Fifth stage
Dermatology
Lec. 4
د. منار
3/11/2016
Eczema (Dermatitis)
Eczema
Is the most common inflammatory skin disease, the characteristic components of
eczematous inflammation are:
• Erythema
• Scale
• Vesicle
Stages of Eczematous Inflammation
There are three stages of eczema subacute,
acute, and chronic.
Stage
Symptoms
Primary and
secondary
Treatment
Acute
Intense itch
Vesicles, blisters, intense
redness
Cold, wet compresses,
Oral or topical steroids,
Antihistamines,
±antibiotics
Subacute
Slight to moderate
itch, pain, burning
Redness, scaling, fissuring
Topical steroids with or
without occlusion,
lubrication, antihistamines,
± antibiotics
Chronic
Moderate to intense
itch
Thickened skin, skin lines
accentuated (lichenified
skin), excoriations,
fissuring
Topical steroids (with
occlusion for best results),
Antihistamines, antibiotics,
lubrication
Acute eczematous inflammation, numerous vesicles on an erythematous base
Subacute and chronic eczematous inflammation, the skin is dry, red, scaling, and
thickened
Subacute eczema, Erythema and scaling are present, the surface is dry, and the borders
are indistinct.
Chronic eczematous inflammation, accentuated skin lines differentiate this process from
psoriasis.
Classification
The classification of eczematous dermatosis is based on aetiology
Exogenous
Endogenous
Atopic Dermatitis
The term atopy was introduced years ago to designate a group of patients who had a
personal or family history of one or more of the following diseases: hay fever, asthma,
very dry skin, and eczema.
Atopic dermatitis (AD) is a chronic, pruritic inflammatory skin disease that occurs most
frequently in children, but also affects many adults.
AD is often associated with elevated serum immunoglobulin E (IgE) levels and a
personal or family history of type I allergies, allergic rhinitis, and asthma.
Prevalence
• Approximately 15% to 30% of children and
2% to 10% of adults are affected.
• About 45% of cases of atopic dermatitis begin within the first 6 months of life, 60%
begin during the first year, and 85% begin before 5 years of age.
• Up to 70% of children have a remission before adolescence.
• Atopic dermatitis can start in adults.
1. Atopic dermatitis
2. Seborrheic dermtitis
3. Discoid eczema
4. Asteatotic eczema
5. Gravitational dermatitis
6. Pompholyx
7. Lichen simplex
1.
Contact dermatitis
•
Irritant
•
Allergic
2.
Infective dermatitis
3.
Photodermatitis
4.
Radiodermatitis
Endogenous
Exogenous
Pathogenesis and Immunology
• Increase serum IgE evel
• Increase histamine level in blood and skin
• Increase blood esinophiles
• Decrease cell mediated immunity; Patients may develop severe diffuse cutaneous
infection with the herpes simplex virus (eczema herpeticum) whether or not their
dermatitis is active.
• Decrease neutrophil and monocyte chemotaxis
• Increase susceptibility to viral and fungal infection, staphylococcal colony may be
high and bacterial infection may supervene.
The disease characteristics vary with age:
Infants :
Facial and patchy or generalized body eczema, with extensor predilection
Adolescents and adults :
Have eczema in flexural areas and on the hands.
The pattern of inheritance is polygenic.
Phases of Atopic Dermatitis
A. Infantile phase (3months – 2 years):
• Face , forehead, scalp , extensor side of the
• Cheek first place
• Diaper freq spared
• limbs
• Itchy dry skin +/- bacterial infection
• Usually progress to childhood stage but may resolve in the age of 1- 1.5 yrs.
Atopic dermatitis—infant phase. Red, scaling plaques confined to the cheeks are one of
the first signs of atopic dermatitis in an infant:
Atopic dermatitis—infant phase. Generalized infantile atopic dermatitis sparing the
diaper area:
B.
Childhood Phase (2 to 12 Years):
• Inflammation in flexural areas (i.e., the antecubital fossae, neck, wrists, and ankles)
• Perspiration stimulates burning and intense itching and initiates the itch-scratch
cycle.
• Tight clothing that traps heat about the neck or extremities further aggravates the
problem.
• The eruption begins with papules that rapidly coalesce into plaques, which become
lichenified when scratched.
• Constant scratching may lead to destruction of melanocytes, resulting in areas of
hypopigmentation
• If they have been vigorously scratched, they may be bright red and scaling with
erosions.
• The border may be sharp and well-defined, as it
is in psoriasis, or poorly defined with papules
extraneous to the lichenified areas.
Hypopigmentation in the antecubital
fossae caused by destruction of
melanocytes by chronic scratching.
Atopic dermatitis, classic appearance of confluent papules forming plaques
Atopic dermatitis—childhood phase: Diffuse inflammation on the face of a child, the
eczema initially spared the perioral area
C. Adult Phase (12 Years to Adult)
• As in the childhood phase, localized inflammation with lichenification
• Mostly in flexural areas.
• Adults may have no history of dermatitis in earlier years, but this is unusual.
Severe generalized atopic dermatitis. The dermatitis has generalized to involve the entire
body.
Criteria for diagnosis
Must be present
•
Pruritus
•
Eczema (acute, subacute, chronic)
•
Typical morphology and age-specific
patterns*
•
Chronic or relapsing history
*Patterns include:
Facial, neck, and extensor involvement
in infants
Current or previous flexural lesions in
children and adult stage
sparing of the groin and axillary
regions
Seen in most cases, adding support to the
diagnosis:
•
Early age of onset
•
Personal and/or family history of atopy
•
Immunoglobulin E reactivity
•
Xerosis
Essential Features
Important Features
White dermographism Keratosis pilaris
Help to suggest the diagnosis of atopic
dermatitis but are nonspecific:
•
Atypical vascular responses (white
dermographism )
•
Facial pallor
•
Keratosis pilaris
•
Pityriasis alba
•
Hyperlinear palms
•
Ichthyosis
•
Cataract
•
Infraorbital fold (dennie-morgan )
•
Persistent dry or itchy skin in adult life
•
Widespread dermatitis in childhood
•
Associated allergic rhinitis, bronchial
asthma
•
Family history of atopic dermatitis
•
Early age at onset
•
Female gender
Associated Features
Unfavorable
Prognostic Factors
Hyperlinear palm
Pityriasis alba
‘
Infraorbital fold
Icthyosis
Complications:
• Bactereal infections eg. Staoh. aureus infection.
• Severe viral infections eg. Herpes simplex infection (eczema
herpeticum), widespread infection with the herpes simplex
• Poor growth
• Local & systemic side effect of steroids
• Negative psychological effects
Eczema herpeticum
Differential diagnosis
•
Scabies
•
Seborrheic dermatitis
•
Contact dermatitis (irritant or allergic)
•
Ichthyosis
•
Cutaneous T-cell lymphoma
•
Psoriasis
Atopic dermatitis
Scabies
Diagnosis
Diagnosis based on the clinical features (essential, important, associated)
Treatment
• We have to deal with the psychological impact on the patient and his family , by
discussing and reassurance.
• Avoid triggering factor.
• Treat the existing lesions.
Prevention
• Avoid wool.
• Use 100% cotton.
• Use soaps only in axilla, groin, and feet.
• Avoid perfumes or makeup that burns or itches.
• Do not scratch.
• Apply soothing lubricants.
• Maintain cool, stable temperatures.
• Do not overdress.
• Avoid sweating.
• Humidify the house in winter.
• Avoid cigarettes.
• Minimize animal dander—no cats, dogs, rodents, or birds.
• Control emotional stress
• Diet control is a controversial treatment method
Treatment
• Topical steroid with different potency strong on dry chronic lesion
• Systemic steroid For generalized sever cases
• For itching Sedative antihistamine
• For infection Antibiotic
• Continuously using Vaseline to the skin
• Others Tacrolimus, tar, phototherapy
Other Type of Endogenous Eczema
Seborrhic Dermatitis
• A chronic superficial inflammation
• Common affect 3-5% of population
• On hairy region (pilosebaceous unit)
• Affect infant up to third months and after puberty (two phases only).
Etiology:
• Androgen increase sebum release
• Also over active normal flora (pityriosporum ovale) which increase activity in
seborrhic area.
Clinical feature
•
Erythematous patch or plaque covered by greasy yellowish scale, indistinct
margin, hair loss uncommon.
•
Most common on scalp, eyebrow, face, mustache, nasolabial folds.
•
Also central chest (presternal area), axillae and groin.
•
Itchy lesion
•
In infant it cover the scalp known as cradle cap
•
Napkin area is often affected which differ from?
•
But it spread beyond the area covered by napkin ( not as in contact
dermatitis )
• Acute onset or wide spread exacerbation of seborrhic dermatitis is commonly seen in
HIV infection.
Seborrhic dermatitis (infant stage)
SD Adult Stage
SD mustache SD Nasolabial fold
Differential Diagnosis
• Psoriasis vulgaris.
• Dermatophytosis (tinea capitis, tinea faciale, tinea corporis),
• Candidiasis (intertriginous).
• Tinea amiantacea.
• Contact dermatitis
Diagnosis: clinical
Treatment
A. General measures:
Regular bathing.
Avoid irritant & oily applications.
B. Topical therapy:
1- Scalp shampoos containing 2 % ketoconazole,
Ketoconazole or any antifungal cream for the face and body.
2- Corticosteroids for more severe cases;
Hydrocortisone or low-potency corticosteroid solution, lotion, or gel (for scalp)
1 % or 2.5% hydrocortisone cream for other sites.
*The main treatment of seborrhoeic eczema of scalp in infancy is
emollients
.
Nummular (Discoid eczema)
• A
chronic, intensely pruritic,
coin-shaped erythematous scaly plaques
• During winter months;
• Often seen in atopic individuals.
• Age: two peaks in incidence: young adults and old age.
• Plaques may be :
Exudative and crust (Wet type).
Or dry scaly (Dry type).
Distribution:
lower legs, trunk, hands and fingers or generalized
Pathophysiology:
unknown
Differential diagnosis:
• Psoriasis
• Tinea corporis
• Herald patch of pityriasis rosea
Diagnosis: clinical, biopsy shows eczema
Treatment:
•
Avoid irritant as soap, wool
•
Emollient as vasaline
•
Medium potency topical steroid
•
If superadded infection so topical and even systemic antibiotic if wide
spread
•
If itching antihistamine
Pityriasis Alba
• Thought to be photoallergy
• Appear on exposed parts
• On children and adolescents
• Self-limiting
• Reassure the family with mild topical
steroid, and sun avoidance
Asteatotic Dermatitis
• Eczematous lesion that occurs in the winter and in old persons
• On the legs, arms, and hands but also may be on the trunk.
• Itchy, erythematous scaling dry, “cracked,” fissured skin.
• Very often the eruption results from too frequent bathing ,frequent washing with
soap , especially in winter when the humidity is low, also in patient taking diuretics
Treatment
• Avoid over-bathing with soap
• Avoid soap and irritant wool
• Emollient vaseline twice daily
• Steroid may be used
Gravitational eczema
• Previously misnamed as stasis or varicosity dermatitis (thought to be due to stasis,
but there is NO stasis.
• Due to Increased hydrostatic ( venous ) pressure and capillary damage with GOOD
blood supply , especially seen on the leg
• Due to faulty valve and increase capillary pressure with widening of the epithelial
pores
Lead to:
• Extravasated fluids lead to edema
• And RBCs lead to hemosiderosis , brownish black discoloration
• Fibrinogen which will converted into fibrin lead to vasoconstriction that cause bad
nutrition , so any truma may lead to persistant leg ulcer
• Most common site is proximal to the medial malleolus
• As an itchy ill-defined, erythematous patches with fine scaling, sometimes with
excoriations, on lower legs, especially around varicosities.
Complications:
1. Contact dermatitis from medication
2. Infection
3. Ulcer
4. Inverted champagne bottle look to the leg may result from prolong disease
ulceration and fibrosis.
Treatment:
• Leg elevation
• Weight reduction
• Topical steroid
• Treatment of secondary bacterial infection (avoid topical neomycin because it cause
sensitization)
Pomphylox
Lesions: very itchy deep seated tiny vesicles along the sides of the fingers, palms, sides,
toes, and soles. May coalesce and become bullae, which weep and become painful dry,
hyperkeratotic and fissured.
Age: Majority under 40 years (range 12 to 40 years).
Sex: Equal ratio.
Associations: It is more common in atopic
Treatment: with potent topical steroid under cover, Antihistamine
Lichen Simplex Chonicus (Neurodermatitis)
Definition: A pruritic eczematous condition resulting from habitual continued rubbing
and scratching at a localized area of the skin, associated with a period of anxiety.
Age: Over 20 years.
Sex: More frequent in women.
Lesion: Characteristicly itchy lichenified plaque, well defined,
unilateral flesh coloured, pink or hyper pigmented.
Pruritus, often in paroxysms and it becomes a pleasure to
scratch.
Often the rubbing becomes reflexive and a subconscious
habit.
Lightly stroking the involved skin with a cotton swab
generates a strong desire to scratch the skin
The constant scratching leads to a vicious cycle of: scratch →
release histamine → itch → scratching
Distribution: especially: back of neck (female), just below
elbow, back of hand, genitalia, buttock, and lower leg.
Diagnosis: clinical, biopsy - rarely required, shows eczema.
Differential diagnosis: hypertrophic lichen planus.
Treatment:
• Relive anxiety
• Stop scratching??
• Super potent topical steroids under occlusion