1. IJDVL
Presenter- Deepika Kothari
Moderator - Saroj Purohit Mam

2. Atopic patch testing

3. INTRODUCTION
● Atopic dermatitis is a chronic inflammatory skin disorder
characterized by intense itching and a relapsing course
especially in infants and children with a personal or family history
of atopic disorders.
● The atopic patch test is now available for identification of
allergens in aeroallergen-triggered atopic dermatitis.

4. METHODS
● 75 subjects with atopic dermatitis fitting Hanifin and Rajka’s criteria and
elevated serum IgE were included in the study.
● EXCLUSION -Patients with active disease who had taken drugs like
antihistamines during the last 1week
● corticosteroids , systemically during the last 4 weeks and topically during the
last 1 week or who were on immunomodulators-topical and oral
● beta blockers or tricyclic antidepressants
● who had dermatitis over the test site
● Pregnant

5. ● Patch testing was done using prick test allergens in aluminium patch test
chambers.
● The test site - upper back
● Test material - aqueous allergens supplied by Creative Drug Industries
(Allergology division, Navi Mumbai) containing 50% glycerine as stabilizing
factor and preserved with 0.4% phenol.
● The antigens used were dust mites: Dermatophagoides farinae, D.
pteronyssinus,pollens of Cynodon dactylon and Parthenium hysterophorus,
foods like rice, wheat, milk, egg and dog and cat epithelia.

6. ● The reading was taken after 48 and 72 hours and interpretation and Grading
of APT reaction was done according to the guidelines by European task force
on atopic dermatitis consensus
INTERPRETATIONS OBSERVATION
- Negative
+ Erythema, infilteration
++ Erythema, up to 3 papules
+++ Erythema more than 4 papules
++++ Erythema spreading papules
+++++ Erythema, vesicles

7. RESULTS
● Out of 75 subjects, 38 were males (51%) and 37 were females (49%) with
mean age of 17.70 (1 to 64) years.
● 70% gave personal or family history
● Commonest site - cubical fossa > popliteal fossa
● 46.66% (35) showed positive reactions
● 50.66% (38) had no reaction and 2.66% (2) manifested angry back syndrome

8. ● Parthenium accounted for 42.8%(15) of all positive reactions followed by
Cynodon 20%(7)
● D. farinae 14%(5), D. pteronyssinus 11%(4), Milk 9%(3) and 6%(2) each to
wheat, egg, dog dander and cat dander and only one subject reacted to rice -
3%.
● among 15 parthenium APT positive subjects, 8 subjects were tested with the
Indian Standard Series (ISS) and of these 6 subjects showed positive
reaction to parthenium in ISS (delayed hypersensitivity).

9. DISCUSSION
● Dust mites are considered to be the most important triggering agent for atopic
dermatitis.
● Cow milk and hen egg allergy are the most important food allergies ,
avoidance resulted in the clinical improvement.

10. ● Parthenium hysterophorus is the most important antigen in India with both
type I and type IV hypersensitivity.
● Cynodon dactylon, also called Bermuda grass,Pet dander especially cat and
dog dander,having triggering factor for atopic dermatitis
● Presence of at least seven papules after 72 h was the APT skin sign with the
greatest diagnostic accuracy for food allergy in children with atopic dermatitis.

11. ● counselling on avoidance of allergen based on APT can reduce the morbidity
● and can reduce the drug load in atopic dermatitis.

12. ● Advantages of APT over skin prick tests are that: it can be tested at a younger age, risk
of anaphylaxis is low And specificity is high.
● Disadvantages are
● sensitivity is lower than SPT,
● it is time consuming and only a few antigens can be tested at a time.
● To date, no “gold standard” exists for the provocation of reactions in aeroallergen
triggered atopic dermatitis and APT has not been standardised.
● The relevance of allergens for atopic dermatitis flares may be evaluated by APT in
addition to skin prick test.

13. Phototherapy for atopic
dermatitis

14. • Management of atopic dermatitis can be
challenging and involves short
‐
term control of acute
symptoms with topical corticosteroids / topical
calcineurin inhibitors, and oral corticosteroids in
severe disease.
• Various types of phototherapy that have been tried
include:
➢ PUVA therapy
➢ UVA1 phototherapy (high
‐
dose [HD], medium
‐
dose [MD],
and low
‐
dose [LD])
➢ UVA/B phototherapy
➢ Narrow
‐
band (NB
‐
UVB) phototherapy
➢ Broad
‐
band UVB (BBUVB) phototherapy.

15. • Phototherapy is considered a second line
treatment in the management of atopic dermatitis.
• can be tried in patients in whom the disease is not
adequately controlled with emollients and topical
corticosteroids / immunomodulators.

16. Material & Methods
• A literature search was performed to collect data on
the use of phototherapy in the treatment of atopic
dermatitis.
• Relevant literature published till March 2014 was
obtained from PubMed, EMBASE, and the
Cochrane Library.

17. Results
➢BBUVB phototherapy
• In the initial study by Jekler and Larko involving, 17
patients with half
‐
side comparison between BBUVB
(0.5–1.0 MED) and visible light, the former was
found to be significantly better.

18. • Hannuksela et al. utilized Psorilux 9050 emitting
UVB and UVA at 280–315 nm and 315– 400 nm to
treat 107 atopic patients and found both the
treatment modalities to be beneficial in 93% of
cases with a significant corticosteroid
‐
sparing effect.
• In another paired comparison study of 21 patients,
UVA was shown to be significantly better than
BBUVB for the total clinical score.

19. ➢NB-UVB phototherapy
• In a study of 21 adults with severe disease, NB
‐
UVB
photo
‐
therapy given, three times weekly for 12 weeks
• There was 68% reduction in disease severity and an 88%
reduction in topical corticosteroid use
• 15 out of 21 patients continued to show benefit 24weeks
after discontinuing NB
‐
UVB

20. • In a randomised controlled trial, 73 patients were
randomized to receive either NB
‐
UVB, BBUVA or
visible light phototherapy twice weekly for 12
weeks.
• NB
‐
UVB was demonstrated to be very effective in
moderate
‐
to
‐
severe adult atopic dermatitis with
remission lasting for 3 months.
• BBUVA phototherapy was only moderately
beneficial

21. • Treatment with oral short
‐
term cyclosporin A for 4 weeks,
followed by a washout phase of 4–6 weeks and
subsequent NB
‐
UVB phototherapy (3 times/week, up to
2 months) has been reported to be effective in the
treatment of severe atopic dermatitis.
• The effect of NB
‐
UVB has been also evaluated in
children.
• In a prospective study done to asses the efficacy of NB
‐
UVB phototherapy in 29 children aged 3–16 years,

22. • They found 61% reduction in mean SASSAD (Six
Area Six Sign Atopic Dermatitis) score in the NB
‐
UVB cohort compared with an increase of disease
severity in the unexposed cohort.
• The effect of NB
‐
UVB has been also evaluated in children.
• In a prospective study done to asses the efficacy of NB
‐
UVB phototherapy in 29 children aged 3–16 years,

23. ➢UVA/B Phototherapy
• Combination phototherapy of UVA and UVB irradiation
can be applied by using special tubes whose emission
spectrum includes both ranges or by combining UVA and
UVB tubes simultaneously or in a serial manner
• Valkova and Velkova demonstrated that combination
UVA/B and topical corticosteroids was significantly better
than UVA/B alone for the reduction of treatment duration
(P = 0.02)

24. • Granlund et al. showed that ciclosporin was significantly
better than UVA/B for the rapid reduction of SCORAD, the
days in remission and the improvement in quality of life
during the first 4 weeks of treatment

25. ➢Photochemotherapy
• In a study by Tzaneva et al., 5
‐
methoxypsoralen (MOP)
PUVA was found to be significantly better than medium
dose UVA1 in reducing the disease severity and
increasing the duration of remission .

26. ➢UVA-1 phototherapy
• Krutman et al. compared UVA
‐
1 phototherapy (given in a
single dose of 130J /cm2 for 15 consecutive days) with
UVA/B irradiation (starting doses 30 mJ/cm2 UVB and 7 J/
cm2 UVA, respectively)
• They found that UVA
‐
1, significantly more effective
compared with UVA/B therapy in reducing the clinical
scores and in the downregulation of eosinophilic cationic
protein levels.

27. Medium dose UVA
‐
1 is as effective as high dose UVA
‐
1 for
the treatment of patients with severe atopic dermatitis
In another study, medium dose UVA
‐
1 cold light (45 J/cm2,
5 times weekly for 4 weeks) showed prolonged therapeutic
improvement in disease activity and quality of life
In another study, 15 irradiation cycles of medium dose UVA
‐
1 phototherapy induced healing of the lesions in chronic
vesicular dyshidrotic hand eczema, in 10 out of 12 patients
with no relapse till 3 months

28. • NB
‐
UVB and medium dose UVA1 are equally effective in the
treatment of patients with moderate
‐
to
‐
severe atopic dermatitis.
• In a randomized investigator
‐
blinded trial, Majoie et al. evaluated 13
adults (aged 20–56 years) with chronic atopic dermatitis and found
NB
‐
UVB and medium dose UVA1 to be equally effective in reducing
disease severity
• Both therapies were equally effective in significantly decreasing
scores for pruritus and clinical severity .

29. Adverse effects
➢ MC :
• Xerosis,
• Erythema
• Burning of the skin
➢ Less common:
• Pruritus (UVA1 and full
‐
spectrum light)
• Exacerbations of eczema (UVA, NB
‐
UVB, visible light,
full
‐
spectrum light)
• Folliculitis (UVA1, PUVA)
• Photo
‐
onycholysis (PUVA)

30. ● hyperpigmentation
● HSV reactivation
● Polymorphic light eruption
● Photo ageing
● Photo carcinogenesis

31. Discussion
• Based on the review of available literature,they concluded that, medium
dose UVA1 and NB
‐
UVB phototherapy are the most effective.
• UVA1 used for controlling acute flares of atopic dermatitis, whereas NB
‐
UVB is the most effective in managing chronic disease.

32. • High dose UVA1 and medium dose UVA1 has been shown to have
similar efficacy, so UVA1 may be the preferred option as the amount
to heat produced is less leading to better patient acceptability.
• Due to paucity of evidence, full
‐
spectrum UVA, BB
‐
UVB and full
‐
spectrum light should not be recommended for the treatment of
atopic dermatitis.

33. • Many studies reported the concomitant use of topical corticosteroids, which
confounds the results
• Another important aspect is the limited availability of UV1 phototherapy is, it’s
high cost
• Phototherapy may not be beneficial for all patients as some may not tolerate
the associated heat and sweating and hence, the treatment needs to be
individualized.

34. • New devices, such as 308 nm monochromatic
excimer light expand the therapeutic options in
patients with localized and therapy
‐
resistant disease,
even though they can treat only limited areas.

35. THANK YOU