SKIN DISEASES DUE TO

IMMUNOLOGYCAL MECHANISM
Faridha S Ilyas

Dermatovenereology Dept
Hasanuddin University /
Dr. Wahidin Sudirohusodo,
General Hospital
 Topics

 Introduction

 Atopic dermatitis

 Urticaria

 Drug eruption

 Contact Dermatitis

 Prick Test & Patch Test

2
 Immune system

health

Immune activation
Immune control

Diseases

Infection
Allergy
Autoimmunity
Cancer etc
 Associated diseases

 Insect bite

 SSJ-NET-Angioedema

 Food allergy

 Leprosy reaction (ENL-RR)

 Bullous diseases

2
 Synonime
Atopic eczema
Disseminate neurodermatitis
Infantil eczema
Flexural eczema
Diffuse neurodermatitis
Constitucional neuodermatitis
Prurigo Besnier
Definition

A chronic inflammatory skin disease

presenting with recurrent itchy red rashes
(eczema) affecting certain part of the body
(face, neck, joint folds of the arm and legs),
usually occur in infant & child with
personal/family history of atopy
Atopy

Hypersensitivity familial against

alergen in the environment,
which health person no reaction.

Related with increasing IgE &

Family history of AD, rhinitis
allergy , asthma.
Hystory

 Wise & Sulzberger to diagnosed

a food and aerosol agent allergy
that can be manifest as eczem,
asthma & hay fever
 Patomechanism
Histamine is a important substance that
give reaction in AD itchy
Histamine  mast cell degranulation
Mast cell degranulation
Acute AD
Chronic AD
Symptom and Sign

 Itch is aprominent feature

 Dry skin

 Eczema : acute Acute eczema

(papules),subacute &
chronic (lichenification)

chronic eczema
 Clinical manifestation
 Severe ithcy  scrath  worse
 Eritematous macule, papul/papulovesicel
 Eczematous area with crust
 Licenification & excoriation
 Dry skin and secunder infection
 3 type : Infantil ( 2month – 2 years)
Child ( 3 -10 years)
Adult (13 – 30 years )
Infantil (2 month-2yr)

papule, vesicel miliar, erosive,

exudative, crust
Predilection both of cheek,
flexor-extensor extremities
Infantil type of AD
Child (3-10yr)
exudative, licenification,
hypopigmentation
Predilection  nape of
neck, flexor cubital &
popliteal
Adult ( 13-30yr)
History taking can be found
infant and child form
Dry lesion, licenification
 Diagnosed
Hanafin & Rajka Criteria
1.Major Criteria
 Pruritus/itchy
 Typical Morfology & distribution of
lesion. infant-child face, extensor.
 Adult  flexural with licenification
 Recurrent/chronic dermatitis
 Family history of atopy/ his self
2. Minor Criteria
 Xerosis
 Ichtiosis/keratosis pilaris
 Hiperlinearis palmar
 type I skin test positive reaction
 Increased serum IgE
 Early onset & food intolerance
 Easily to suffer skin infection
 Hand & foot dermatitis
 Eczema on areola mammae
 Conjunctivitis
 Dennie morgan fold
 Orbital darkening
 Redness/pale on face
 Pitiriasis alba + Pitiriasis rubra pilaris
Diagnosed  all major criteria
or
all major criteria
+
minor criteria
Differential Diagnose

 Seborrhoic Dermatitis
 Iritan/allergic Contact Dermatosis
 Numularis Dermatitis
 Scabies
 Psoriasis
Therapy
 H1 antihistamine decrease of itchy
 Hidration (oilated baths)  emolien (hydrate
petrolatum) prevent xerosis.
 Topical anti inflammatorytar, corticosteroid
 Systemic corticosteroid
 Topical Tacrolimus (new therapy)
 Identification and avoidance provocation factor
: soap, chemical agent, wool clothes,
environment, exercise, sun exposure, stress
and infection
Complication
Secunder infection 
S.aureus colonisation 
trigger secunder infection 
cause of reccurent
Atopic Dermatitis child type
Dermatitis atopic adult type
 URTICARIA
Hives, nettle rash, biduran, kaligata
Definition: skin lesion
consist of a wheal-
flare and localized
intracutneous edema
with surrounded
redness area, pruritic
or burning sensation.
, disappear in the
short period
 Idiopathic

Immune Mechanism Direct Mast cell

IgE degranulation
Complement
Autoimmune

Arachidonic metab
Physical stimuli altering agents

Mediator
release

Causes of Urticaria
 Urticaria ?
Angioedema?

akut chronic

food drug infeksi

idiopatik Urticaria Physical Angioedema

CIU vasculitis urticaria tanpa urtikaria

obat Makanan
Infeksi
fokal “food additive”
keganasan Urtikaria
hepatitis autoimun
stres Helicobacter
infestasi pylori

idiopatik
Class of Urticaria (etiopathog)

 Immunologic
 Non Immunologic
 Idiopathic
Class of Urticaria (clinical)
 Ordinary urticaria (all urticaria not class below)
 Physical Urticaria
 Urticaria vasculitis
 Contact urticaria
 Angioedema without wheal
 Distinctive urticarial syndrome
 Fig 5-8 . Activation of mast cell in type I hypersensitivity and release
of their mediators. ECF, eosinophil chemotactic factor; NCF, neutrophil
Chemotactic factors; PAF, platelet-activating factor.
MAST CELL DEGRANULATION
 MAST CELL DEGRANULATION
Protease Triptase
Biogenic Histamin serin netral Kimase
Mast cell amine
activation Granule Karboksi peptidase A
Preformed
mediator protein
Granule Katepsin G
macromolecule
Heparin
Proteoglikan
Release Condroitin sulfat
mediator
AA Siklo-oksigenase PGD2
Lipid-derived LTD4
Newly Lipoksigenase
mediator LTC4
syntesized
mediator PAF LTE4

Sitokin
Figure 19-6 Biologic effects of mediators of immediate hypersintivity
Treatment

Grattan CE. Immunology and Drug Therapy of Allergic Skin Diseases 2000: 137-156
Many factors can influence in drug eruption:
 Pharmacogenetic variation in drug methabolizing enzyme
 HLA association
 Active viral infection and concurrent use of other
medication
 Drug-drug interaction
 Host factor : age

44
 Patomechanism

 Type I reaction (Anafilaktik)

 Type II reaction (Cytotoxic)
 Type III reaction (complex immune)
 Type IV reaction (Delayed type
hypersensitivity
Clinical Feature

 Urticaria
 Angioedema
 Morbiliform eruption
 Exanthema fixtum (FDE)
 EM
 NET
 SSJ
Morbiliform type Erythrodema type
49
EM SSJ NET
 DRUG ALLERGY TESTING METHODS

IMMUNOLOGIC IN VIVO IN VITRO

REACTION
TYPE I Immediate skin prick RAST. ELISA
and intradermal

TYPE II None Coombs

TYPE III Intradermal Arthus Test Precipitin Test

RAST,ELISA

TYPE IV Patch Test Lymphocyte

Proliferation

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Terapi
 Really diagnosed drug eruptions all
drug which is predicted has to be
stopped.
 Therapy  corresponds to clinical
picture
 Uji Kulit

Hasil tergantung dari

Metode utk mengetahui kemampuan alergen
adanya sensitifitas menghasilkan rx alergi
spesifik pada penderita pada skala kecil melalui
penyakit atopi/riwayat pemberian dgn sengaja
alergi sebelumnya sejumlah alergen pada
penderita.

Uji Tusuk - Uji Tempel

 Advantage & disadvantage

Advantage : Disadvantage :

-Painless & safe - Influenced by drug

- minimally SE - Itchy

-comfortable - Difficult interpretation

- Simple
Procedure
 Interpretation

 Reaction skin appearance

- Tidak beda dengan kontrol
+ Sedikit eritem, urtika, 0.5 cm
+ Urtika 0.5 – 1 cm, eritem sedang
++ Urtika 0.5 – 1 cm, eritem sedang,
nyata pseudopodia
+++ Urtika 1 cm, eritem sedang nyata
pseudopodia
Patch Test
Tes Tempel
Skin Patch Test
 Patch testing is a way of identifying whether a
substance that comes in contact with the skin is
causing inflammation of the skin contact dermatitis.
 Patch testing can be used to assist in the diagnosis of
contact dermatitis.
Indication
1. Patients with suspected contact dermatitis.
2. Patch testing should be performed in all cases dermatitis of
the hands, face, lower legs, and feet, which do not clear up
in a short time.
3. Patch testing should also be considered which there has
been chronic medicament usage.
4. Patient with persistent atypical discoid eczema.
 Contraindication :
 Acute and diverse dermatitis  eksaserbation.
 Patient who receive systemic prednisone < 20 – 30
mg/d or topical corticosteroid  affect result.
 Toxic systemic material  high concentration
Procedure

Allergens in patch testing Patch test applied Several positif result

chambers
Allergen

The Europan Standard series Patch Test

Interpretation
 +? = mild erythema
 + = positive reaction: erythema, infiltrate
 ++ = strong positive reaction: erythema, papul, vesikel
 +++ = extreme positive reaction: bulosa, IR = irritant
reaction. Red skin improves once patch is removed.
 NT = not tested.
Thank You