what Is Eczema? - Home | Pharmac€¦ · What is eczema? •Clinical features ... The...
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WHAT IS ECZEMA?
Dr Diana Purvis
Paediatric Dermatologist
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What is eczema?
• Clinical features
• Epidemiology
• Prognosis
• Etiology and pathogenesis
• Immunology
• Skin barrier
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Eczema
• From the Greek: ‘to boil over’
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Eczema
• From the Greek: ‘to boil over’
• Pruritic papulovesicular dermatitis characterised by
erythema, oedema and a serous exudate in the
epidermis, an inflammatory infiltrate in the dermis, oozing
and vesiculation, and crusting and scaling; and later by
lichenification, thickening, signs of excoriations and
altered pigmentation. • TheFreeDictionary.com
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Eczema
• From the Greek: ‘to boil over’
• Pruritic papulovesicular dermatitis characterised by
erythema, oedema and a serous exudate in the
epidermis, an inflammatory infiltrate in the dermis, oozing
and vesiculation, and crusting and scaling; and later by
lichenification, thickening, signs of excoriations and
altered pigmentation. • TheFreeDictionary.com
• “The itch that rashes”
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• Itchy skin condition plus three of
• History of involvement of the creases
• Personal history of atopy (or 1st degree relative if <4 years)
• Generally dry skin
• Visible flexural eczema
• Onset under 2 years of age • UK Working Party, BJD 1994
Diagnostic criteria for atopic eczema
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Features of eczema
Major features: • Pruritis
• Rash
• face and extensors in infants
• flexural in older children
• Chronic or chronically relapsing
• Personal or family history of other atopic disease
Other common features: • Dryness
• Dennie-Morgan folds
• Allergic shiners
• Facial pallor
• Pityriasis alba
• Keratosis pilaris
• Icthyosis vulgaris
• White dermatographism
• Conjunctivitis
• Keratoconus and cataracts
• Elevated serum IgE
• Skin prick test positivity
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Eczema - subtypes
• Eczema / atopic dermatitis
• Seborrhoeic dermatitis
• Discoid, nummular eczema
• Dyshidrotic eczema / pompholyx
• Contact dermatitis
• Varicose eczema
• Asteatotic eczema
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Infant Child/adolescent Adult
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Prognosis
• Outcome of any individual is difficult to predict
• Spontaneous resolution in 40-60% of infants, especially with mild
disease
• 20% have resolved by adolescence, 65% less severe
• Prevalence is 2 – 3% in adults
• Adults whose childhood eczema has remitted can present with
hand dermatitis
• Poor prognosis:
• Generalised eczema
• Associated asthma and hayfever, high IgE levels
• Family history of troublesome eczema
• Early age of onset
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Epidemiology of eczema
• Prevalence of has increased three-fold since 1960s
• 10-20% of children in industrialised countries eg Europe, USA
• 1-3% of adults
• Lower prevalence in agricultural economies eg China, Africa
• Environmental factors seem critical in disease expression
• Risk factors include:
• Small family size
• Increased income and education
• Migration from rural to urban environments
• Increased use of antibiotics
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The hygiene hypothesis
• The ‘Western lifestyle’ predisposes to allergic disease
• Lack of early childhood exposure to infectious agents, symbiotic
microorganisms and parasites
• Suppresses the natural development of Th1 predominant
immune response
• Promotes a Th2 dominant or allergic response
• Supported by reduced risk of eczema with:
• owning a pet
• attending daycare
• use of probiotics
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The atopic march
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How atopic is atopic eczema?
• Up to 50% of hospital eczema patients are not sensitised,
even higher in community settings
• Population attributable risk for allergic sensitisation
causing eczema <50% in affluent countries, as low as
zero in non-affluent countries (ISAAC)
• Genetic risk
• “atopic disease” asthma, eczema, allergic rhinitis do tend to cluster
in families
H Williams, C Flohr J All Clin Imm 2006
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Pathogenesis of eczema
Two hypotheses:
1) Inside-out
Immunological disturbance causes IgE-
mediated sensitisation, epithelial barrier
dysfunction is secondary
2) Outside-in
Epidermal barrier dysfunction allows
irritants and allergens into the skin, with
immunological disturbance secondary
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Itch
Scratch
Leaky skin barrier
Inflammation
Immune dysfunction
Eczema Soap
Irritants
Infection
Allergens
House dust mite
Cat/dog fur
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Itch
Scratch
Leaky skin barrier
Inflammation
Immune dysfunction
Eczema Soap
Irritants
Infection
Allergens
House dust mite
Cat/dog fur
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Itch
Scratch
Leaky skin barrier
Inflammation
Immune dysfunction
Eczema Soap
Irritants
Infection
Allergens
House dust mite
Cat/dog fur
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The skin as a barrier
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The skin as a barrier
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The stratum corneum
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The skin barrier
• Skin barrier function maintained by:
• Regular desquamation
• Intercellular lipid bilayers
• Natural Moisturising Factors
• Production of antimicrobial peptides
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The skin barrier is impaired in eczema
• Genetic defects • Filaggrin gene mutation in 30% of eczema patients
• Filaggrin involved in production of natural moisturising factors
• Other genes affecting stratum corneum function eg SPINK5, loricrin
• Reduced ceramides and water binding
• Decreased sebaceous secretion
• Impaired production of antimicrobial peptides • Defensins and cathelicidins
• Staphylococcus aureus colonisation in 90%
• Increased viral infections
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The skin in eczema
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1. Irvine et al. J Invest Dermatol 2006; 126: 1200–02. 2. Bieber T. N Engl J Med 2008; 358: 1483–94.
Gene-environment interaction
Genetic
background
Environmental
factors
Skin
barrier
Immune
system
Microbiological
agents (bacteria, virus, etc,)
Stress
Allergens (inhalative, food, contact)
Climate
Irritants
New discovery: filaggrin gene mutation
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Itch
Scratch
Leaky skin barrier
Inflammation
Immune dysfunction
Eczema Soap
Irritants
Infection
Allergens
House dust mite
Cat/dog fur
What causes eczema?
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Itch
Scratch
Leaky skin barrier
Inflammation
Immune dysfunction
Eczema Soap
Irritants
Infection
Allergens
House dust mite
Cat/dog fur
What causes eczema?
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Itch
Scratch
Leaky skin barrier
Inflammation
Immune dysfunction
Eczema Soap
Irritants
Infection
Allergens
House dust mite
Cat/dog fur
What causes eczema?
Triggers
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3/26/09 41
Brick => Corneocyte
Mortar => Lipid Lamellae
Cork MJ, Hunter LW & Danby SG; Academic Unit of Dermatology Research, The University of Sheffield.
Brick wall model of
the skin
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The Normal Skin Barrier
3/26/09 42 Cork MJ, Hunter LW & Danby SG; Academic Unit of Dermatology Research, The University of Sheffield.
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2/10/2015 43
Irritants &
allergens
Cork MJ, Hunter LW & Danby SG; Academic Unit of Dermatology Research, The University of Sheffield.
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The skin barrier in atopic dermatitis
3/26/09 44
Broken
mortar
in AD
Cork MJ, Hunter LW & Danby SG; Academic Unit of Dermatology Research, The University of Sheffield.
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TEWL
2/10/2015 The Academic Unit of Dermatology Research, The University of Sheffield. 45
Irritants &
allergens
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46
Emollients
Cork MJ, Hunter LW & Danby SG; Academic Unit of Dermatology Research, The University of Sheffield.
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NO itch
NO scratching
Effective skin barrier
NO inflammation
NO immune dysfunction
NO eczema
Emollients, treat inflammation
Avoid soap
and irritants,
treat
infection,
treat with
steroids,
immuno-
suppressant
Address allergens
minimise exposure,
immune modulation
Treat
inflammation,
cool,
antihistamines
Treat itch,
physical
barriers,
distraction