Eczema Atopic Dermatitis

Contact Dermatitis

Fahad Al Sudairy , M.D.

ECZEMAAn inflammatory skin reaction to a variety

of agents characterized histologically by

spongiosis and clinically by a variety of

features, notably vesiculation

CLASSIFICATION

1) Endogenous Eczema

2) Exogenous Eczema

Endogenous Eczema

Atopic Eczema

Seborrhoeic Eczema

Discoid Eczema

Pityriasis Alba

Pompholyx

Gravitational Eczema

Asteatotic Eczema

Exogenous Eczema

Irritant Contact Dermatitis

Allergic Contact Dermatitis

Photo Allergic Contact Dermatitis

Infective Dermatitis

Stages of Eczema

Acute Eczema

Subacute Eczema

Chronic Eczema

Clinical Staging AcuteWeeping, papules, vesicles &

bullae

Chronic Dryness, redness, lichenification,

scaling & fissuring

Acute Eczema

ACUTE ECZEMA

Spongiosis

Intercellular edema of keratinocytes in the epidermis

ACUTE ECZEMA

ACUTE ECZEMA

Chronic Eczema

Chronic Eczema

Hyperkeratosis (thickening of the stratum corneum)Parakeratosis (retention of nuclei in the stratum corneum).Hypergranulosis (thickening of the stratum granulosum)Acanthosis (thickening of the stratum spinosum)

Thickening of the epidermis

Chronic Eczema

Atopic Eczema

Atopy – genetically determined increased

liability to form IgE

Aetiology – unknown

• inherently itchy & dry skin

• psychological

• climatic

• allergic factors

DIAGNOSTIC GUIDELINES FOR ATOPIC DERMATITIS

Must have: • An itchy skin condition (or parental report of scratching or

rubbing in a child) plus

Three or more of the following: • History of involvement of the skin creases such as folds of

elbows, behind the knees, fronts of ankles or around the neck (including cheeks in children under 10 years of age)

• A personal history of asthma or hay fever (or history of atopic disease in a first-degree relative in children under 4 years of age)

Cont’d

• A history of general dry skin in the last year

• Visible flexural eczema (or eczema involving the

cheek/forehead and outer limbs in children under 4 years of

age)

• Onset under 2 years of age (not used if child is under 4

years of age)

DIAGNOSTIC FEATURES OF ATOPIC DERMATITIS

Major features (3 of 4 present)• Pruritus • Typical morphology and distribution of skin lesions • Chronic or chronically relapsing dermatitis • Personal or family history of atopy

Minor features (3 of 23 present)• Xerosis • Ichthyosis / palmar hyperlinearity / keratosis pilaris • Immediate (type I) skin test reactivity • Elevated serum IgE

Cont’d

• Early age of onset • Tendency toward cutaneous infections / impaired cell-

mediated immunity • Tendency toward non-specific hand or foot dermatitis • Nipple eczema • Cheilitis • Recurrent conjunctivitis • Dannie-Morgan infraorbital fold • Keratoconus • Anterior subcapsular cataract • Orbital darkening

Cont’d

• Facial pallor / erythema • Pityriasis alba • Anterior neck folds • Pruritus when sweating • Intolerance to wool and lipid solvents • Perifollicular accentuation • Food intolerance • Course influenced by environmental / emotional factors • White dermographism / delayed blanch

PHASES OF ATOPIC DERMATITIS

infantile phase – 2-6 months

cheeks, forehead, scalp

child restless, sleepless

crawling – extensor aspect of knees

CONT’D

childhood phase - 18-24 months

elbows & knee flexures

sides of neck

wrists & ankles

reticulate pigmentation on neck

CONT’D

adult phase

lichenification of hands & flexures

photosensitivity

allergic hand eczema

TREATMENT

General measures

wear cotton clothes

avoid overheating rooms

avoid irritant soaps

reassurance

foods

CONT’D

Local emollients

topical steroids

tacrolimus ointment

Systemic antihistamines

oral corticosteroids

low dose cyclosporin

azathioprine

SEBORRHOEIC ECZEMA

occurs in sebaceous gland rich areas

Etiology - unknown, malassezia furfur

erythema, greasy yellowish scales

CONT’D

infants

cradle cap

face

flexures

CONT’D

adults

Scalp - dandruff

Retro-auricular area

Face, blephritis, conjunctivitis

Trunk

Severe recalcitrant to treatment – in HIV

CONT’D

Treatment

no permanent cure

keratolytics

mild topical steroids

antifungals

DISCOID ECZEMA

rounded plaques of eczema

clearly demarcated edge

sites - limbs

atopy, dry skin, allergic contact

emotional factors

POMPHOLYX

eczema of palms & soles characterized by

vesicles & bullae

hyperhidrosis, drugs, food allergies,

emotional stress

spontaneous remission – 2-7 weeks

PITYRIASIS ALBA

ill-defined erythematous scaly patches – leave

hypopigmentation

3-16 years, atopic eczema

face, neck, arms

Treatment - emollients, tar, 1% hydrocortisone

STASIS ECZEMA

eczema secondary to venous hypertension

often obese

lower legs

edema, varicosities, purpura, ulceration,

infection

CONTACT ECZEMA

IRRITANT CONTACT DERMATITIS

Irritant substance physical or chemical

which produces cell damage if applied for

sufficient length of time and in adequate

concentration

CONT’D

strong irritant – response immediate

weak irritant – repeated exposure

IRRITANT CONTACT DERMATITIS

First exposure gives response

Everyone exposed can develop

Strictly limited to area of contact

IRRITANT CONTACT DERMATITIS

Subjective irritant response

Immediate type stinging e.g. ethanol, chloroform

Delayed type stinging e.g. 5% lactic acid, phenol

Immediate non-immune contact

e.g. arthropods, caterpillar, capsaicin

Chronic irritant dermatitis e.g. hair dressers

Toxic burn e.g. strong acids

Caustic burn wet cement

Dermatitis eyelid volatile irritant

Irritant dermatitis in barber

Irritant finger web eczema

Dry irritant contact

Dry fingertip dermatitis

ALLERGIC CONTACT DERMATITIS

occurs in only those allergic to a contactant

mediated by lymphocytes (delayed hypersensitivity)

not dose related

MOST COMMON ALLERGENS

Rubber

Perfumes

Some Plants

Metals - nickel

Dyes

Cosmetics

Medicaments

Irritant Contact Dermatitis Allergic Contact Dermatitis

Accounts for approximately 80% of all contact dermatitis

Accounts for the remaining 20% of all contact dermatitis

Result from a local toxic effect It is a delayed-type hypersensitivity reaction of Th1 response

Affect every one ,no sensitization is required Prior sensitization is required

Reaction soon after contact -minutes to hours Reaction delayed for hours to days

Repeated or prolonged exposure is required, a dose-response relationship

Small amount of allergen is enough to elicit the reaction

No cross-reaction Cross-reaction can occur

Burning prominent Burning not prominent

Lesions are restricted to the area where the irritant damaged the tissue

Localized, but may be more diffuse

Negative patch test Positive patch test

CD TO RUBBER

CD TO RUBBER

CD TO PERFUME

CD TO PLANTS

CD TO PLANTS

COSMETICS - NAIL POLISH

COSMETICS - LANOLINE

HAIR DYE - PPD

SHOE CONTACT DERMATITIS

CD TO NICKLE

CD TO NICKLE

CD TO MEDICAMENTS

CD TO MEDICAMENTS

OCCUPATIONAL CD - ACRYLATE

NAPKIN DERMATITIS

DIAGNOSIS

History

Examination

Patch testing

Remove the causative agents

Treat the dryness (Emollients)

Choose the correct steroid for the site and

activity of disease

Antihistamines (Itching)

MANAGEMENT

TOPICAL STEROIDS

CLASSIFICATION

USES

COMPLICATIONS

TOPICAL STEROIDS POTENCY RANKING  

Class 1 (Superpotent) Clobetasol propionate OINTMENT AND CREAM 0.05% (dermovate , temovate)

Betamethasone dipropionate OINTMENT (optimized vehicle) 0.05% (diprolene)

Class 2 (High Potency) Betamethasone diproprionate CREAM 0.05% (diprolene)

Betamethasone diproprionate OINTMENT 0.05% (diprosone)

Betamethasone diproprionate CREAM 0.05% (diprosone)

Mometasone furoate ointment 0.1% (elocom)

Cont’d

Class 3 (High Potency) Fluticasone proprionate OINTMENT 0.05% (cutivate)

Class 4 (Medium Potency) Hydrocortisone valerate OINTMENT 0.2% (Westcort)

Mometasone furoate CREAM 0.1% (elocom)

Triamcinolone acetonide OINTMENT 0.1% (Kenalog)

Hydrocortisone butyrate OINTMENT 0.1% (Locoid)

Cont’d

Class 5 (Medium Potency) Fluticasone proprionate CREAM 0.05% ( cutivate ) Hydrocortisone valerate CREAM 0.2% (Westcort) Hydrocortisone butyrate CREAM 0.1% (Locoid)

Triamcinolone acetonide CREAM 0.1% (Kenalog)

Class 6 (Low Potency) Alclometasone diproprionate OINTMENT 0.05% ( perderm ) Alclometasone diproprionate CREAM 0.05% ( perderm )

Class 7 (Low Potency) Topicals with hydrocortisone acetate 1 %

Important about topical steroidsWhat skin conditions are

topical corticosteroids used for?

Potency of topical corticosteroids

How safe are topical steroids?

Does the formulation of steroid make any difference?

Misuse of topical steroids How long should topical

steroids be used for?

How often should topical steroids be applied?

How much should be applied?

How much should be prescribed?

Can topical corticosteroids be used safely on infected skin?

Using topical steroids in children and geriatric group

Tachyphylaxix

SUGESSTED AMOUNT FOR TOPICAL THERAPY

AREA TREATED SINGLE APPLICATION (G) BID FOR I WEEK

FACE 1 15SCALP 2 30ONE HAND 1 15ONE ARM 3 45ANTERIOR TRUNK 4 60POSTERIOR TRUNK 4 60ONE LEG INCLUDING FOOT

5 70

ANOGENITAL AREA 1 15WHOLE BODY 30-40 450-500

Topical Steroids in Adults

Area of skin to be treated (adults)

Size is roughly: FTUs each dose (adults)

A hand and fingers (front and back)

About 2 adult hands 1 FTU

A foot (all over) About 4 adult hands 2 FTUs

Front of chest and abdomen

About 14 adult hands 7 FTUs

Back and buttocks About 14 adult hands 7 FTUs

Face and neck About 5 adult hands 2.5 FTUs

An entire arm and hand About 8 adult hands 4 FTUs

An entire leg and foot About 16 adult hands 8 FTUs

Regional differences in penetration

1. mucous membranes

2. scrotum

3. eyelids

4. face

5. chest and back

6. upper arms and legs

7.lower arms and legs

8. dorsa of hands and feet

9.palmar and plantar skin

10. nails

Skin absorption of topical steroids

Steroids are absorbed at different rates from different parts of the body.

A steroid that works on the face may not work on the palm. But a potent steroid may cause side effects on the face.

Forearm absorbs 1% Armpit absorbs 4% Face absorbs 7% Eyelids and genitals absorb 30% Palm absorbs 0.1% Sole absorbs 0.05%

Thank You