Pengaruh Riwayat Atopik terhadap Timbulnya Dermatitis Kontak Iritan ,
DERMATITIS KONTAK PADA PEKERJA BANGUNAN,
DERMATITIS KONTAK AKIBAT KERJA PADA PETANI
Practical Management Strategies for Diaper Dermatitis
The
continuous use of diapers is at the root of IDD. Maximizing
"diaper-free" time is a widely recommended preventative strategy, but
is not very practical. Frequent diaper changes are essential for maintaining
dryness and keeping urine and feces separated. Diapers should be changed as
soon as they are wet or soiled, at least every 3–4 hours and more frequently in
the neonate due to increased skin fragility. Parents should forego
tight-fitting diapers and consider a diaper slightly larger than the infant to
minimize the contact between skin and urine or feces. Common IDD should resolve
when children become toilet trained.
The
advent of disposable diapers and the ongoing development of new diaper
technology has radically changed the face of IDD.Early cellulose-core
containing disposable diapers were dramatically improved by the addition of
cross-linked sodium polyacrylate polymers to the diaper core. These polymers,
also called absorbent gelling materials, bind water in a gel matrix when
hydrated. This gel effectively traps moisture away from the skin surface. It
controls pH through its buffering capacity, and by separating urine from feces.
These diapers are referred to as super absorbent diapers. In a study of 1,614
infants, super absorbent diapers were associated with reduced skin wetness,
superior pH control, and less diaper dermatitis compared with cellulose-core
disposable and cloth diapers. Originally, these diapers were developed with an
impenetrable backsheet (outer cover) to prevent leaks, but this led to
increased humidity and skin maceration. A "breathable" diaper was
subsequently developed with a backsheet that is permeable to air and vapor but
still impenetrable to leaks. This backsheet is readily identified by its
cloth-like, rather than plastic, texture. The "breathable"
superabsorbent diaper has been shown to reduce the prevalence of severe IDD by
up to 50%. Nearly all commercially available disposable diapers in North
America now use polyacrylate gel-core technology, and many use the breathable
backsheet (e.g., Pampers®, Procter & Gamble; Huggies®, Kimberly-Clark). A
novel diaper has recently been developed that transfers a petrolatum and zinc
oxide-based formula to the child's skin. In a double-blinded, randomized trial,
infants using this diaper had consistently less skin erythema and diaper rash
compared with those using a superabsorbent diaper alone over a 4-week period of
use.
Cloth
diapers are not recommended for patients with IDD. They increase skin wetness,
promote mixing of urine and feces, and are associated with Jacquet erosive
diaper dermatitis.
Application
of a suitable barrier preparation is the cornerstone of prevention and
treatment of IDD. There is a notable absence of controlled trials to support
and guide the use of barrier preparations for IDD. Anecdotal evidence is
abundant and suggests a barrier preparation should be applied to the diaper
area after every diaper change and bath. A suitable barrier preparation should
minimize transepidermal water loss (TEWL) and decrease permeability to
irritants. The barrier corrects these deficits by forming a lipid barrier over
the skin surface, or by penetrating the stratum corneum and assuming the role
of endogenous intercellular lipids. The barrier also minimizes cutaneous
friction. The barrier must be lipid-rich, long-lasting and adherent to the
macerated and eroded diapered skin.
Pastes
are the most hardy and desirable barriers, followedbyointments.Ointments are
superior to creams and lotions, which are poorly adherent, minimally occlusive,
and contain preservatives. Diaper pastes are tenacious semisolid compounds
containing a high proportion (usually >10%) of a fine powder such as zinc
oxide, titanium dioxide, and starch or talc. Pastes should be applied thickly,like
"icingonacake",andcan be covered by petroleum jelly to avoid sticking
to the diaper. Products containing fragrance, preservatives, and other
ingredients with irritant or allergic potential should be avoided. Products
containing boric acid, camphor, phenol, and salicylates should be avoided due
to potential systemic toxicity. The local ostomy nurse may also be a valuable
resource in identifying suitable barrier preparations in severe IDD.
Children
predisposed to IDD should be bathed daily in a lukewarm bath using an
irritant-free and fragrance-free soap or cleanser followed by liberal
application of a barrier preparation to the diaper area. The diaper area should
be cleaned gently and dried by patting with a towel to avoid any undue
friction. Aggressive wiping at diaper changes should be avoided. Residual
adherent barrier paste does not need to be wiped off along with the urine and
stool at each diaper change. Mineral oil can help facilitate paste removal, if
required.
It
is a commonly held belief that baby wipes contribute to IDD; however an
investigator-blinded, parallel-comparison study of 102 infants found no
difference between skin cleaned with an alcohol-free, nonwoven disposable wipe,
and skin cleaned with water and a cleanser. Moreover, skin cleaned with wipes
had statistically better rash scores in the intertriginous areas, suggesting
that wipes may help parents access hard-to-reach areas. These wipes were found
to be safe and well tolerated in infants with atopic dermatitis. Baby wipes can
cause an allergic contact hand dermatitis in caregivers, in a
"grip-like" distribution. It is prudent to choose wipes without
fragrance and preservatives to avoid allergic sensitization( Table
2 ).
Candida
infection is often associated with moderate-severe cases of IDD. C. albicans
is present in the mouth, inguinal and perianal skin more frequently in patients
with IDD. The azoles, nystatin, and ciclopirox are all appropriate topical
anticandidal agents, but few well-designed comparative trials are available to
guide clinical practice. Twice-daily application is recommended until
resolution. In a National Ambulatory Medical Care Survey (NAMCS), more than
200,000 visits for diaper dermatitis in the US were reviewed; nystatin and
clotrimazole were the most commonly prescribed topical antifungals (27% and 16%
respectively). A prospective, randomized study compared topical nystatin with
mupirocin in the treatment of IDD complicated by C. albicans infection.
Treatment with both agents resulted in mycological cure; however, resolution of
IDD was observed in all patients treated with mupirocin compared with only 30%
treated with nystatin. Application of miconazole nitrate 0.25% in a zinc oxide
and petrolatum base has demonstrated efficacy and safety in vehicle-controlled,
randomized, double-blinded trials. In an open trial, ciclopirox 0.77% topical
suspension demonstrated significant improvement in rash severity and superior
mycological cure by 7 days in patients with IDD and C. albicans
infection. There is little evidence to support the addition of an oral
antifungal to topical therapy in IDD. Patients with concomitant oral thrush,
however, may benefit from a course of systemic antifungal therapy.
A
short course of a mild topical corticosteroid is frequently necessary in
moderate-to-severe IDD. Hydrocortisone 1% ointment can be applied to affected
areas twice daily for a limited duration. Mid-to-high potency corticosteroids
should never be used in the diaper area. The NAMCS documented a surprisingly
high rate of moderate-to-high potency halogenated topical corticosteroid use in
IDD. Triamcinolone acetonide or betamethasone dipropionate use, either alone or
in combination with antifungals, was documented in a staggering 24.3% of visits
for diaper dermatitis. Atrophy, systemic absorption, candidiasis, and granuloma
gluteale infantum are all associated with mid-to-high potency corticosteroid
use in the diaper area. The topical calcineurin inhibitors, tacrolimus and
pimecrolimus, have not been studied for the treatment of IDD. These agents have
been studied for efficacy and safety as a steroid-sparing treatment for atopic
dermatitis in infants <2 years old. Although they are not approved for use
in this age group, they may be a useful off-label alternative for IDD in the
appropriate clinical setting.
A
number of other agents have been reported to be efficacious in the treatment of
IDD. A recent pilot study found clinical and mycological benefits using a 1:1:1
mixture of honey: olive oil: beeswax to treat IDD. Eosin, an orange-red dye
derived from coal tar, is a common agent used for IDD in Europe. It was found
to have a greater rate of clearance of IDD within 5 days compared with zinc
oxide and a moderate-potency topical corticosteroid ointment. In a randomized,
vehicle-controlled study, topical vitamin A cream did not improve the outcome
of IDD.
Source : http://www.medscape.com/viewarticle/545552_5
Tidak ada komentar:
Posting Komentar