Case Series

Atopic Dermatitis in Children

with Cow’s Milk Allergy
dr. Avyandita Meirizkia

Advisor:
dr. Yusmala Helmy, Sp.A(K) 1
dr. R. A. Myrna Alia, Sp.A(K)
 2

Introduction
 Atopic dermatitis (AD), or eczema, is the most
common chronic relapsing skin disease seen in
infancy and childhood.
 It affects 10-30% of children worldwide and
frequently occurs in families with other atopic
diseases, such as asthma, allergic rhinitis, and food
allergy
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 Cow’s milk allergy (CMA) is a disease of infancy

and usually appears in the first few months of life
 Its prevalence increase in the past 2-3 years
 Usually underdiagnosed and overdiagnosed
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1st Case
Boy, 6 months old, good nutritional status

Chief Complaint:

 Redness in cheek and

 5

Present Illness History

1,5 mo 2 wk
before Redness in cheek before
Redness is
Recurrent thickened

Appear in arms
and leg
Spread to
arm, leg, neck
Appear 1,5
months after
consuming cow’s Fussy baby
milk formula

No history of using
lotion, oil, and
Scratching
powder
 6

Past Illness History

 Diarrhea with bloody mucous stool at 3 months old, after
given a cow’s milk formula for 2 days

Familial Illness History

 Atopic mother, rhinitis allergy
Immunization history
7

• Appropriate basic immunization by age

Developmental History

• Able to prone (appropriate by age)

Growth History

• Appropriate by age, increase every

month

Nutritional History

• Exclusive breastfeed until 3 months old.

• Cow’s milk formula 6x 90-120cc/days
• Adequate intake
 8

Physical Examination
General examination

• compos mentis

Vital sign

• HR 136x/min, RR: 42x/min Temp: 36.5C

Nutritional Status

• BW: 7kg Body Height 65cm

• W/A zscore 0sd - -2sd
• H/A zscore 0sd - -2sd
• W/H zcore 0 – 1 sd
• Good nutritional status
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Head

•Normocephaly, anemic conjunctiva (-)

Thorax

•Simetris, Retraction (-)

Lung

•Vesicular, rhonci (-/-), wheezing (-)

Heart

•Heart Sound normal, Murmur (-), Gallop (-)

Stomach

•Flat, not palpable hepar and lien, normal bowel sound

Extrimity

•Warm, CRT< 3
 10
Dermatological status

 Eritema maculopapular lesion

spread to cheek, ear, neck,
upper and lower extremities

 Dry lession

 Squamas in some parts

 Skin erosion

 Satelite lession (-)

 Xerosis (+)
11
 12

2nd Case
Boy, 2,5 months old

Chief Complaint:

 Redness in cheek
 13

Present Illness History

• Redness in cheek
• Reccurent
• Fever (-) diarrhea (-)
• No history of using baby lotion, oil, powder
• Consumed cow’s milk formula since birth
• Was hospitalized in NICU for 52 days
 14

• Was hospitalized in NICU for 52 days

• PT-AGA + ELBW + Grade II Hyaline
Membrane Diseases + Sepsis + Apnea of
Prematurity + Cholestasis Intrahepatik
• Had urdafalk 3 x 20mg

• Atopic Father, Asthma

Immunization history
15

• Hepatitis B(+) Polio (+)1x, DPT 1x, BCG (+)

Developmental History

• Not able, (appropriate for correction age

38 week)

Growth History

• Appropriate by correction age (fenton

chart)

Nutritional History

• Cow’s milk formula for low birth weight

since birth 8x60cc/days
• Adequate intake
 16

Physical Examination
General examination

• compos mentis

Vital sign

• HR 142x/min, RR: 50x/min Temp: 36.5C

Nutritional Status

• BW: 2,4 kg
• Body Height 48cm
• Good nutritional status
 17
Head

•Normocephaly, anemic conjunctiva (-)

Thorax

•Simetris, Retraction (-)

Lung

•Vesicular, rhonci (-/-), wheezing (-)

Heart

•Heart Sound normal, Murmur (-), Gallop (-)

Stomach

•Flat, not palpable hepar and lien, normal bowel sound

Extremities

•Warm, CRT< 3
 18
Dermatological Status

 Papul eritema lession in

cheek

 No erosion

 Xerosis (+)
 19

Initial Problem
Case 1 Case 2
 Redness  Redness

 Dry skin  Dry Skin

 Suspected Cow’s Milk  Suspected Cow’s Milk

Allergy Allergy

 Cholestasis intrahepatic
 20

Diagnoses
Case - 1 Case - 2
 Atopic dermatitis ec susp.  Atopic dermatitis ec susp.
Cow’s Milk Allergy Cow’s Milk Allergy

Initial analysis and Planning
1st Case
•Elimination and Provocation
test
•Stop Cow’s Milk
•Extensive Hydrolyzed Formula
6x120cc (489 kcal/day)
•Emolien, right after bath
•Corticosteroid topical 1x/day
•Breastfed
•Bath 2 times a day
•Dry the skin with pat-pat
21
2nd Case
• Elimination and Provocation
test
• Stop Cow’s Milk
• Extensive Hydrolyzed
Formula 6x120cc (324
kcal/day)
• Emolien, right after bath
• Bath 2 times a day
• Dry the skin with pat-pat
 22

Prognoses
 Quo ad vitam : dubia ad bonam

 Quo ad fungsionam : dubia ad bonam

 23

Progress Note
1st Case
January 22nd (7 days after elimination test) 24
Complaint Redness in face, arms and leg thinning
Dermatological Thinning of maculopapular eritema in face,
Status arms, leg
Xerosis (+)
Satelite lession (-)
Treatment Extensive Hydrolyzed Formula
Bath 2 times a day
Emolient after bath
Stop topical corticosteroid
February 8th (3 weeks after elimination test) 25
Complaint Redness in face, arms and leg thinning
Dermatological Maculopapular eritema (-)
Status Xerosis (-)
Satelite lession (-)
Treatment Extensive Hydrolyzed Formula
Bath 2 times a day
Emolient after bath
Plan for provocative test
February 13th (3 days after provocative test ) 26
Complaint Redness in face
Dermatological Maculopapular eritema (+)
Status Xerosis (-)
Satelite lession (-)

Treatment Soya  Extensive Hydrolyzed Formula

Bath 2 times a day
Emolient after bath
 27

Progress Note
2nd Case
February 14th (4 weeks after elimination test) 28
Complaint Redness in face
Dermatological Macuopapular eritema (-)
Status Xerosis (+)
Treatment Extensive Hydrolyzed Formula
Provocative Test to Cow’s Milk Formula
 29

Literature Review
 30

Atopic Dermatitis
 Atopic dermatitis (AD), or eczema, is the most
common chronic relapsing skin disease seen in
infancy and childhood.
 31

Type of Atopic Dermatitis

Extrinsic / Allergic Intrinsic / Non Allergic
 70-80% in atopic dermatitis  20-30%

 Sensitization of allergen  No sensitization of allergen

 Elevation of IgE  Lower IgE


Clinical Manifestation
Infantile ( 2months-2 years)
 Symptom: intense pruritus
 Distribution: Often symmetric.
Cheeks, forehead, ears,
scalp, extensor surfaces of
extremities and trunk
 Morphology: Erythema,
papules, vesicles, oozing, and
crusting. Dry scale as
opposed to greasy scale in
seborrheic dermatitis.
Postinflammatory
hypo/hyperpigmentation is
common.
32
Childhood (2years-puberty
 Symptom: intense pruritus
 Distribution: Wrists, ankles,
neck, posterior thighs,
buttocks, antecubital and
popliteal fossae
 Morphology: Poorly defined,
erythematous, scaly patches,
frequently studded with crust,
exudate, and erosions.
Lichenification may be
present in antecubital and
popliteal fossae. Nummular
patches may also be evident
 33

Hanifin Rajka Criteria

3 major criteria
 Pruritus
 Eczema (acute, subacute, chronic)
 Typical morphology and age-specific
patterns
 Infants and children—facial, neck,
and extensor involvement
 Familial atopic history
 34

 3 minor criteria
 35

5 pillar of DA treatment
 Education and empowerment of the patient and caregiver
 Educate about sign and symptoms, trigger factors, prognoses, and
treatment
 How to take care of DA
 Bath 1-2 times a day, lukewarm water, 10-15mins
 Hydrate soap
 Emolients

 Modification and avoidance of allergen

 Maintain skin barrier with hydration by reducing the

Transepidermal water loss with moisturizer

 Controlling of skin inflamation by giving steroid topical

 Elimination of itch-scratch cycle by giving antihistamin, intermitten

 36

Cow’s Milk Allergy

 Cow’s milk allergy (CMA) is a disease of infancy and usually
appears in the first few months of life.
 Cow’s milk allergy is the second most common food allergen in
young Asian children, after egg.

 Sensitization on atopic dermatitis patients in Pediatric Allergy

Clinic (2013):
 White egg (31%)
 Cow’s milk (23.8%)
 Yolk egg (21.4%)
 37

Cow’s Milk Allergy

IgE Mediated Allergy Non IgE Mediated

Rapid Onset, more severe

allergic reaction; Clinical Occurs over a period hour or
Manifestation: urticaria, days; IgG mediated; Allergic
angioedema, rashes, atopic Eosinophilic GE, Anemia, FTT
dermatitis, anaphylaptic
 38

Clinical Manifestation
 Symptom appear within 1 week after cow’s milk
formula sensitization

 With one or more organs, gastrointestinal and skin

 Skin: Pruritus, erythema, significant atopic eczema
 Gastrointestinal
 Colic, Reflux (GERD), food refusal, Constipation
 Respiratory: airway symptoms
 39

Diagnoses
 IgE Specific :
 RAST test (Radio Allergo Sorbent Test)
 Skin prick test

 Elimination and Provocation Test

 Mild to Moderate Allergy : Extensive Hydrolize
Formula, 2-4 weeks

 Double Blind Placebo Controlled Food Challenge

 Blood in feses
 40

Elimination and Provocation

Test
 Mild to Moderate Cow’s Milk Allergy
 Elimination test for 2-4 weeks with extensive
Hydrolyzed Formula
 Positive Provocation Test
 If symptoms appear after provocation
 Negative Provocation test
 If Symptoms disappear after provocation
Cow’s Milk Formula with History of Cow’s Milk 41
42
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Cow’s Milk Allergy in Breastfe
44
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Case Analysis
 4
Case Analysis 6
Diagnoses of Atopic Dermatitis
1st Case

 3 major criteria
 Typical morphology and
distribution in facial and extensor
 Chronic relapsing dermatitis
 Family history of atopy
 Diagnoses of Atopic
Dermatitis using Hanifin
Rajka Criteria

 3 minor criteria  3 major criteria 3 minor

 Xerosis, early age onset, triggered criteria
by food
 Sensitivity 87.9-960,
2nd Case Specificity 77.6-93.6
 3 major criteria
 Typical morphology and
distribution in facial and extensor
 Chronic relapsing dermatitis
 Family history of atopy

 3 minor criteria
 Xerosis, early age onset, triggered
by food
 4
Case Analysis 7
Diagnoses
 4
Case Analysis 8
Diagnoses of Cow’s Milk Allergy
1st Case
 Occur in first year of life
 Non IgE mediated
 Appear late after
sensitization of cow’s milk  Appear late after
sensitization
 Familial atopic history
 Colic
 Dermatitis atopic
 Histroy of Familial atopy

2nd Case
 In severe case
 Occur in first year of life
 Anemia
 Appear late after
sensitization of cow’s milk  Failure to thrive
 Familial atopic history
 4
Case Analysis 9
Diagnoses of Cow’s Milk Allergy
 5
Case Analysis 0
Atopic History
Patient Literature

1st Case  25-30% risk of allergy if one

of the parents has allergy
 Mother with rhinitis allergy

2nd Case

 Father with Asthma

 5
Case Analysis 1
Atopic History
 5
Case Analysis 2
Treatment for Cow’s Milk Allergy
1st Case

 Elimination and Provocation  Elimination of cow’s milk 2-4

test weeks
 Stop Cow’s Milk  Extensive Hydrolized formula
 Extensive Hydrolyzed Formula  Provocative Test
6x120cc (489 kcal/day)
 Monitoring
2nd Case

 Elimination and Provocation

test

 Stop Cow’s Milk

 Extensive Hydrolyzed Formula

6x120cc (324 kcal/day)
 5
Case Analysis 3
Treatment for Cow’s Milk Allergy (1 st Case)
 5
Case Analysis 4
Treatment for Cow’s Milk Allergy (1 st Case)
 5
Case Analysis 5
Treatment for Cow’s Milk Allergy (2nd Case)
 5
Case Analysis 6
Treatment for Cow’s Milk Allergy (2 nd Case)
 5
Case Analysis 7
Treatment for Atopic Dermatitis
1st Case

 Bath 2 times a day  Skin Hydration and

 Emolien, right after bath
 Corticosteroid topical
1x/day
emolients to adress barrier
dysfunction
 Soaking baths 2 times a day
 Topical corticosteroid

2nd Case

 Bath 2 times a day

 Emolien, right after bath

 5
Case Analysis 8
Treatment for Atopic Dermatitis
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Thank You