Post on 12-Aug-2015
DERMATITIS / ECZEMA
Dr. Angelo Smith M.DWHPL
Effect on Quality of Life(Burden of Disability)
10-15% children suffer from atopic dermatitis
Asteototic dermatitis is becoming more and more common in the elderly
Hand dermatitis is a major cause of absence from work
Critical components of the physical exam of the skin should include:
Type Color Shape Arrangement Duration Distribution
Adequate history should include:
Skin symptoms Constitutional symptoms Travel/Occupation Systems review Self care
Shapes of Lesions
The shape of a lesion frequently gives clues to the etiology of the skin lesion.
Shapes include lesions that are: round, polygonal, polycyclic, annular, iris, serpiginous, umbilicated,and target.
Margination is also important – are the lesions well or ill defined
Arrangement – are the lesions grouped or disseminated
Distribution of Lesions
A significant number of skin diseases are limited to specific regions of the body
Are the lesions isolated, localized, regional, or generalized
Are the lesions symmetrical; limited to exposed areas, sites of pressure, or intertriginous areas
Classification of Eczema / Dermatitis
Historically Endogenous (occurring from within) dermatitis was given the name “eczema”
Exogenous dermatitis (occurring from without) was termed “dermatitis”
Classifications of Eczema Endogenous Atopic or IgE Seborrheic Discoid or
nummular Pompholyx Venous Asteatotic Juvenile plantar Erythoderma
Exogenous Allergic Toxic irritant
contact Photosensitive
Eczema - Common Definitions
Any itching rashAny red itching rashAny red itching rash that has
scales or is dryThe itch that rashesAny rash that cannot otherwise
be identified
Eczema-Dermatological Definition
An acute, subacute but usually chronic pruritic inflammation of the epidermis and the dermis, often occurring in association with a personal family history of hay fever, asthma, allergic rhinitis or atopic dermatitis. 1
1 Color Atlas and Synopsis of Clinical Dermatology
Characteristics of Acute Eczema
Well demarcated plaques of erythema and edema on which are superimposed and closely spaced small vesicles filled with clear fluid with punctate erosions and crusting
Distribution may be isolated and localized or general
Acute Eczema (Note the erythema, vesicles and swelling)
Term dyshidrotic is a misnomer as sweat glands are not involved
Also known as pompholyx
Characteristics of Subacute Eczema
Plaques of mild erythema with small dry scales and or superficial desquamation, sometimes associated with small red, pointed or round papules
Distribution may be isolated and localized or general
Subacute Eczema
Note erythema, swelling and desquamation
Dermatitis
Commonly misdiagnosed as tinea
Characteristics of Chronic Eczema
Plaques of lichenification with deepening of the skin lines with satellite, small, firm flat or round top papules, excoriations and pigmentations or mild erythema
Distribution – isolated and localized or generalized
Chronic Eczema
Note lichenification, scaling and fissuring
Dermatitis
Commonly misdiagnosed as psoriasis
Acute - Subacute - Chronic
Swelling and erythema
Punctate erythema,
desquamation
Lichenification
Atopic Dermatitis
10-20% of population
Primary symptom: itch
Location, location, location
Associated with atopic background
Periorbital pallor
Atopic / IgE Eczema
Characteristics: 60% have onset in the first year of life Influenced by genetics and
environmental factors More common in males that females Ethnicity may be a factor –less common
in Asians; more common in Westerners and higher socioeconomic families
Theory is - manifestation of well nourished immune system rarely challenged by infection
Rare to have adult onset2/3 of patients have family history of
asthma, hay fever or allergic rhinitis
May persist months to yearsAll patients have dry skinExacerbations caused by
allergens, stress, hormones, climate, skin dehydration
Physical characteristic may include all phases
Distinctive Characteristics:Lesions are usually bilateralLocated frequently in skin
folds/creases and flexor surfaces
Distribution
Note:
•Bilateral
•Skin folds and flexor surfaces
Triggers:
Irritants Dry skin; bathing without moisturizing Harsh/perfumed soaps, detergents Disinfectants Contact with wool, occupational
chemicals/fumes
Allergens Dust mites Pet dander (cat more allergenic than dog) Pollens, seasonal and molds Foods- strawberries, carrots
InfectionsBacterialViral
1.Cold and other URI viruses2.GI viruses
Fungal
EnvironmentalExtremes in temperature and/or humidityPerspirationStress
D / D
Confused with:Scabies, seborrhea, psoriasis and, contact dermatitis
Infantile Phase(patients 2 months to 2 years of age)
Eruption may become generalized, in most cases it first manifests with severe “cradle cap” or severe intertriginous rashes (groin, neck, axillae).
As the patient approaches age 2 years, the flexor creases become involved.
Lesions consist of scaly, red, and occasionally oozing plaques that tend to be symmetric.
Occurs on the scalp face, particularly
cheeks neck chest extensor extremities
Childhood Phase(patients aged 2 years to 12 years of age)
These patients tend to be less acute and lesions less exudative than those seen in infancy.
Inflamed lesions become lichenified (especially in Asian and African-American patients)
secondary to chronic rubbing and scratching.Lesions tend to occur symmetrically, with characteristic
distribution in the flexural folds.
Occurs on the:Antecubital and popliteal fossaeNeck, wrists, and anklesMay occur on the eyelids, lips, scalp, and postauricular areas
Adolescent and Adult Phase(patients 12 years and older)
Post inflammatory hyper or hypo pigmented changes tend
to be seen. The appearance of atopic dermatitis may change to a more poorly defined, itchy, erythematous rash, possibly
with papules and/or plaques.
Lichenified plaques of atopic dermatitis are
typically less well demarcated than are the plaques seen in psoriasis.
These plaques tend to blend into surrounding
normal skin.
Characteristics: Positive family history is common
Seen in all age groups equally May occur on presternal area and mid upper back Stress may increase symptoms Pityrosporum ovale may be causative factor
Distinctive Characteristics: Red greasy scaling rash consists of patches and
plaques with indistinct margins and an underlying red glazed look to the skin
Most commonly located in the hairy areas, nasolabial folds, retroauriclar folds
Excoriations from scratching are rare
SEBORRHEIC DERMATITIS
Redness and flakes appear in the head.
Eruptions on scalp may appear.
Treated with shampoos containing ketokonazole or hydrocortisone
Allergic (Contact) Eczema
Characteristic: Delayed, cell mediated hypersensitivity Strong sensitizer results in reaction soon
after exposure Weak sensitizer my take months or years
to develop reaction Age does not influence capacity for
sensitization but more common in adults Black skin is less susceptible Important cause of disability in industry Non seasonal
Characteristics: usually clears quite rapidly on
withdrawal of offending agent may appear as erythematous
papules, vesicles or bullous more common where epidermis is
thinnerDistinctive Characteristics: Initial lesions usually limited to
contact area not bilateral lesions with sharp borders or angles
are pathognomonic
Causes
Metals- nickel, platinum (10% of women)
Detergents Plants and fibers Chemicals and dyes Polyethylene glycol and polysorbate
60 Topical antibiotics and medications Animal keratin
Distribution
Note: distribution
Note:
Linear distribution with satellite lesions
Allergic Contact Dermatitis
Poison Ivy/Oak/Sumaclinearity
Allergic Contact Dermatitis
Potassium Dichromate in Leather
Allergic Contact Dermatitis
Latex Cleaning products Cosmetics Occupational exposures
Check the feet and nails!!!
Allergic Contact Dermatitis
Allergic Contact Dermatitis
Contact dermatitis with Nickel.
Reddish marking and itching will occur.
Irritant Contact Dermatitis Prevention is key!
Lip licker dermatitis
Nummular Dermatitis
Coin shaped patches and plaques
Secondary to xerosis cutis
Primary symptom itch
Notice the surrounding xerosis
Characteristics: usually -personal or family history of
allergy, especially asthma, hay fever, and childhood eczema
Distinctive Characteristics - Coin-shaped papulovesicular patches that develop in to scaling and crusting lesions; lesions may be as large as 4-5cm in diameter with distinct margins, initial eruptions on arms and legs; intense itching; tends to be chronic
Characteristics: Most severe during winter; may be
aggravated by systematic administration of iodine or bromine; secondary bacterial infections are common
Treatment: skin hydration, topical corticosteroids, intralesional injection, coal tar ointments, UVB treatment, treat secondary infection
Note:
•Coin shaped lesions
• dorsal surface arms
•bilateral
Asteatotic Dermatitis
Extreme case of xerosis
Riverbed type cracking
Xerotic Eczema, “Winter Itch”
Characteristics:Seen mainly in elderlyWorse in the winterPrecipitated by excessive
washingTreatment:Avoid excessive washing and
use of soapEmollientsIncrease humidity in the
environmentTopical steroids for a short
periods of time
Stasis Dermatitis
Venous hypertension Full spectrum of timing Id reaction common Complicated by ulceration
Pseudokaposi’s (acroangiodermatitis)
Venous ulceration
Dispigmentation (chronic)
Lipodermatosclerosis
Id reaction
Superimposed allegic contact
Do: 1) dry weeping lesions 2) cover for infection
Don’t: 1) apply neosporin 2) just hope steroids
will fix it
Localized Neurodermatitis(known as Lichen Chronicus Simplex)
Characterisitcs: Origin often small patch of dermatitis or insect
bite starting the itch –scratch- itch cycle Condition unrelated to allergies or family history More common in women Nonseasonal aggravated by stress worse at night may be secondary to atopic eczema, contact
dermatitis, lichen planus, psoriasis, or insect bite
Distinctive Characteristics:
Lesions lichenified or excoriated
usually limited to a single patch at hairline of nape of neck or on wrists, ankles, ears, or anal area
Not bilateral
Llichenification of dark skin develops a “follicular pattern”
Lichen simplex chronicus
Prurigo simplex
No fungus on the scrotum!
Butterfly sign
Prurigo Nodularis
Consider screening
Stepped Approach to Treatment of Eczema
Conservative Therapy1. Education - prevention 2. Use of astringents and
emollients/moisturizers3. OTC products (hydrocortisone,
Benadryl, Calamine, etc.) Low to mid potency steroid
creams High potency steroid creams Coal Tar PUVA therapy (phototherapy)
Prevention Checklist
Moisturize dailyWear cotton, avoid wool and tight
clothesTake lukewarm showers, using mild
soap or nonsoap cleansersPat dry – do not rubApply moisturizer within 3 min. to
“lock in” moistureAvoid extremes of heat / humidity and
perspirationLearn triggers and how to avoid themKeep fingernails shortRemove carpets and pets from the
home
Avoidance
Irritants: Recommend non-irritant
fabric, such as cotton. Wool may induce itching
Overheating and sweating: Excess dryness or humidity
should be avoided.An air conditioner or
humidifier in a child’s bedroom may help to avoid the dramatic changes in climate that may trigger outbreaks.
Allergens: Environmental elimination
of airborne substances may bring lasting relief.
Soap Free Cleansers
Cetaphil Aquanil Aveeno Daily Mositurizer Eucerin Gentle Hydrating Cleanser Lobana Body Shampoo Moisturel pHisoderm
Indications: For use in those eczema patients who may be sensitive to one or more of the various potential sensitizers in soaps and shampoos.To cleanse, reduce irritation (if sensitive to soaps), and reduce dryness (thereby increase absorption of other topicals).
Emollients / Moisturizers
Aquaphor Balmex Daily AmLactin Cutemol DML Forte Eucerin Original Hydrisinol Lanolor
Indication: To soften and soothe rough, dry skin and increase absorbability of topical medications
Directions: Apply as necessary or as prescribed; generally after showering/bathing and pat drying; apply liberally to affected areas
Neutrogena Norwegian Formula
Lac-Hydrin Aveeno Pen-Kera Curel Lubriderm Advanced
Therapy Minerin
Astringents
Astringents – reduce secretions (by causing contraction of tissues) and are antibacterial
Best used in eczema where vesicular or draining lesions are present
Acetic Acid 5% (white vinegar) – especially useful in Pseudomonas infections
Burow’s Solution (Domeboro and others) Potassium Permanganate
Points to Remember
Topical Steroids should be applied only to inflamed skin (active disease).
When Topical Steroids are applied immediately after bathing their penetration and potency are increased.
Low-potency topical steroids are recommended for use on the face and in skin folds.
Coal Tar Preparations
Tegrin cream and lotion Medotar ointment PsoriGel gel Polytar and Tegrin soaps Tegrin, T/Gel, and other shampoosIndication: to relieve and control
itching, and flaking skin associated with psoriasis and seborrhea as well as eczema
Directions: Depending on product 1-4 times daily
Contraindications: HypersensitivityPrecautions: Do not use on broken skin, genital or
rectal area except on the advise of your health care provider.
Photosensitivity x 24hr after application May stain light colored hairWarning: High concentrations of some chemicals in
coal tar may cause cancer. Concentrations of 0.5% to 5% appear to be safe.
PUVA Therapy
Indications: Psoriasis, eczema, pruritic rashes of other causes
Consists of psoralen (photosensitizing agent) followed by UVA phototherapy
Must avoid sunlight for 24h after psoralen
Sessions are 3d/wk, may be from 12-30 sessions, increasing in duration
Side effects are redness, burning, occasional nausea