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