Eczema & PsoriasisEczema & Psoriasis

Dr. Jerald E. HurdleKennebec Medical Consultants

Waterville, ME 04901

Dr. Jerald E. HurdleKennebec Medical Consultants

Waterville, ME 04901

Learning ObjectivesLearning Objectives

To familiarize you with the many presentations of eczema & psoriasis,

To understand how to get the most out of topical therapies, and

To recognize newer therapies now becoming available.

To familiarize you with the many presentations of eczema & psoriasis,

To understand how to get the most out of topical therapies, and

To recognize newer therapies now becoming available.

EczemaEczema

From the Greek “to boil over”

Eczema = Dermatitis

Wastebasket term for many undiagnosed rashes

Histology shows edema or spongiosis

From the Greek “to boil over”

Eczema = Dermatitis

Wastebasket term for many undiagnosed rashes

Histology shows edema or spongiosis

Eczema is itchy!Eczema is itchy!

Acute: Vesicles

Sub acute: Sub acute: Juicy PapulesJuicy Papules

Chronic: LichenificationChronic: Lichenification

Lesions tend to have Lesions tend to have indistinct bordersindistinct borders

Acute: Vesicles

Sub acute: Sub acute: Juicy PapulesJuicy Papules

Chronic: LichenificationChronic: Lichenification

Lesions tend to have Lesions tend to have indistinct bordersindistinct borders

Eczema is itchy!Eczema is itchy!

Acute: VesiclesAcute: Vesicles

Sub-acute: Juicy PapulesSub-acute: Juicy Papules

Chronic: LichenificationChronic: Lichenification

Lesions tend to have Lesions tend to have indistinct bordersindistinct borders

Acute: VesiclesAcute: Vesicles

Sub-acute: Juicy PapulesSub-acute: Juicy Papules

Chronic: LichenificationChronic: Lichenification

Lesions tend to have Lesions tend to have indistinct bordersindistinct borders

Eczema is itchy!Eczema is itchy!

Acute: VesiclesAcute: Vesicles

Sub acute: Sub acute: Juicy PapulesJuicy Papules

Chronic: LichenificationChronic: Lichenification

Lesions tend to have Lesions tend to have indistinct bordersindistinct borders

Acute: VesiclesAcute: Vesicles

Sub acute: Sub acute: Juicy PapulesJuicy Papules

Chronic: LichenificationChronic: Lichenification

Lesions tend to have Lesions tend to have indistinct bordersindistinct borders

Lesions tend to have Lesions tend to have indistinct bordersindistinct borders

Lesions tend to have Lesions tend to have indistinct bordersindistinct borders

New patients presenting to a dermatology clinic

New patients presenting to a dermatology clinic

Types of Dermatitis Essential: 11.4% Contact: 2.8% Atopic: 2.6% Seborrheic: 3.7% Stasis: 0.4% Lichen Simplex Chronicus (LSC): 0.8%

Types of Dermatitis Essential: 11.4% Contact: 2.8% Atopic: 2.6% Seborrheic: 3.7% Stasis: 0.4% Lichen Simplex Chronicus (LSC): 0.8%

Source: Hershey Medical Center Dermatology Clinic

Essential DermatitisEssential Dermatitis

Pruritus

Eczematous lesions not conforming to other patterns of dermatitis

Pruritus

Eczematous lesions not conforming to other patterns of dermatitis

Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus

Essential DermatitisEssential Dermatitis

Dyshidrotic

AutosensitizationAutosensitization

XeroticXerotic

NummularNummular

Dyshidrotic

AutosensitizationAutosensitization

XeroticXerotic

NummularNummular“tapioca” on lateral borders of fingers

Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus

Essential DermatitisEssential Dermatitis

DyshidroticDyshidrotic

Autosensitization

XeroticXerotic

NummularNummular

DyshidroticDyshidrotic

Autosensitization

XeroticXerotic

NummularNummularHypersensitivity to a substance produced by local dermatitis

Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus

Essential DermatitisEssential Dermatitis

DyshidroticDyshidrotic

AutosensitizationAutosensitization

Xerotic

NummularNummular

DyshidroticDyshidrotic

AutosensitizationAutosensitization

Xerotic

NummularNummular • “crazy paving" appearance:

• affects elderly particularly in winter

Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus

Essential DermatitisEssential Dermatitis

DyshidroticDyshidrotic

AutosensitizationAutosensitization

XeroticXerotic

Nummular

DyshidroticDyshidrotic

AutosensitizationAutosensitization

XeroticXerotic

Nummular

Coin-shaped lesions

Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus

Contact DermatitisContact Dermatitis

Irritant vs. Allergic

Only affects area of contact

Rx : avoid contactant

Irritant vs. Allergic

Only affects area of contact

Rx : avoid contactant

Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus

Contact DermatitisContact Dermatitis

Cosmetics

Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus

Contact DermatitisContact Dermatitis

Nickel

Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus

Contact DermatitisContact Dermatitis

Poison Oak

or

Poison Ivy

Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus

Contact DermatitisContact Dermatitis

Irritant

Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus

Atopic DermatitisAtopic Dermatitis

Triad of atopic disease

Pruritus

Waxing/waning course

Hands/face/neck common in adults

Triad of atopic disease

Pruritus

Waxing/waning course

Hands/face/neck common in adults

Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus

Seborrheic DermatitisSeborrheic Dermatitis

Dandruff on the body

Hypersensitivity to yeast

Rx: Anti yeast & steroids

Dandruff on the body

Hypersensitivity to yeast

Rx: Anti yeast & steroids

Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus

Stasis DermatitisStasis Dermatitis

Eczema overlying edematous legs

Chronic

: Compression

Beware of Ulcers

Eczema overlying edematous legs

Chronic

: Compression

Beware of Ulcers

Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus

Lichen Simplex ChronicusLichen Simplex Chronicus

Localized chronic dermatitis

Occluded steroids may help

Localized chronic dermatitis

Occluded steroids may help

Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus

Scratch

Scratch

Itch

Itch

Treatment Of EczemaTreatment Of Eczema

Gentle skin care

↓ Frequency of washing

Cooler Water

Avoid Soap

Gentle skin care

↓ Frequency of washing

Cooler Water

Avoid Soap

Treatment Of EczemaTreatment Of Eczema

Use cream based emollients as soap

Encourage greasiest

Copious quantities

Use cream based emollients as soap

Encourage greasiest

Copious quantities

increasing greasiness

Treatment Of EczemaTreatment Of Eczema

Topical Steroids

Ointments > Cream

Use lowest effective potency

BID

Topical Steroids

Ointments > Cream

Use lowest effective potency

BID

clobetasol

fluocinonide

triamcinolone

aclomethasone

hydrocortisone

Potency

PsoriasisPsoriasis

PsoriasisPsoriasis

2-5% Caucasians

Onset at any age

2 peaks in 20s & 50s

May be pruritic

2-5% Caucasians

Onset at any age

2 peaks in 20s & 50s

May be pruritic

Psoriasis: precipitantsPsoriasis: precipitants Genetics

Stress

Infections -- i.e. Strep

Trauma (Koebner)

Medications: Lithium, β Blockers

Obesity (insulin resistance)

Alcohol

Genetics

Stress

Infections -- i.e. Strep

Trauma (Koebner)

Medications: Lithium, β Blockers

Obesity (insulin resistance)

Alcohol

Chronic Plaque Chronic Plaque

Commonest

Extensor surfaces

Stable disease

Commonest

Extensor surfaces

Stable disease

Guttate Guttate

Explosive onset

May be preceded by Strep infection

Consider other Dx: Pityriasis Rosea & syphilis

Explosive onset

May be preceded by Strep infection

Consider other Dx: Pityriasis Rosea & syphilis

Palmar Plantar PustulosisPalmar Plantar Pustulosis

Commoner in smokers

Tends to be difficult to treat

Groups of sterile pustules

Commoner in smokers

Tends to be difficult to treat

Groups of sterile pustules

Erythrodermic PustularErythrodermic Pustular Rare

Skin often painful

Pustules tiny (look close)

Later get lakes of pus

Need to admit patient to stabilize

Rare

Skin often painful

Pustules tiny (look close)

Later get lakes of pus

Need to admit patient to stabilize

Nail PsoriasisNail Psoriasis

Commoner in pts with Ps arthritis

Pitting

Oil spots

Onycholysis

Difficult to Rx

Commoner in pts with Ps arthritis

Pitting

Oil spots

Onycholysis

Difficult to Rx

TreatmentsTreatments

Remember Koebner

Point to a scar

Remember Koebner

Point to a scar

Emollients

Topical Agents

UV light

Systemics

Biologics

Emollients

Topical Agents

UV light

Systemics

Biologics

TreatmentsTreatments

Corticosteroids (potent & super potent)

Vit D Analogue (Dovonex)

Tars (LCD)

Anthralin (Dithrocream)

Corticosteroids (potent & super potent)

Vit D Analogue (Dovonex)

Tars (LCD)

Anthralin (Dithrocream)

Emollients

Topical Agents

UV light

Systemics

Biologics

Emollients

Topical Agents

UV light

Systemics

Biologics

TreatmentsTreatments

Immunosuppressant

UVB (Narrow band vs. broadband

PUVA: Psoralen + UVA

Treatment course 3x weekly for 6 weeks

Beware of skin cancer!

Immunosuppressant

UVB (Narrow band vs. broadband

PUVA: Psoralen + UVA

Treatment course 3x weekly for 6 weeks

Beware of skin cancer!

Emollients

Topical Agents

UV light

Systemics

Biologics

Emollients

Topical Agents

UV light

Systemics

Biologics

TreatmentsTreatments

Retinoids: Acitretin monitor LFTs & Lipids (avoid in ♀ of childbearing potential)

Methotrexate (once weekly) monitor LFTs & CBC

Cyclosporine : monitor BP & Renal function : great rescue drug but need exit strategy!

Retinoids: Acitretin monitor LFTs & Lipids (avoid in ♀ of childbearing potential)

Methotrexate (once weekly) monitor LFTs & CBC

Cyclosporine : monitor BP & Renal function : great rescue drug but need exit strategy!

Emollients

Topical Agents

UV light

Systemics

Biologics

Emollients

Topical Agents

UV light

Systemics

Biologics

TreatmentsTreatments

Anti-TNF: Etanercept, infliximab & adalumimab

IL 12/23 blockers

Watch out for TB/infections

No long term safety data

$$$$

Not Better than CyA or MTX

Anti-TNF: Etanercept, infliximab & adalumimab

IL 12/23 blockers

Watch out for TB/infections

No long term safety data

$$$$

Not Better than CyA or MTX

Emollients

Topical Agents

UV light

Systemics

Biologics

Emollients

Topical Agents

UV light

Systemics

Biologics

TreatmentsTreatments

Avoid systemic corticosteroids!!! Avoid systemic corticosteroids!!!

Snowbird

Eczema: Key PointsEczema: Key Points

Appearance varies from blisters to scaling plaques

Itching is prominent

Distribution can be localized or generalized

Appearance varies from blisters to scaling plaques

Itching is prominent

Distribution can be localized or generalized

Psoriasis: Key PointsPsoriasis: Key Points

Well demarcated erythematous, silvery, scaling plaques

Elbows, knees & scalp are typically involved

Inflammation and epidermal proliferation

Well demarcated erythematous, silvery, scaling plaques

Elbows, knees & scalp are typically involved

Inflammation and epidermal proliferation

Learning ObjectivesLearning Objectives

To familiarize you with the many presentations of eczema & psoriasis,

To understand how to get the most out of topical therapies, and

To recognize newer therapies now becoming available.

To familiarize you with the many presentations of eczema & psoriasis,

To understand how to get the most out of topical therapies, and

To recognize newer therapies now becoming available.

And Remember…And Remember…

For scaling rashes of uncertain etiology…

“if it scales, scrape it!”

For scaling rashes of uncertain etiology…

“if it scales, scrape it!”