Eczema Atopic Dermatitis Contact Dermatitis Fahad Al Sudairy, M.D.

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Transcript of Eczema Atopic Dermatitis Contact Dermatitis Fahad Al Sudairy, M.D.

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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 Endogenous EczemaExogenous Eczema

Endogenous EczemaAtopic EczemaSeborrhoeic EczemaDiscoid Eczema Pityriasis AlbaPompholyxGravitational EczemaAsteatotic Eczema

Exogenous EczemaIrritant Contact DermatitisAllergic Contact DermatitisPhoto Allergic Contact DermatitisInfective DermatitisStages of EczemaAcute EczemaSubacute EczemaChronic Eczema Clinical Staging AcuteWeeping, papules, vesicles & bullaeChronicDryness, redness, lichenification, scaling & fissuring

Acute EczemaACUTE ECZEMA

SpongiosisIntercellular edemaofkeratinocytesin theepidermisACUTE ECZEMA

ACUTE ECZEMA

Chronic EczemaChronic 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 13Chronic Eczema

Atopic EczemaAtopy genetically determined increased liability to form IgEAetiology unknowninherently itchy & dry skinpsychological climaticallergic factors

DIAGNOSTIC GUIDELINES FOR ATOPIC DERMATITISMust 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)

Contd

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 DERMATITISMajor 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

Contd

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

Contd

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 blanchPHASES OF ATOPIC DERMATITIS infantile phase 2-6 monthscheeks, forehead, scalpchild restless, sleeplesscrawling extensor aspect of knees

25ATOPIC ECZEMA CONTDchildhood phase - 18-24 monthselbows & knee flexuressides of neckwrists & anklesreticulate pigmentation on neckCONTDadult phaselichenification of hands & flexuresphotosensitivityallergic hand eczema

28ATOPIC ECZEMA

30RETICULAR PIGMENTATION IN Atopic Eczema

TREATMENTGeneral measureswear cotton clothesavoid overheating roomsavoid irritant soapsreassurancefoodsCONTDLocalemollientstopical steroids tacrolimus ointmentSystemicantihistaminesoral corticosteroidslow dose cyclosporinazathioprine

SEBORRHOEIC ECZEMAoccurs in sebaceous gland rich areasEtiology - unknown, malassezia furfurerythema, greasy yellowish scales

CONTDinfants cradle capfaceflexures

39CRADLE CAP

40Cradle Cap

41SD

CONTDadultsScalp - dandruffRetro-auricular areaFace, blephritis, conjunctivitisTrunkSevere recalcitrant to treatment in HIV

CONTDTreatmentno permanent curekeratolyticsmild topical steroidsantifungals

DISCOID ECZEMArounded plaques of eczema clearly demarcated edgesites - limbsatopy, dry skin, allergic contactemotional factors

54Discoid (Numular) EczemaPOMPHOLYXeczema of palms & soles characterized by vesicles & bullaehyperhidrosis, drugs, food allergies, emotional stressspontaneous remission 2-7 weeks

PITYRIASIS ALBAill-defined erythematous scaly patches leave hypopigmentation3-16 years, atopic eczemaface, neck, armsTreatment - emollients, tar, 1% hydrocortisone

STASIS ECZEMAeczema secondary to venous hypertensionoften obeselower legsedema, varicosities, purpura, ulceration, infection

CONTACT ECZEMAIRRITANT CONTACT DERMATITIS Irritant substance physical or chemical which produces cell damage if applied for sufficient length of time and in adequate concentration

CONTDstrong irritant response immediateweak irritant repeated exposure

IRRITANT CONTACT DERMATITISFirst exposure gives responseEveryone exposed can developStrictly limited to area of contactIRRITANT CONTACT DERMATITISSubjective irritant responseImmediate type stinging e.g. ethanol, chloroformDelayed type stinging e.g. 5% lactic acid, phenolImmediate non-immune contact e.g. arthropods, caterpillar, capsaicinChronic irritant dermatitis e.g. hair dressersToxic burn e.g. strong acidsCaustic burn wet cement

Dermatitis eyelid volatile irritant

Irritant dermatitis in barber

Irritant finger web eczema

Dry irritant contact

Dry fingertip dermatitis

76PHOTODERMATITIS

77PHOTODERMATITIS

78PHOTODERMATITISALLERGIC CONTACT DERMATITISoccurs in only those allergic to a contactantmediated by lymphocytes (delayed hypersensitivity)not dose relatedMOST COMMON ALLERGENSRubberPerfumesSome PlantsMetals - nickelDyesCosmeticsMedicamentsIrritant 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

92CONTACT SHOE DERMCD TO NICKLE

94Nickel Contact Eczema

95Nickel Contact Eczema

CD TO NICKLE

CD TO MEDICAMENTS

CD TO MEDICAMENTS

OCCUPATIONAL CD - ACRYLATE

NAPKIN DERMATITIS

DIAGNOSISHistoryExaminationPatch testingRemove the causative agents Treat the dryness (Emollients)Choose the correct steroid for the site and activity of diseaseAntihistamines (Itching)

MANAGEMENTTOPICAL STEROIDSCLASSIFICATIONUSESCOMPLICATIONS

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)

Contd 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)

ContdClass 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 corticosteroidsHow 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 groupTachyphylaxix

SUGESSTED AMOUNT FOR TOPICAL THERAPYAREA TREATED

SINGLE APPLICATION (G)

BID FOR I WEEK

FACE115SCALP230ONE HAND1 15ONE ARM345ANTERIOR TRUNK460POSTERIOR TRUNK460ONE LEG INCLUDING FOOT570ANOGENITAL AREA115WHOLE BODY

30-40450-500Topical Steroids in AdultsArea of skin to be treated (adults)Size is roughly:FTUs each dose (adults)A hand and fingers (front and back)About 2 adult hands1 FTUA foot (all over)About 4 adult hands2 FTUsFront of chest and abdomenAbout 14 adult hands7 FTUsBack and buttocksAbout 14 adult hands7 FTUsFace and neckAbout 5 adult hands2.5 FTUsAn entire arm and handAbout 8 adult hands4 FTUsAn entire leg and footAbout 16 adult hands8 FTUsRegional differences in penetration1. mucous membranes2. scrotum3. eyelids 4. face5. chest and back6. upper arms and legs7.lower arms and legs8. dorsa of hands and feet9.palmar and plantar skin10. nails

Skin absorption of topical steroidsSteroids 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%

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