Eczema (Contact Dermatitis)

A Case PresentationEczema

DefinitionEczema: Come from the Greek name for boiling, a reference to the tiny vesicles (bubbles) that are commonly seen in the early acute stage of the diseaseAn immune-mediated inflammation of the skin arising from an interaction between genetic (e.g. epidermal barrier function, immune system) and environmental factors (foods, airborne allergens, Staphylococcus aureus colonization on skin due to deficiencies in endogenous antimicrobial peptides, topical products)The eczemas are a disparate group of diseases, but unified by the presence of itch and, in the acute stages, of oedema (spongiosis) in the epidermis

Dermatitis: means inflammation of skin, its a broader term than eczema which is only a type of several skin inflammations

EtiologyEndogenous Factors

Exogenous FactorsIrritantAllergicPhotodermatitis

Localization:Face, Neck, Scalp, Extremities, Abdomen etc

Types of EczemaInfantile (Atopic) EczemaIrritant Contact EczemaAllergic Contact EczemaOccupational EczemaSeborrhoeic Eczema (on upper part of the body)Discoid (Nummular) EczemaJuvenile plantar dermatosisNapkin dermatitisPhotodermatitisPompholyxGravitationalAsteatotic

Classic Presentation of Eczema

Erythema(Macules)OozingPapulusVesiclesCrustingScalingHealing

PathogenesisSimilar in all types involving similar inflammatory mediators (prostaglandins, leukotriens, cytokines)Helper T cells sometimes activated by superantigens from Staph. aureusEpidermal cytokines help to produce spongiosis & that their secretion by keratinocytes elicited by T lymphocytes, irritants, bacterial products, & other stimuli

HistologyActure stage:SpongiosisIntraepidermal vesciles & blisters

Chronic stage:Less spongiosis & vesicationAcanthosisHyperkeratosis & parakeratosis

These changes accompanied by various degree of vasodiletation & lymphocyte infiltration

Clinical PresentationIn Acute Phase Erythema (macules) [Redness) Weeping and crusting;blistering usually with vesicles but, in fierce cases, with large blisters;Papules and swelling usually with an ill-defined border; andscaling.

In Chronic PhaseLess vesicular & exudationNumular skin lesionsLichenificationMore scaly and epithelial disruptionFissures

ComplicationsHeavy bacterial colonization esp. in seborrhoeic, atopic, nummularLocal superimposed allergic reaction to medicaments can provoke disseminationInterfere with sleepInterfere with workInterfere with sporting, activiteis

Differential DiagnosisSeparated from other skin conditions that look like it. NB: Eczemas are scaly, with poorly defined margins. Exhibit features of epidermal disruption such as weeping, crust, excoriation, fissures and yellow scale (because of plasma coating the scale).Papulosquamous dermatoses, such as psoriasis or lichen planus, are sharply defined and show no signs of epidermal disruption.Occasionally, a biopsy is helpful in confirming a diagnosis of eczema, but it will not determine the cause or type. Once the diagnosis of eczema becomes solid, look for clinical pointers towards an external cause. This determines both the need for investigations and the best line of treatment.Sometimes, an eruption will follow one of the well known patterns of eczema, such as the way atopic eczema picks out the skin behind the knees, and a diagnosis can then be made readily enough. Often, however, this is not the case, and the history then becomes especially important.

Differential DiagnosisPsoriasis: sharply marginated, very scaly, involve knee & elbowScabies: itchy contacts, face spared, burrows, affect nipple & genitaliaLichen planus: mouth lesion, violaceous flat topped papulesFungal infection: annular lesions with active edgePalmoplantar pustulosis: obvious pastules on palm & soleAngiodema & erysipelas: Unusually swollen, on face

InvestigationsPatch testPhotopatch testTotal & specific IgE antibodiesRAST

TreatmentSystemicCorticosteroidsMycophenolate MofetilAntihistaminicsSedativesDiureticsCalcineurine inhibitorsTopicalCorticosteroidsAntisepticsKeratoliticsTacrolimusEmollients

Treating Acute weeping EczemaRest & liquid applicationNonsteroidal preparationDaily 10 min soaks in cool 0.65% aluminium acetate solutionSaline or tap water & soaks followed by a smear of corticosteroid cream or lotionPotassium permanganateCalamine lotionMagenta paintWet wrap dressing: esp. in children a bath followed by steroid application covered with double layers of tubular dressing

Treating Subacture EczeaSteroid lotions or creamsVioforms, bacitracinFucidic acid, mupirocin, neomycin

PatientPatient presented with:Itchy back, feet, hands, arms, on face and under shinScales on palms of handsItchy around 20:00-22:00 pm4 months ago patient has accident:Cuts on hands and kneesDr prescribed medication (antibiotics),Appearance of vesicles and later on oozing, followed by crusting and scaling on right hand and area of trauma (Koebner Phenomenon)Later given treatment for eczema

Anamnesis10 yrs ago patient was pierced with a knife on right armAfter taking medication eczema appearedGiven treatment and eczema was treatedBut after he ate chocolate, it appeared again

Current condition was aggrevated by energy drinks and diet

Treating Chronic EczemaSteroid in ointment baseIcthamoleZinc c

Nothing stronger than 0.5-1% hydrocortisone oint. On face or in anfantsMild potency corticosteroids not more than 200g/wkModerate potency corticosteroids not more than 50g/wkPotent corticosteroids not more than 30g/wkream or paste

Systemic TherapySystemic steroid (prednisolone)HydroxyzineDoxepinTrimeprazineSystemic antibiotics

Common Patterns of EczemaIrritant Contact Dermatitis80% of dermatitis casesMostly industrialUsually on hands & forearmAcute reaction elicited after brief contactCommonly by detergents, alkalis, solventsMay lead to loss of work

DDX: allergic contact dermatitis, atopyPatch test with irritants is not helpful & may be misleadingRx: avoid irritants, use protective measures, barrier creams, topical steroids & emollients, change of job

Allergic Contact DermatitisThe mechanism is delayed type 4HypersensetivityPrevious contact is neededIts specific to one chemical usuallyRemote areas may be affectedSensetization is persists indefinitelyMost allergens are simple chemicals that bind to a protein to become complete antigenAreas involved eyelids, external auditory meatus, hands & feet

Allergic Contact Dermatitis (cont)High risk individuals are hair dressing, working in flower shop, dentistyCommon allergens: chrome, nickle, cobalt, lanolin, neomycin, rubber, poison ivy & oakJewellery, bra clips, jeans stud are common causesPatch test is recommended

Treatment: Avoid allergens, topical steroid, adding ferrous sulphate to cement to reduce its water soluble chromate content

Atopic EczeaMeans without place in greekIs a state in which exuberant production of IgE occurs as a response to common environmental allergensAtopic patient develop one or more of atopic diseases as asthma, aczema, hay fever, & food allergiesConcordance rate in monozygotic twins is 86%, in dizygotic is 21%75% begin before 6 months, 80-90% before 5 years, totally affect 3% of infants60-70% will clear by their early teens

Atopic Eczema has 3 PhasesInfantile: vesicular, weeping, start at faceChildhood: leathery, dry, excoriated, affects elbow, knee flexures, wrist ankleAdults: lichenification, more wide spread, white dermographism is striking

Atopic DermatitisCardinal feature is itchingIf there is no itching, it is probably not eczemaDiagnostic criteria:Must have:Chronically itchy skin

Plus 3 or more of the following: History of itching in skin creases History of asthma or hay fever General dry skin Visible flexural eczema Onset in first 2 years of life

Complications: bacterial infections, widespread Herpes simplex, M. contagiosum

Prick test used to show type 1 reaction

Treatment: Explanation, reassurance, avoid exacerbating factors, topical steroids, tacrolimus, sedative antihistamines, antibiotics, UVA, UVB, cyclosporin

Seborrhoeic Eczemacommon eczema of the hairy areas show characteristic greasy yellowish scalesRed scaly exudative or dry scaly or intertriginousAffects scalp, ears, eyebrows, face, presternal area, armpits, umblicus, groinMay be familial (hereditary), affect those with dandruff (a scaly flake formed on and shed from the scalp)There may be overgrowth of of pityrosporum yeastsMay be early sign of AIDSMainly affect adults, usually recurrentMay associated with furunculosis, or superadded candida infection

Treatment: topical imidazole, sulphur, salicylic acid, topical steroids, ketoconazole shampoo

Discoid (Nummular) EczemaCommon endogenous eczemaAffects limbs of middle age malesReaction to bacterial antigen is suspectedMultiple coin shaped vesicular crusted itchy plaques

Treatment: topical steroid & antibiotics

PompholyxRecurrent bouts of vesicles or blisters on palms, fingers & or sole of adultsCause is unknown,may provoke by stress or heat or may be allergy to nickleRecurrent infection & lymphangitis is a recurrent problem, it may follow acute Tinea pedis

Treatment: antibiotics, aluminium acetate, potassium permanganate, steroids

Gravitational (stasis) EczemaUsually accompanied by venous insufficiency, haemosidrin depositionChronic patches of eczema on lower legsPatient may become sensetized to local antibiotics or to preservatives in medicated bandages

Treatment: eliminate oedema, topical steroids, zinc cream

Asteatotic EczemaItchy eczema patches on lower legs of elderlyContributory factors: Dry skin in old, low humidity in winter, cental heating, diuretics, hypothyroidism

Treatment: Steroids, restrict bathing, daily use of emollients

Localized Neurodermatitis (Lichen Simplex)Single fixed itchy lichenified plaque on nape of neck in women, legs in men & anogenital area in both sexesSkin damaged from repeated rubbing or scratching as a habit in response to stress

Treatment: topical steroid with occlusion, tranquilizers are with little effect

Juvenile Plantar DermatosisMay be related to modern socks & shoe liningWith subsequent sweat gland blockageAlso referred to as toxic sock syndromeForefeet & undersides of toes become dry shiny with deep painful fissures

Treatment: use of cork insole in shoes, cotton or wool socks, emmolients, icthammol, steroid

Napkin (Diaper) DermatitisIrritant in nature aggravated by waterproof plastic pants, feces, urineMoist glazed sore erythema of napkin area sparing skin folds (which diff. it from seborrhoeic eczema)Candida superinfection is common appears as erythematous vesicopustules on periphery

Treatment: keep this area clean & dry, use disposal diapers, topical zinc, caster oil, silicone, mild steroid-antifungal combinationThe child should be allowed to be free of napkins as much as possible

Patient CaseWas admitted to hospital for trauma injuries due to arm injuryAfter treatment, he noticed vesicles The itchy vesicles healed but returned after he ate somethingDiagnosis was eczema and it was treated successfully

Current ConditionMotorbike accident 4 months agoHe noticed itchy vesicles in the region of the trauma to the skin (knee and hands)Itchy skin on hands, feet, back and all arms, face, underneath the shinFirst course of treatment was successfulCondition returned after he drank energy drink, and it was successfully treated againHe then ate chocolate afterwards and the condition returned and how he Is on third course of medication

Clinical ManifestationScaly skin on hands and knee, at sight of traumaPapules on back and handItchy skin all over the bodyFluid-filled vesicles: they first appeared red and later burst open and begun to healItch aggravates at around 20:00-22:00Cold temperature helps

Scales on Hands

Papules On The Back

Areas of Trauma

Possible diagnosisProbably patient has allergic contact eczema

ReferenceRichard P.J.B., et al (2008) Clinical Dermatology, Fourth Edition,