DERMATITIS EKSEMATOSADr. Kristo A. Nababan, SpKK

Nummular eczemaCharacteristic: Oval patches with crusted papulovesicles

Localisation: Trunk Extremities

Dermatitis Numularis

Differential DiagnosisAcute vesico papular dermatitis: Contact dermatitis Infections: Dermatophyte, HS virus, Varicella Zoster, BacteriaChronic vesico papular dermatitis: Chronic CD, psoriasis, drug eruption, fungal infect

Biopsy- Intercellular edema widening intercellular spaces sponge like appearance epidermal (spongiosis)- Acute & severe : intra epidermal vesicular- Chronis: Epidermal hyperkeratotic Thickened (acanthotic) Dermis: lymphocyte infiltration

Therapy1. Corticosteroid:- topically- injectable intralesional- sistemic 2. Wide spread acute/ subacute eczematous: prednisone/ triamcinolone 40 mg/i. m wet dressing/bath: acute dermatitis3. Chronic: baths containing oil moisturizers4. Itching: hydroxyzine/ diphenhydramine

ATOPIC DERMATITIS Chronic relapsing inflammatory skin disease.

It is frequently associated with asthma, allergic rhinitis.

DebateAD is primarily an allergen induced disease or

Simply an inflammatory skin disorder found in association with respiratory allergy

Atopy Familial hypersensitivity of skin and m. membrane against environmental substances

Atopy / Atopic Syndrome Sindrome consist of :

Bronchial asthma

Allergic rhinitis

Atopic Dermatitis

EpidemiologyPrevalence: AD Common health problem

10%> in children

Natural historyAD start early in life ( 60% of the patients develop the disease in infancy

Majority improve < 5 years

>> pats: resp. allergic disease: asthma & allergic rhinitis

Prognosis- Depend of the severity

- Start early in life more severe persist

- recurrent of AD adolescent

EthiologyTexture o/ t skin is abnormal with defective lipid barrier---> TEWL increase( Transepidermal Water Loss)

This is due to abnormal metabolism of fatty acid is not clear

Factors Contribute to the Development of A. D.Genetics

Environmental

Immunological

PharmacologicA. D.

Genetics Factors- Immunological abnormalities/ atopy

- Hypersensitivity o/ t skin

important development AD-genetic influence elevated Ig E product T cell disregulation

Role of AllergenFood: Milk, Egg infancy

Aeroallergen late childhood (house dust mite) 80% (+) skin prick test

Food-50% children AD clinical reactivity to food protein-Young children allergic to food: Milk Peanut soy wheat75% (+) to food -Food direct contact provoke AD

Aero allergenOlder children, adultaero allergen(house dust mite, mould)

Food allergy less important

- Prick test and patch tes20-60% (+) to mite

Role of InfectionPat AD develop viral, bacterial, fungalSkin infection

Staphylococcus Aureus, Beta haemolytic strept common cutaneous pathogens- Staphy Aureus exotoxn, exoenzyme inflammatory skin lesion

Atopic DermatitisAD can be divided into three stages:1. Infantile atopic dermatitis: 2 months-2 years of age 2.Childhood atopic dermatitis: 2 years-10 years 3. Adolescent and adult atopic dermatitis

Infantile Atopic Dermatitis60 % In the first year of lifeUsually . 2 month of age Clinic: Itchy erythema of the cheeks Intraepidermal vesiclesrupture moist, crusted areas extend to other part of the body (scalp, neck, forehead, wrist, extensor extremities buttocks and diaper area spared

Chidhood Atopic DermatitisChildhoodClinic: less acute lesions Lesions less exudative, drier, >papular Locations: antecubital, popliteal fossae, flexor wrist, eyelids, face, around the neck lichenified, slightly scaly/ infiltrated plaques

Adolescents and adult ADOlder patientsClinic: Localized erythematous, scaly, papular/ vesicular plaques Pruritic, lichenified plaques Location: antecubital and popliteal fossae, front and sides of neck, forehead, area about the eyes Eruptions generalized more severe in flexures lichenified Plaques often erythematous/ hyperpigmented

Major Clinical features of AD (base on Hanifin and Rajka)Intense pruritus & excoriationTypical morphology and distribution of skin lesions:-facial and extensor involvement in infant and early childhood -flexural lichenification in adultChronic or chronically relapsing dermatitis (>6 weeks)Personal and family history of atopic disease

Minor features-Dryness of the skin (xerosis)-Ichthyosis, keratosis pilaris, hyperlinear palms-Non specific hand/foot dermatitis-Scalp dermatitis e.g. cradle cap-Allergic shiners-Recurrent conjunctivitis and keratoconus- IgE reactivity-Dennie-Morgan infraorbital fold-Orbital darkening-Pityriasis alba-Food hypersensitivity

Intense pruritusItching, Scratching the day worse at night sleep disruptionPat AD threshold of itching decreasedHumidityExcessive sweatingExposure to allergens, irritants (soap, detergent acrylic, wool) itch

Whats the etiology of pruritus in AD ?- Not well understood

- Local release of proinflammatory mediators & cytokines

Rukwied and Heyer (1999) Pruritus:- Histamine- Cytokines- leukotrienes- neuropeptide- proteases

Morphological characteristic of AD-Acute lesions are papules, vesicles on erythematous background with sign of erosion, bleeding and serous exudate-Sub acute lesions are erythematous and scaly papules on dry background-Chronic lesions are fibrotic papules on lichenified (thickened) back ground-Excoriation due to scratching in a all stage-Infection may alter the appearance with the presence of oozing or local abscess-Even uninvolved skin is often dry and scaly

InvestigationTotal Ig E > not helpful diagnosis

Skin prick test (SPT)Specific Ig E (RAST) more helpful

Diagnosis

3 or more major criteria

3 or more minor criteria

Atopic Dermatitis in Child

TREATMENT OF ATOPIC DERMATITIS

Basic Treatment Skin care Emollients Avoidance of irritants, sudden changes of temperature, humidity

Identification of specific Exacerbating factorsAnti inflammatoryTreatmentAllergensMicrobesEmotional factors

Avoidance of trigger factorsIrritants detergents soapAllergens: Food allergen Airborne allergensChild < 5 years : Usually allergy to 1 or > food cows milk, egg, wheat, beanHouse dust mite: older children young adult4. Emotional stress

TOPICAL EMOLLIENTBASIS TOPICAL TREATMENT :2 3 X / DAYWATER LOSS ITCHING

Topical treatmentCREAM / LOTION : EARLY PHASE

OINTMENT : LICHENI FIED SKINSEVERE CASE :AFTER OINTMENT WETWRAP DRESSINGEPIDERMAL WATER LOSS

TOPICAL CROMOLYN IN WATER SOLUBLE EMOLLIENT VEHICLE ANTI INFLAMATORY EFFECT

ANTIBIOTICFUSIDIC ACIDGRAM (+)TETRA CYCLINESKIN CLEANSER 10% POVIDONE IODINEGENERALIZED INFECTION : ANTI MICROBIAL BATH (CHLORHEXIDIN 0,005%)SISTEMIC ANTIBIOTIC : FLUCLOCXACILLIN : MUPIROCIN

OTHER TREATMENT STRATEGIESUVA PHOTOTERAPYCICLOSPORINIF

Atopic Dermatitis in Child

Atopic Dermatitis in Infant and Child

Atopic Dermatitis in Child

CONTACT DERMATITIS

An inflammatory reaction of the skin precipitated by an exogenous chemical

Contact DermatitisIrritant CD: produced by substance that has direct toxic effect on the skinAllergic: trigger an immunologic reaction tissue inflammation

PathogenesisIrritant CD: nonspecific inflammatory reactions due toxic injury of the skinAllergic CD: Cell mediated immunity/ type IV A. Sensitization phase B. Elicitation PhaseSensitization: hapten + protein LCs Th1

antigensTinflammatorymediatorslymphokinesactivated macrophage

Irritants Subtances direct toxic effect of the skinAcidsAlkalisSolventsDetergents

AllergensTriggers immunologic reaction tissue inflammation

MetalsPlantsRubber chemicalsMedicines

Clinical appearance

Acute (vesicles) Chronic (lichenification)

Incidence:

- Frequent problem- 50% occupational illness

HistoryFirst determine: ACD/ICDStrong irritant several hours skin damageWeaker irritants multiple application & days dermatitisAllergic Contact Dermatitis:Requires 24-48 hoursOften exposure Clinical diseaseOccasionally dermatitis (8-12 hours) up to 4-7 hoursDetailed history of occupation, hygiene habits, hobbies

The most common Sensitizers

Poison IvyPara phenylenediamineNickelRubber compoundsEthylenediaminePoison ivy: in the summerAllergen: pentadecylcatechol (oleoresin of the plant)

PPDPermanent coloring of hairCross reaction : Azo, aniline dye, Benzocaine, procaine, Hydrochlorothiazine SulfonamidesWhen completely oxidized (fur coat), PPD not allergenic

NickelMost commonly in womanEar piercingIn all metalsHypoallergenic earring: one cannot be certain that they are free of nickelStainless steel: nickel bound so tightly ACD (-)

Rubber compound

Shoes ACD on dorsa of the feetAllergen: Mercaptobenzothiazole Thiurams

Ethylenediamine

Preservative in Mycolog cream, ointment (-) Dyes, insecticides, Rubber accelerators, Synthetic waxes, In aminophyllinSensitive individual generalized eczematous dermatitis

Physical ExaminationAcute/chronicDepend upon the nature of the exposure patches/plaque, angular corner, geometric on lines, sharp marginLocalization: Head& neck: cosmetics, hair dyes, permanent waves, shampoos Eyelid: eye cosmetic, nail polish Photo allergic: produce by a photoreaction between SUV & allergen, of the neck, arms

Physical ExaminationThe dorsum of the hands: industrial chemicals (irritants): petroleum, solventsThe dorsum of the feet: shoes (rubber, leather tanning agents)Groins and buttocks in infants: Diaper dermatitis: moisture and feces

DDOther eczematous eruptionsAtopic dermatitisSeborrhoic dermatitisStasis eczemaSuperficial fungus infectionsBacterial cellulitis

DiagnosisPatch test: The test material, in different vehicles (commonly white petrolatum)Is applied to the skin under a metal disc, called a Finn chamberA test battery of 20-24 allergens is used as standard allergensThe sheet is placed on the upper back, scaled with adhesive tapeThe patch is removed after 48 hours read

TherapyPreventionAvoidance of irritant/allergen change in life style & occupationProtective clothingOccupational: protective, barrier cream little benefitSubstitutedTopical steroidAntihistamine

Dermatitis Kontak IritanDKI pd tangan & ujung-ujung jari akibat asam

Dermatitis Kontak AlergiDKA akibat kalung nikelDKA akibat semen

Seborrheic Dermatitis/ Morbus UnnaDefinition: a chronic, superficial, inflammatory process affecting the hairy regions of the body

Etiology: unknown/ Pityrosporum ovale

Dandruff is scaling of the scalp without inflammationIncidence: a common problem, 2-5% adult 18-40 years, baby (cradle cap), children 6-10 years, woman> man

Seborrheic DermatitisPredilection hairy region: scalp, eyebroweyelidNasolabial creases, ears, chest

History

The occurrence of Seborrheic Dermatitis parallels the increased sebaceous gland activity occurring in infant, after puberty, pruritus

Physical examinationPredilection for the hairy regions where there are numerous sebaceous gland: scalp, eyebrows, eyelids, nasolabial creases, ears, chest, intertriginous area: axilla, groin, buttocks, infra mammary foldsBilateral and symmetricallyMost mild form, dandruff, fine whittis scaling without erythema.Patch/plaque: indistinct margin, erythema, yellowish, greasy scaling, uncommon hair loss

Physical examination S.DMild form: dandruff fine whitish scaling without erythema / Pityriasis sicaMild Moderate: erythema, yellowish greasy scaling

DD 1. A.D (infantile eczema) if infant Loc: diaper area & axilla diagnosis S.D If lesion: forearms, shins AD 2. Psoriasis: scalp, groin, other area papilosquamous patches & plaque 3. T. capitis: hair loss, urban black Biopsy : non diagnostic

Therapy S.DAnti seborrheic shampoos (sulfur, salicylic acid, selenium sulfide, zinc pyrithione)Shampoos must be rubbed in to the scalp 5-10 minutesInflam. Seborrrheic: topical steroid lot/gel in hairy area; hydrocortisone cream non hairy skin

Course & Complication

Infancy : to remit after 6-8 monthsAdult : chronic, unpredictable

STASIS DERMATITIS

Defination:

An eczematous eruption of the lower leg secondary to peripheral venous disease

STASIS DERMATITIS Venous incompetence hydrostatic pressure, capillary damage extravasation of red blood cell & serum inflammatory eczematous process

Incidence

Adults (middle age old age)

History: Chronic pruritic eruption precede by edema & swelling Patients with Stasis dermatitis have often had thrombophlebitis

Physical examination Varicose vein are prominentEdemaBrown pigmentationPetechiaeSub acute and chronic dermatitisThickened skin, scaling and /or weepingAny portion of the leg prominent site is above the medial malleolus

DD 1. Contact Dermatitis 2. Peripheral Arterial Disease 3. Superficial Fungal Infection 4. Bacterial cellulitis

Examination of peripheral pulses, history of topical agent, KOH, gram steins, bacterial culture should be done

Biopsy Sub acute or chronic dermatitis with hemosiderin, fibrosis, and dilated capillaries in the dermis

TherapyPrevention of venous stasis and edema use of supportive hoseStanding should be restrictedPatients who are obese weight reductionIf this fails bed rest with elevation of legsTopical steroidWet compresses if there is oozing or crusting

Course and Complications Dusky erythema Ulceration total bed rest with leg elevation with antiseptic cleansing Systemic antibiotics not helpful Application of skin grafts Allergy to topical preparation 60% ( topical antibiotics)

LICHEN SIMPLEX CHRONICUS/Neurodermatitis-Definition:

A chronic eczematous eruption o/ t skin, that is result of scratching

Pruritus scratching lichenification & itching

LSC

Pruritus scratching and precipitated by frustration, depression and stress lichenification further itching, resulting itch-scratch-itch cycle

History

Patient may have history of emotional or psychiatric problem

Physical Examinations

Patients: anxiousLichenified plaque, scratching (+)

Liken Simplek Kronikus/ Neurodermatitis

DD1. Chronic dermatitis2. Psychodermatoses (factitious dermatitis, delusion of parasitosis

Factitious dermatitis: self inflicted injury o/ t skin bizarre eruption (often ulcerated), linear and geometric outlines

Delusion of parasitosis: in disturbed/ anxious eccentric individual Begins intractable pruritus crawling sensation, that they are harboring parasites & bring specimens Active lesions: excoriated, crusted papule secondary to picking

DD3. Neurotic excoriations Linear :dug out lesions: Upper mid back (Where scratching fingers cannot reach. Neurotic woman

Therapy

DifficultTranquilizer and anti depressantsTopical steroid and intralesional steroid

Tabel ECZEMATOUS ERUPTIONS

Incidence*HistoryPhysicalDifferentialDiagnosis Lab.Nonspeciffic eczematous dermatitis11.4PruritusAcute-vesicles, weeping, crusted patchesSubacute-juicy papulesChronic-lichenified, scaling plaquesContact dermatitisAtopic dermatitisSeborrheic dermatitisFungal infectionPsoriasisDrug rash-Contact dermatitis2.8Irritant-contact precedes rash by hours to days Allergic-contact precedes rash by 1-4 daysVesicles, juicy papules, lichenified plaquesSharp marginsGeometric or linear configurationConforms to area of contactEczematous dermatitisFungal infectionCellulites Patch testAtopic dermatitis2.6Allergic rhinitis AsthmaVesicles, juicy papules-infantsLichenified plaques-adults and older children Head, neck, antecubital and popliteal fossaContact dermatitisScabies IgESeborrheic dermatitis3.7DandruffScaling papules and patchesScalp, eyebrows, nasal, sternumAtopic dermatitisPsoriasisFungal infectionHistiocytosis XLupus erythematosus-Stasis dermatitis0.4Varicose veins Leg swelling ThrombophlebitisJuicy papulesLichenified plaquesBrown pigmentation Lower legsCellulitisContact dermatitisArterial diseaseFungal infection-Lichen simplex chronicus0.8Rash subsequent to pruritusLichenified plaqueWithin reach of fingersPsoriasis -

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