Atopic Dermatitis overinfected / real clinical case

Note: some images can be disturbing to people.

Hello and welcome back to my blog about the medical area. In this opportunity I will share with the scientific community of blockchain a very particular pathology that occurs in one of the most important organs in the human being.

Skin lesions represent a challenge in the medical field, as identifying them and determining the differences between them requires a great deal of knowledge and practice, as they often generate confusion, in fact when the wrong treatment is indicated and these lesions are modified, make it difficult to identify this pathology that affects the skin.

Now let's get to know a little about this important organ.

The skin is the largest organ of the human body, its function is to cover and protect the organism from aggressive external agents, fulfilling the role of barrier against thermal exposure, chemical, mechanical, toxic and microorganisms.

On the other hand, this organ is extremely important for the control and maintenance of body fluids, moreover it allows us to exteriorize our feelings and emotional state, through the flushed skin, paleness, our hairs are bristling and if that were not enough our skin has the property of emanating pheromones (smell).

This wonderful organ and the largest that our organism has, has an approximate surface area of 2 meters squared, being proportional to the weight and height of the person, with an estimated weight of 4 kg which represents 6% of our weight.

The skin is made up of 3 layers called, in order from outside to inside, that is, from the outermost to the innermost, which are:

Epidermis: it is the first layer of the skin and we can observe it in all the corporal surface, it possesses variable thicknesses, as it is the case of the palms of the hands and soles of the feet, conformed by two groups of cells denominated keratinocytes and dendritic cells (Melanocytes, Langerhans Cells and indeterminate Cells) and that these in turn are constituted by:

Corneal layer.

Lucid layer.

Granulose layer.

Thorny layer.

Basal layer.

^{Layers of epidermis. Licensed CC BY-SA 3.0. Author OpenStax College}

Melanocytes, which are part of the dendritic cells, are responsible for synthesizing Melanin whose function is to give dark pigment to the skin and protect us from solar radiation. This pigment is taken to the keratinocytes in packages called Melanosoma and these are activated by stimuli such as solar radiation and inflammation.

We must bear in mind that all races have the same amount of melanocytes the difference is determined by the type of Melanin for example, eumelanin darker or pheomelanin lighter. As well as the size, shape and distribution of Melanosome packages.

Dermis: it represents the support layer and offers properties of elasticity and resistance to the skin, constituted by connective tissue, which is formed by 3 types of fibers; Collagen, Elastic and Reticular.

^{Illustration of dermal circulation and layers. Licensed CC BY-SA 3.0. Author BruceBlaus}

It is divided into:

Papillary Dermis continues the epidermis, richly vascularized, and with greater number of cells. And the Reticular Dermis deepest area made up of fibers.

The dermis contains inside sweat glands, sebaceous glands, nerves, lymphatic and blood vessels and finally the hair follicle.

Hypodermis or Subcutaneous Cellular tissue: this layer is located in the lower part of the dermis, made up of adipocytes which are described as those fat cells stored inside the triglycerides. In this layer there are few blood vessels and fibrous partitions that separate the fat into lobes.

Its main function is to serve as a thermal insulator, represents a rich reservoir of stored energy and very useful in case of acting as a shock absorber for blows that can receive the body.

^{Microbiology and Skin layers. Licensed CC BY-SA 4.0. Author CNX OpenStax}

Generally speaking, fat is deposited both in the hypodermis and around the viscera and it is for this reason that 2 large groups are distinguished; subcutaneous fat and visceral fat.

Skin Annexes

Hair is defined as a fine keratinized structure, which is located in almost all the extension of the skin, except the palm of the hand, sole of the feet, lips among others. It is divided into stem and root or hair follicle. It also has a muscle called the erector muscle, which originates from the dermis and when it contracts, the hair is elevated, which is what is known as goose bumps.

Sebaceous gland secretory glands (holocrine), which are located attached to the adipose follicle, its function is that the hair is detached from the circulating cells of the follicle and thus promotes the growth of it.

There are two types of sweat glands:

Ecrines, distributed over the entire surface of the body, responsible for producing what is known as sweat, whose composition is water and salts (ClNa, ammonia, uric acid, urea and lactic acid) and act as a thermoregulator of the skin.

Apocrines, located in the armpits and genitals, play an important role in the production of pheromones.

Nerve Terminals that give you the property of pain perception, heat, pressure and touch.

Nails formed by the keratin and are strongly adhered to the nail bed, its function is to protect defense and allow the behavior of the hand in the form of tweezers to handle small objects.

One of the pathologies of the skin is the over-infected atopic Dermatitis.

This pathological one, considered as a chronic inflammatory dermatosis and that in spite of having an almost exclusive presentation in the infancy with 70 to 90 % of the cases, has also been described presentations in adults and it is more frequent when it has genetic antecedents of this type of pathology or when already in early age of it has determined outbreaks of atopic dermatitis.

Real clinical case

Female patient of 17 years of age without pathological antecedents of importance who refers to the onset of current disease approximately 2 weeks ago characterized by pruritic lesions of papules type of predominance in upper and lower limbs, which later with the days become confluent lesions in the form of scaly plaque with signs of phlogosis, (edema, flushing and heat) reason for which is taken to the emergency service of his locality.

Among the most outstanding personal antecedents, he manifests that he suffers from asthma since his childhood. She had a caesarean section one year ago without any complications. And finally, atopic dermatitis 4 years ago with resolution.

Among her gynecological antecedents, she presents development at age 14 and an abortion at age 15.

Physical exam

Blood Pressure: 100/60mmHg.

Heart rate: 75pxm.

Breathing rate: 17rxm.

Saturation: 97%.

Patients in stable clinical conditions, febrile to the touch hydrated eupneica, skin and mucous membrane normo colors, tolerating oxygen environment and decubitus. Pupils isocoric normoreactive to light, ORL without alterations, non painful mobile neck without adenopathies. Confluent lesions in the form of an itchy scaly plaque with signs of phlogosis, without secretion. Cardiopulmonary stable normoexpansible thorax, apex in 5th intercostal space clavicular midline. Rhythmic heart sounds without murmur. Audible respiratory noises in both hemi thorax. Depreciable soft abdomen not painful without visceromegaly. Symmetrical extremities is evident in upper extremities pruriginous lesions in the arm and forearm and at hand level papular lesions with signs of phlogosis and scarce non-foul serous secretion. In lower limbs, lesions with loss of continuity are evidenced, involving pruritic and painful epidermis. Neurological vigil, consciously oriented in time, space and person without cranial peers without meningeal signs.

Laboratory tests:

CB	13.500
Sec	70%
Lymphocytes	30%
Hb	12
Plaq	4301,000
Urea	17
Creatinine	0.7

Images of the patient (previous authorization)

^{@anestrada12
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This chronic pathological skin disease, which is expressed in the form of eczema and courses with outbreaks, is generally more common in children. However, there is a small percentage of cases in adults but with severe clinical symptoms.

There is a genetic predisposition for children with a family history who have had atopic dermatitis. As well as the presence of the filagrin gene whose function lies in epidermal differentiation and barrier function.

It is also associated with alterations of the innate immune system, alteration in the subpopulations of T lymphocytes and IgE levels.

Clinical manifestations of the case

Initially, lesions given by the follicular papule are observed, which later leads to the formation of eczematous plaques that change with time.

It is divided into 3 phases:

This plaque is characterized by zones of erythema, pruritus edema, vesiculation, serous exudation and finally crust, which represents the acute phase.

Subacute phase the plaques are poorly defined with thin scales (scaling and excoriations).

In the chronic phase the lichenification is characteristic, with thickened plates, crossed by grooves that delimit bright rhomboid areas, result of scratching and friction. This is known as skin thickening and accentuation of folds.

All these phases can coexist or happen one after the other with the evolution of the disease. We must be clear that itching is a cardinal symptom in this entity, generally exacerbated in the morning and at night or with changes of climate (heat) and sweating.

Associated with infectious processes:

Staphylococcus aureus and M. furfur are the agents implicated or associated to these atopic dermatitis pictures, secondary to the alteration generated by dermatitis and the pruritus due to excessive tearing allows the entry of these agents and therefore their colonization and superinfection. Requiring association to treatment with antibiotic therapy.

In the case of our patient receives treatment with corticosteroid for 15 days and first generation cephalosporin type antibiotic therapy Endovenous and being referred to the dermatology service.

Sources:

Anatomy of the Skin

Human skin

Human Anatomy/Picture of the Skin By Matthew Hoffman, MD

Just Skin Deep — Your Immune System at the Surface. Posted June 5, 2015 by Rachel Cotton in Biology, Blog Pick of the Month, Body, Medicine, PLoS, PLoS Blogs, ResearchBlogging, Student Column, Students, The Student Blog

Organ Level — Skin (Epidermis and Dermis)

Melanocyte

Mechanisms regulating melanogenesis. An Bras Dermatol. 2013 Jan-Feb; 88(1): 76–83. Inês Ferreira dos Santos Videira, Daniel Filipe Lima Moura, and Sofia Magina

Layers of the Skin

Dermis. From: Emerging Nanotechnologies in Immunology, 2018

Structure and Function of the Skin By Julia Benedetti , MD, Harvard Medical School

Integumentary system

Sebaceous gland

Atopic Dermatitis. Ann Dermatol. 2010 May; 22(2): 125–137. Thomas Bieber, M.D., Ph.D.corresponding author

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