UV-stråler

fra sollys v.h.a melaninproduktion


Nyt koncept i forståelsen af

Atopisk dermatitis

Epidermal årsag

Immunologisk årsag

Kombination


Ændringer i huden ved AD

• 15 -50 % har filaggrin mutationer

• Den mekaniske barriere er defekt

• Nedsat mængde fedtstoffer i huden

• Øget vandtab fra huden

• Øget inflammation i huden


The normal skin barrier

Allergens

Allergens

Water

Water

Water

Water

Water

Water

Water

Water

Water

Water

Water

© 2010 Elliott/Danby/Cork/Cork

7


Broken skin barrier in atopic dermatitis

© 2010 Elliott/Danby/Cork/Cork

8


Broken skin barrier in atopic dermatitis

Subclinical

inflammation

© 2010 Elliott/Danby/Cork/Cork

9


Broken skin barrier in atopic dermatitis

Leading to

inflammation

Lymphocyte

Allergens activate inflammatory cells

© 2010 Elliott/Danby/Cork/Cork

10


Defective epidermal barrier in

individuals with atopic dermatitis

Staphylococcus

aureus

Allergens

Dust mite

DC

TH1

IL-4

TH2

IL-13

Journal of Investigative Dermatology (2009),

Volume 129, 1896-1908


AD and Filaggrin


Filaggrin: function.

• Aggregates keratin

filaments and is involved in

the keratinization of the

stratum corneum

• Filaggrin is degraded to

free amino acids called

natural moisturizing factors


The normal structure of the epidermal barrier located in

the lower part of the stratum corneum

Intact lipid lamellae

NMF

H 2

O

NMF

H 2

O

High levels of

protease inhibitors:

e.g., LEKTI,

CYSTATIN A

Filaggrin

Low levels

of proteases

Pro-filaggrin

JID (2009), 129, 1896-1908


A defective epidermal barrier which permits the

entry of allergens and the loss of moisture

H2O

Defective lipid lamellae

H2O

NMF

H 2

O

NMF

H 2

O

Low levels of

protease inhibitors:

e.g., LEKTI,

CYSTATIN A

High levels

of proteases

Filaggrin

Pro-filaggrin

JID (2009), 129, 1896-1908


Emollient Therapy for Primary

Prevention of AD

• 22 babies at high risk for developing AD

• Treated with emollients daily from birth

• Mean follow up was 547 days

• Only 3 out of 20 developed AD

• No control group

• Skin barrier repair from birth may prevent

development of AD

Simpson E et al. JAAD 2010; 63(4): 587-93


Steroidbesparende effekt af

fugtighedscreme

• 173 spædbørn under 12 mdr. med AD

• Alle blev behandlet med steroidcremer

• Halvdelen blev også behandlet med

Exomega fugtighedscreme 2 gange dgl.

på ikke eksematiseret hud

• Studiet varede 6 uger


Fugtighedscreme reducerer forbruget af

steroid creme

a: Forbrug af stærk steroid

creme

b: Forbrug af moderat

steroid creme


Emollients in AD

Patients successfully treated (%)

80

70

60

50

40

30

20

10

Baseline

Elidel, n=96

Vehicle, n=96

4 8 12 16 20 24

Week


Emollients in AD

• Ceramide containing emollient

can reduce SCORAD and TEWL

in children with AD.

75

50

SCORAD

50

25

TEWL

30

10

0 3 6 12 20 0 3 6 12 20 weeks

J Am Acad Dermatol. 2002 Aug;47(2):198-208.


Baggrund for studiet

• Aqueous cream BP bruges ofte til atopikere

• Indeholder 1% natrium lauryl sulfat

• Mange atopikere får forværring af eksem

ved brug af cremen

• Forsøg hvor cremen bruges 2 gange daglig

hos patienter der tidl. har haft AD


Aqueous cream BP øger TEWL


Konklusion

• Creme med natrium lauryl sulfat 1%

appliceret 2 gange daglig i 4 uger :

• Øger TEWL

• Nedbryder hud barrieren hos patienter med

tidligere AD

• Giver irritative reaktioner hos mange


• Zactoline indeholder op til 3% NLS

• Vær opmærksom på irritative reaktioner hos

atopikere behandlet med Zactoline

• Eventuel alternativ creme til wet wrap

• Kan anvendes til skæl løsning mm.


Daglig Fugtighedspleje

• Fugtighedscreme er steroidbesparende!

• Fugtighedscreme hver dag, også når der

ikke eksem

• Forebygger og vedligeholder


Daglig Fugtighedspleje

• Fed creme til meget tør hud

• Mindre fed til væskende hud

• Om vinteren fede cremer om sommeren

mindre fede

• Find en creme der passer

• Det skal ud af tuben før det hjælper!

• Undgå parfumerede produkter


PO-SCORAD

Patienternes redskab til at

bedømme sværhedsgraden af

deres atopiske eksem


SCORAD and PO-SCORAD

• Redskaber til at bedømme atopisk eksem

SCORAD:

PO-SCORAD:

Behandleren

Patienten

• Udviklet af European Task Force on Atopic

Dermatitis (ETFAD)


SCORAD og PO-SCORAD

SCORAD: SCORing Atopic Dermatitis

PO-SCORAD: Patient Oriented- SCORing

Atopic Dermatitis


ETFAD

• En europæisk arbejdsgruppe der består af

dermatologer med særlig interesse for AD

• Den første officielle EADV task force for

en dermatologisk sygdom


ETFAD

• Udvikler redskaber til at behandle og

bedømme AD

• Afholder videnskabelige symposier ved

EADV møderne


Vurdering

• Et vigtigt skridt i behandlingen af kronisk

sygdom.

• Har til formål at bedømme patientens kliniske

tilstand på en reproducerbar måde

• Til bedømmelse af ekffektiviteten af en given

behandling:

– Til patient monitorering

– Ved kliniske afprøvninger


• Et nyttigt redskab til at

bedømme AD

• Valideret og anvendt i mere

end 400 artikler

MEN:

• Det er lægens redskab

• Kan kun anvendes når

patienten er i

konsultationen

SCORAD


Lægens og patientens vurdering:

To forskellige synspunkter

Denne

bold er gul

Denne

bold er

blå


Hvad skete der mellem disse to besøg?

Week 1

SCORAD:50

Week 4

SCORAD:20

?


Patient Oriented SCORAD

PO-SCORAD

• Mange selv-evaluerings scoringssystemer ved

AD :

– SA-EASI

– Skin detective

POEM

Houseman T.S, Patel M.J., Camacho F., Feldman S.R., Fleischer A.B., Balkrishnan R. Use of the selfadministered

eczema area and severity index by parents caregivers : results of a validation study. Br J

Dermatol. 2002; 147:1192-1198.

Charman C.R., Venn A.J., Williams H.J. The Patient-Oriented Eczema Mesure. Developpement and

initial validation of a new tool for measuring atopic eczema severity from the patient’s perspective. Arch

of Dermatol.2004; 140: 1513-1519.

T. Lob-Corzilius et al. The ‘Skin Detective Questionnaire’: A Survey Tool for Self-Assessment of

Patients with Atopic Dermatitis. First Results of Its Application. Dermatol Psychosom 2004;5:141–146.


PO-SCORAD

– Why did we want to create a new patient

oriented atopic dermatitis score?

– To offer an EBM tool to the patients

– To align and compare the patient’s score with

the validated doctor’s score (SCORAD)

– To use a common terminology when

communicating with the patient


Feasibility study

• Development of the Patient Oriented SCORAD

(PO-SCORAD):

• A small prospective pilot study was performed at

the thermal spa in Avene in France

• 34 patients

• Both adults and children


• Primary end points:

Feasibility study

– Acceptability of the PO-SCORAD based on the SCORAD

index.

– Feasibility judged by a questionnaire given to the patient

after patient/physician scoring at D0 and D18

• Secondary end point:

– Validity by comparison and correlation of the SCORAD

and the PO-SCORAD at D0 and D18


Acceptability: Is time an issue?

< 5 minutes 48%

5 to 10 minutes 48%

> 10 minutes 4%

< 2 % of patients found the scoring to be time consuming


Acceptability

• Two items were difficult to assess for the patients:

– Oedema (65%)

– Lichenification (70%)

• The remaining items were considered not at all

difficult to assess by 70% of the patients or parents


Correlation between

SCORAD and PO-SCORAD

PO-SCORAD

PO-SCORAD

SCORAD (day 0+18) SCORAD (day 18)


Self assessment is possible

• Self-assessment in AD: is

feasible and relatively easy

to perform for the patient

• A significant , but modest

correlation was found

between the physicians and

the patients scores


Limitations of the pilot study

The patient had no illustrated book with pictures of:

• The different signs in the scoring system

• The graduation of the severity of the signs

• It was a small study with few patients


PO-SCORAD: European validation study

• Objectives: To validate the PO-SCORAD in a large

European population of patients exhibiting all forms

of AD severity

• Patients: n=461 (185 adults and 286 children) from 9

European countries


POSCORAD: European validation

study

Severity of the patients’ AD was assessed at the inclusion

(D0) and at the follow-up visit (D28):

• By the investigator using the SCORAD

• By the patient using the PO-SCORAD


A tool to assess your eczema :

PO-SCORAD

• Creation of an

illustrated book

dedicated to the

patient

• Adaptation of the

SCORAD items

terminology to the

public language




Better understand your disease

Better recognize the symptoms

Better communicate with your

doctor


The extent of your eczema

o

Shade in the areas where

your eczema is situated.


Appearance, severity of your eczema:

Are the eczema

zones red?

Slightly red

Fairly red

Extremely red


Are the

eczema zones

swollen?

Slightly swollen

Fairly swollen

Extremely swollen


Are there crusts

or oozing in the

eczema areas?

A little

Moderately

Extreme


Are there scratch

marks on the

skin ?

A little

Average

A lot


Is the skin

thickened ?

Slightly thickened

Moderately thickened

Severely thickened


Itching and sleep problems over

the last 3 days

– Were you disturbed by itch (see scale below)?

– Did you have trouble sleeping (see scale

below)?

On the scale:

0 means : no itching and no sleep loss.

10 means : The worst itch and the most severe sleep disturbance imaginable.


Results

• 372 (79%) Mild to moderate AD

(SCORAD≤50)

• 99 (21%)

Severe AD(SCORAD>50)


PO-SCORAD and SCORAD scores

correlated at Day 0

PO-SCORAD

r=0.67 p


Consistency was confirmed at day 28,

with a stronger linear correlation

PO-SCORAD

r=0.79 p


Results

PO-SCORAD and SCORAD scores were

closely correlated at D0 (r =0.67 p


• Self- assessment scales can give an idea of

the dynamics of disease activity between

visits in your office

• We believe it can enhance the patient’s

knowledge, independence and adherence to

treatment


Electronic version


Tak for opmærksomheden

More magazines by this user
Similar magazines