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NUMMULAR DERMATITIS AND NEURODERMATITISMuhammad Faiz Mohd Nazri C11110867Nur Arifah Mohd Said C11110841

ADVISORdr. Suci Nugraeni

SUPERVISORdr. Safruddin Amin,Sp.KK(K), MARS

DEFINITIONAlso known as discoid eczema.A chronic disorder of unknown etiology.Papules and papulovesicles coalesce to form nummular plaques with oozing, crust and scale.

Also known as lichen simplex chronicusA chronic, severely pruritic disorder characterized by one or more lichenified plaques.

NUMULAR DERMATITISNEURO-DERMATITIS2EPIDEMIOLOGYPredominantly is a disease of adulthood. Men > women. The peak incidence in both males and females is 50 65 years of age. There is a second peak in women around 1525 years of age.Rare in infancy and childhood.

Affects adults, predominantly from ages 30 - 50. Females > males.Patients with coexistent atopic dermatitis have been found to have earlier age of onset (mean age: 19 years) as compared to the non-atopic group (mean age: 48 years).

NUMULAR DERMATITISNEURO-DERMATITISNUMMULAR DERMATITIS

Pathogenesis of N.D. is still unknown. Most of the patients do not have a personal or family history of atopy even it may be seen in atopic eczema. The state of hydration of the skin in elderly patients decreased. The role of infection (Candida albicans and Staphylococcus).ETIOPATOGENESIS12345Pinpoint oozing and crusting eventuate, and are distinctive

Plaques range from 1- 3 cm in size. The surrounding skin is generally normal but may be xerotic

Pruritus varies from minimal to severeCentral resolution may occur, leading to annular forms. Chronic plaques are dry, scaly, and lichenifiedThe classic distribution of lesions is the extensor extremities. In women, the upper extremities, including the dorsal hands are more commonWell-demarcated coin-shaped plaques form from coalescing papules and papulovesiclesNUMULAR DERMATITISCLINICAL MANIFESTATION123456Three types of nummular dermatitis :

Hyper- and hypo-pigmentation are seen with chronicity

Repeated rubbing and scratching (conscious or unconscious) gives rise to a lichenified, scaly plaque with excoriations

Itching may be paroxysmal, continuous, or sporadic

Most common sites : The scalp Nape of the neck (esp. in women) Ankles Extensor aspects of the extremities Anogenital region (women labia majora, men scrotum)Itch severity worsen with sweating, heat, or irritation from clothing and psychological distress

NEURO-DERMATITISCLINICAL MANIFESTATION12345 HISTOPATHOLOGYNummular dermatitisPathology may show acute, subacute or chronic dermatitis.

Acute phase: The dominant histopathology is spongiosis which is intercellular edema that caused stretching and ruptured of bonds between cells which accompanied by formation of vesicle.Subacute phase: Spongiosis and vesiculation diminished and there is an increased acanthosis which is related to keratinized parakeratotic layer, which usually consists of coagulated plasma layered with picnotic nucleases from inflamed cells.

Chronic phase: Hiperkeratotic slowly replaced the parakeratotic layer. Acanthosis is more prominent than spongiosis.

NeurodermatitisThe histological changes vary with site and duration. HISTOPATHOLOGY

Acanthosis and variable degrees of hyperkeratosis are observed. The rete ridges are lengthened. Spongiosis is sometimes present, & small areas of parakeratosis are occasionally seen. DIFFERENTIAL DIAGNOSISNummular dermatitisAllergic contact dermatitisAtopic dermatitisTinea corporis

NerurodermatitisLichen planusPsoriasisALLERGIC CONTACT DERMATITISATOPIC DERMATITISTINEA CORPORISDEFINITIONType IV hypersensitivity reaction diseaseChronic relapsing skin disease, mostly occur in early childhoodDermatophytosis of glabrous skinETIOLOGYSkin contact with environmental allergensDefect of skin barrier & highly immune response to allergenT. tonsuran, T. rubrum, E. floccosumCLINICAL MANIFEST-ATIONAcute pruritus, erythema, edema, vesiclesChronic lichenified erythematous plaqueAcute intense pruritus, erythematous papule, vesicle, serous exudateChronic lichenified & fibrotic papuleAnnular/serpigin-ous plaque with scale, vesicles at border, central clearingPHOTODISTRIBUT-IONHands, feets, faceFlexural folds of extremitiesGlabrous skin except palm, soles, groin

LICHEN PLANUSPSORIASISDEFINITIONChronic inflammatory disorder affecting skin, mucous membrane, nails & hairChronic inflammatory skin disorderETIOLOGYDefect in specific immunology mechanismGenetic defect with triggering factor such as trauma, infection, & medicationCLINICAL MANIFEST-ATIONSymmetric, erythematous to violaceous(violet), flat-topped, polygonal papulesErythematous with silvery scaly plaques, crust, pinpoint bleedingPHOTODISTRIBUTIONWidespread, flexure aspects of arms and legsScalp, elbow, knees, hands, feet, nails

MANAGEMENTSNummular dermatitisTOPICAL:Topical steroids in the mid- to high-potency range (cream/ointment). Used 2-3 times/day. - 0,05% clobetasol proprionate - 0,1% triamcinolone acetonideCalcineurin inhibitors (cream/ointment). Used 2 times/day.- Tacrolimus 0,03% children, 0.1% adult- Pimecrolimus 1% Tar preparations 2-5%Emollients xerosis.SYSTEMICOral corticosteroid is given in severe cases. Oral antihistamines if pruritus is severe. - Hydroxizine 75 -100 mg/day - Citirizine 5mg or 10mg per dayOral antibiotics are indicated when secondary infection is present. - Dicloxacillin 500 mg every 6 hours

For widespread involvement, phototherapy with broad-or narrow-band ultraviolet B may be beneficial

NEURODERMATITIS

Treatment is aimed at interrupting the itchscratch cycle. Systemic causes of itch should be identified and addressed. TOPICALPotent topical steroids as well as nonsteroidal antipruritic preparations such as pramoxine, menthol, or phenol.Emollients are an important adjunct.Topical tacrolimus also can be applied.

SYSTEMIC

Intralesional steroids, such as triamcinolone acetonide, given in varying concentrations according to the thickness of the plaque.

Sedating antihistamines, such as hydroxyzine, or tricyclic antidepressants, such as doxepin, may be used to abolish night time itch.

Selective serotonin reuptake inhibitors (SSRIs) have been recommended for relief of day time pruritus.

PROGNOSISNummular dermatitis usually chronic. Recurrence at prior sites of involvement is a feature of the disease.

Neurodermatitis run a chronic course with persistence or recurrence of lesions. Exacerbations occur in response to emotional stress.