Dermatitis 101:Dermatitis 101:Diagnosis and Diagnosis and Treatment of Treatment of

EczemaEczema

Adrian Guevara MDAdrian Guevara MD

Dermatitis 101Dermatitis 101

AtopicAtopic SeborrheicSeborrheic ContactContact

AllergicAllergic IrritantIrritant

NummularNummular AsteatoticAsteatotic StasisStasis Neurodermatitis/Lichen Simplex ChronicusNeurodermatitis/Lichen Simplex Chronicus

Dermatitis 101Dermatitis 101

Dermatitis=“Eczema”=SpongiosisDermatitis=“Eczema”=Spongiosis

Acute DermatitisAcute Dermatitis

Dermatitis 101Dermatitis 101

Dermatitis 101Dermatitis 101 Subacute DermatitisSubacute Dermatitis

Commonly misdiagnosed as tinea

Dermatitis 101Dermatitis 101 Chronic DermatitisChronic Dermatitis

Commonly misdiagnosed as psoriasisCommonly misdiagnosed as psoriasis

24 y/o male 2 year h/o 24 y/o male 2 year h/o red, scaly feetred, scaly feet

Allergic Contact Allergic Contact DermatitisDermatitis

Type 4 Hypersensitivity ResponseType 4 Hypersensitivity Response Classically well demarcated/patternedClassically well demarcated/patterned Exposure can be infrequent (once a Exposure can be infrequent (once a

month)month) Patch testing is gold standard for Patch testing is gold standard for

diagnosisdiagnosis Severe reactions need systemic Severe reactions need systemic

steroidssteroidsForget the dose pack

Allergic Contact Allergic Contact DermatitisDermatitis

Poison Ivy/Oak/SumacPoison Ivy/Oak/Sumac

linearity

Allergic Contact Allergic Contact DermatitisDermatitis

Potassium DichromatePotassium Dichromate

in Leatherin Leather

Allergic Contact Allergic Contact DermatitisDermatitis

LatexLatex Cleaning productsCleaning products CosmeticsCosmetics OccupationalOccupational

exposuresexposures

Check the feet and nails!!!

Allergic Contact Allergic Contact DermatitisDermatitis

40 y/o female homemaker 40 y/o female homemaker with dry, itchy handswith dry, itchy hands

Irritant Contact Irritant Contact DermatitisDermatitis

Most contact dermatitis is irritant in Most contact dermatitis is irritant in naturenature

OccupationalOccupational morbitymorbity

Irritant vs allergicIrritant vs allergic Prevention is key!Prevention is key!

Look at the cuticles

Lip licker dermatitisLip licker dermatitis

Blunting of vermillionAccentuation of angles

4 y/o boy with chronic, 4 y/o boy with chronic, itchy, bleeding plaquesitchy, bleeding plaques

Atopic DermatitisAtopic Dermatitis

10-20% of 10-20% of populationpopulation

Primary Primary symptom:symptom: itch itch

Location, Location, location, locationlocation, location

Associated with Associated with atopic atopic backgroundbackground

Periorbital pallor

Look for keratosis pilaris

52 y/o male with 52 y/o male with erythematous, scaly patches erythematous, scaly patches

of face and scalpof face and scalp

Seborrheic DermatitisSeborrheic Dermatitis DistributionDistribution

Face, scalp, axillae, upper chestFace, scalp, axillae, upper chest Chronic conditionChronic condition

Nonsteroidal adjuvantsNonsteroidal adjuvants Disease associationsDisease associations

45 y/o female with 45 y/o female with intermittent “fungus all intermittent “fungus all

over”over”

Nummular DermatitisNummular Dermatitis

Coin shaped patches Coin shaped patches and plaquesand plaques

Secondary to xerosis Secondary to xerosis cutiscutis

Primary symptom itchPrimary symptom itch

Notice the surrounding xerosis

Asteatotic DermatitisAsteatotic Dermatitis

Extreme case of Extreme case of xerosisxerosis

Riverbed type Riverbed type crackingcracking

52 y/o male with painful, 52 y/o male with painful, itchy rash on right legitchy rash on right leg

Stasis DermatitisStasis Dermatitis

Venous hypertensionVenous hypertension Full spectrum of timingFull spectrum of timing Id reaction commonId reaction common Complicated by ulcerationComplicated by ulceration

Pseudokaposi’s Pseudokaposi’s (acroangiodermati(acroangiodermati

tis)tis)

Venous ulceration

Dispigmentation (chronic)

Lipodermatosclerosis

Id reactionId 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

Elephantiasis Verrucosa Elephantiasis Verrucosa NostrasNostras

14 y/o anxious female who 14 y/o anxious female who can’t stop itchingcan’t stop itching

Neurodermatitis/Lichen Neurodermatitis/Lichen Simplex ChronicusSimplex Chronicus

Paroxysmal pruritusParoxysmal pruritus Habitual excoriating Habitual excoriating

or rubbingor rubbing Skin thickens to Skin thickens to

defenddefend Consider underlying Consider underlying

diseasedisease

Increased skin markings

Lichen simplex Lichen simplex chronicuschronicus

Prurigo simplex

No fungus on the scrotum!

Butterfly sign

Prurigo Nodularis

Consider screening

PreventionPrevention

Remove the offending agentRemove the offending agent Edema, allergen, irritant, yeast, long Edema, allergen, irritant, yeast, long

fingernailsfingernails Daily cleansing and Daily cleansing and

MOISTURIZINGMOISTURIZING Dove, Oil of Olay, NeutrogenaDove, Oil of Olay, Neutrogena Mild temperaturesMild temperatures Cream/Ointment based emollientsCream/Ointment based emollients

Neosporin, antifungals ≠ moisturizers

TreatmentTreatment

Topical SteroidsTopical Steroids Clobetasol Clobetasol II TriamcinoloneTriamcinolone IVIV DesonideDesonide VIVI HydrocortisoneHydrocortisone VIIVII

TreatmentTreatment TIMTIM

Protopic 0.1% ointProtopic 0.1% oint Elidel crElidel cr

LightLight nbUVBnbUVB

Systemic Systemic immunosuppressivesimmunosuppressives PrednisonePrednisone CyclosporineCyclosporine AzathioprineAzathioprine IVIGIVIG

Only on thin skin !!!

TreatmentTreatment

AntihistaminesAntihistamines Mechanism of action: Mechanism of action: soporificsoporific

Indications for Dermatitis ≠ Urticaria

7 m/o infant with itchy 7 m/o infant with itchy skinskin

75 y/o nursing home patient 75 y/o nursing home patient with intolerable itchy skinwith intolerable itchy skin

Common PitfallsCommon Pitfalls

MisdiagnosisMisdiagnosis Scabies (intensely pruritic, Scabies (intensely pruritic,

burrows/vesicles, others itch)burrows/vesicles, others itch) Psoriasis (elbows/knees/inflammatory Psoriasis (elbows/knees/inflammatory

arthritis/nail changes)arthritis/nail changes) Fungus (central sparing, well Fungus (central sparing, well

marginated, scaly border)marginated, scaly border)

Lose the Lindane!

25 y/o male tx’d for eczema 25 y/o male tx’d for eczema in antecubital fossa with in antecubital fossa with

“some cream”“some cream”

Common PitfallsCommon Pitfalls

MistreatmentMistreatment Lose the Lotrisone!Lose the Lotrisone!

1) Commit to a diagnosis1) Commit to a diagnosis 2) Shotgunners: “Don’t be a wimp”2) Shotgunners: “Don’t be a wimp”

Quadriderm: betamethasone, Quadriderm: betamethasone, gentamycin, clotrimazolegentamycin, clotrimazole

AnimaxAnimax

The EndThe End