Eczema

Eczema (Dermatitis )

Dr. Manar Ghanem
LEC. 4
17 / 11 / 2016

Objective

Define eczema
Detrmine its prevalence
List stages, types and clinical presentations of eczema
Determine etiological factors and clinical features of endogenous dermatitis.
Management plan for endogenous dermatitis

Eczema

Is the most common inflammatory skin disease
The characteristic components of eczematous inflammation
Erythema
Scale
Vesicle

Stages Of Eczematous Inflammation

There are three stages of eczema:

acute,

subacute,
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. Numerousvesicles on an erythematous base..

Subacute And Chronic Eczematous Inflammation.The Skin Is Dry, Red, Scaling, And Thickened

Subacute eczema. Erythema and scalingare present, the surface is dry, and the borders are indistinct.


Chronic eczematous inflammation , Accentuated skin lines differentiatethis process from psoriasis.

Classification

The classification of eczematous dermatosis is based on aetiology
Exogenous
Endogenous

Why ??

Classification of dermatitis
• Atopic dermatitis
• Seborrheic dermtitis
• Discoid eczema
• Asteatotic eczema
• Gravitational dermatitis
• Pompholyx
• Lichen simplex
1. Contact dermatitis
Irritant
Allergic


2. Infective dermatitis
3. Photodermatitis
4. Radiodermatitis
Endogenous
Exogenous

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.

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 prediliction .

Adolescents and adults :

Have eczema in flexural areas and on the
hands.


The pattern of inheritance is polygenic.

Phases of atopic dermatitis 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. Generalizedinfantile atopic dermatitis sparing the diaper area,

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

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. thedermatitis 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


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

White dermographism

Keratosis pilaris

Hyperlinear palm

Pityriasis alba

Icthyosis

Infraorbital fold


• Bactereal infections ex.S.Aureus infection.
• Severe viral infections Herpes simplex infection (eczema herpeticum). Widespread infection with the herpes simplex
• Poor growth.
• Local& systemic side effect of steroids
• Negative psychological effects

Complications:

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 , reassurance

Avoid triggering factor

Treat the existing lesions

Prevention

Avoid wool.
Use 100% cotton.
Use soaps only in axilla, groin, 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

NASOLABIAL FOLD SD

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-For 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 photo allergy
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, eyhematous 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 overbathing with soap

Avoid soap and irritant wool

Emollient vasaline 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 becouse 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 atopics
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, 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