eczemaeczema

EczemaEczema: Come from the Greek name : Come from the Greek name for boiling, a reference to the tiny for boiling, a reference to the tiny vesicles (bubbles) that are commonly vesicles (bubbles) that are commonly seen in the early acute stage of the seen in the early acute stage of the diseasedisease

DermatitisDermatitis: means inflammation of : means inflammation of skin, it’s a broader term than eczema skin, it’s a broader term than eczema which is only a type of several skin which is only a type of several skin inflammationsinflammations

Eczema classificationEczema classification Mainly by exogenous irritantMainly by exogenous irritantFactors (contact) allergicFactors (contact) allergic photodermatitisphotodermatitis

Other types atopicOther types atopic seborrhoeicseborrhoeic discoid (nummular)discoid (nummular) pompholyxpompholyx gravitationalgravitational asteatoticasteatotic neurodermatitisneurodermatitis juvenile plantar juvenile plantar

dermatosisdermatosis napkin dermatitisnapkin dermatitis

pathogenesispathogenesis Similar in all types involving similar Similar in all types involving similar

inflammatory mediators (prostaglandins, inflammatory mediators (prostaglandins, leukotriens, cytokines)leukotriens, cytokines)

Helper T cells sometimes activated by Helper T cells sometimes activated by superantigens from superantigens from StaphStaph. . aureus aureus

Epidermal cytokinesEpidermal cytokines help to produce help to produce spongiosis & that their secretion by spongiosis & that their secretion by keratinocytes elicited by T lymphocytes, keratinocytes elicited by T lymphocytes, irritants, bacterial products, & other irritants, bacterial products, & other stimulistimuli

histologyhistology Acute stage:Acute stage: spongiosisspongiosis intraepidermal vesicles & blistersintraepidermal vesicles & blisters Chronic stage:Chronic stage: less spongiosis & vesication less spongiosis & vesication acanthosisacanthosis hyperkeratosis & parakeratosishyperkeratosis & parakeratosis

These changes accompanied by various These changes accompanied by various degree of vasodiletation & lymphocyte degree of vasodiletation & lymphocyte infiltration infiltration

Clinical appearanceClinical appearance

Acute eczema:Acute eczema:

weeping & crustingweeping & crusting

blistering with vesicles blistering with vesicles

redness, papules, swelling redness, papules, swelling

scalingscaling

Chronic eczemaChronic eczema::

less vesicular & exudationless vesicular & exudation

more scaly, pigmented, thickenedmore scaly, pigmented, thickened

lichenificationlichenification

fissuresfissures

complicationcomplication Heavy bacterial colonization esp. in Heavy bacterial colonization esp. in

seborrhoeic, atopic, nummularseborrhoeic, atopic, nummular

Local superimposed allergic reaction to Local superimposed allergic reaction to medicaments can provoke disseminationmedicaments can provoke dissemination

Interfere with sleepInterfere with sleep

Interfere with workInterfere with work

Interfere with sporting, activiteisInterfere with sporting, activiteis

DDXDDX Psoriasis:Psoriasis: sharply marginated, very sharply marginated, very

scaly, involve knee & elbowscaly, involve knee & elbow

Scabies:Scabies: itchy contacts, face spared, itchy contacts, face spared, burrows, affect nipple & genitaliaburrows, affect nipple & genitalia

Lichen planus:Lichen planus: mouth lesion, mouth lesion, violaceous flat topped papulesviolaceous flat topped papules

Fungal infection:Fungal infection: annular lesions with annular lesions with active edgeactive edge

Palmoplantar pustulosis:Palmoplantar pustulosis: obvious obvious pastules on palm & solepastules on palm & sole

Angiodema & erysipelas:Angiodema & erysipelas: Unusually Unusually swollen, on faceswollen, on face

investigationsinvestigations

Patch testPatch test

Photopatch testPhotopatch test

Total & specific IgE antibodiesTotal & specific IgE antibodies

RASTRAST

tratmenttratment acute weeping eczema: acute weeping eczema: rest & liquid applicationrest & liquid application

Nonsteroidal preparationNonsteroidal preparation

Daily 10 min soaks in cool 0.65% Daily 10 min soaks in cool 0.65% aluminium acetate solution aluminium acetate solution

Saline or tap water & soaks followed by a Saline or tap water & soaks followed by a smear of corticosteroid cream or lotionsmear of corticosteroid cream or lotion

potassium permanganatepotassium permanganate

Calamine lotionCalamine lotion

Magenta paintMagenta paint

Wet wrap dressing: esp. in children a Wet wrap dressing: esp. in children a bath followed by steroid application bath followed by steroid application covered with double layers of tubular covered with double layers of tubular dressingdressing

Subacute eczema:Subacute eczema:

steroid lotions or creamssteroid lotions or creams

Vioforms, bacitracinVioforms, bacitracin

fucidic acid, mupirocin, neomycinfucidic acid, mupirocin, neomycin

Chronic eczema:Chronic eczema:

steroid in ointment basesteroid in ointment base

IcthamoleIcthamole

Zinc cream or pasteZinc cream or paste

nothing stronger than 0.5-1% nothing stronger than 0.5-1% hydrocortisone oint. On face or in hydrocortisone oint. On face or in anfantsanfants

mild potency c.s. not more than mild potency c.s. not more than 200g/wk200g/wk

Moderate potency c.s. not more than Moderate potency c.s. not more than 50g/wk50g/wk

Potent c.s. not more than 30g/wkPotent c.s. not more than 30g/wk

Systemic therapySystemic therapy systemic steroid (prednisolone)systemic steroid (prednisolone)

HydroxyzineHydroxyzine

DoxepinDoxepin

TrimeprazineTrimeprazine

Systemic antibioticsSystemic antibiotics

Common patterns of Common patterns of eczemaeczema

Irritant contact dermatitisIrritant contact dermatitis 80% of dermatitis cases80% of dermatitis cases

Mostly industrialMostly industrial

Usually on hands & forearmUsually on hands & forearm

Acute reaction elicited after brief contactAcute reaction elicited after brief contact

Commonly by detergents, alkalis, Commonly by detergents, alkalis, solventssolvents

May lead to loss of workMay lead to loss of work

DDX: allergic contact dermatitis, DDX: allergic contact dermatitis, atopyatopy

Patch test with irritants is not helpful Patch test with irritants is not helpful & may be misleading& may be misleading

Rx: avoid irritants, use protective Rx: avoid irritants, use protective measures, barrier creams, topical measures, barrier creams, topical steroids & emollients, change of jobsteroids & emollients, change of job

Allergic contact dermatitisAllergic contact dermatitis The mechanism is delayed type 4 The mechanism is delayed type 4

hypersensetivity hypersensetivity

Previous contact is neededPrevious contact is needed

Its specific to one chemical usuallyIts specific to one chemical usually

Remote areas may be affectedRemote areas may be affected

Sensetization is persists indefinitelySensetization is persists indefinitely

Most allergens are simple chemicals that Most allergens are simple chemicals that bind to a protein to become complete bind to a protein to become complete antigenantigen

Areas involved eyelids, external auditory Areas involved eyelids, external auditory meatus, hands & feetmeatus, hands & feet

High risk individuals are hair dressing, High risk individuals are hair dressing, working in flower shop, dentistyworking in flower shop, dentisty

Common allergens: chrome, nickle, cobalt, Common allergens: chrome, nickle, cobalt, lanolin, neomycin, rubber, poison ivy & lanolin, neomycin, rubber, poison ivy & oak oak

Jewellery, bra clips, jeans stud are Jewellery, bra clips, jeans stud are common causescommon causes

Patch test is recommendedPatch test is recommended

Rx: avoid allergens, topical steroid, Rx: avoid allergens, topical steroid, adding ferrous sulphate to cement to adding ferrous sulphate to cement to reduce its water soluble chromate reduce its water soluble chromate contentcontent

atopyatopy Means without place in greekMeans without place in greek

Is a state in which exuberant production of Is a state in which exuberant production of IgE occurs as a response to common IgE occurs as a response to common environmental allergensenvironmental allergens

Atopic patient develop one or more of Atopic patient develop one or more of atopic diseases as asthma, aczema, hay atopic diseases as asthma, aczema, hay fever, & food allergiesfever, & food allergies

Concordance rate in monozygotic twins is Concordance rate in monozygotic twins is 86%, in dizygotic is 21%86%, in dizygotic is 21%

75% begin before 6 months, 80-90% 75% begin before 6 months, 80-90% before 5 years, totally affect 3% of before 5 years, totally affect 3% of infantsinfants

60-70% will clear by their early teens60-70% will clear by their early teens

It has 3 phaces:It has 3 phaces:

1.1. Infantile: vesicular, weeping, start at faceInfantile: vesicular, weeping, start at face

2.2. Childhood: leathery, dry, excoriated, Childhood: leathery, dry, excoriated, affects elbow, knee flexures, wrist ankleaffects elbow, knee flexures, wrist ankle

3.3. Adults: lichenification, more wide spread, Adults: lichenification, more wide spread, white dermographism is strikingwhite dermographism is striking

Cardinal feature is itchingCardinal feature is itching Diagnostic criteria:Diagnostic criteria:

Must haveMust have::

chronically itchy skinchronically itchy skin

plus 3 or more of the followingplus 3 or more of the following::

history of itching in skin creaseshistory of itching in skin creases

history of asthma or hay feverhistory of asthma or hay fever

general dry skingeneral dry skin

visible flexural eczemavisible flexural eczema

onset in first 2 years of lifeonset in first 2 years of life

Complications: bacterial infections, Complications: bacterial infections, widespread Herpes simplex, M. widespread Herpes simplex, M. contagiosumcontagiosum

Prick test used to show type 1 reactionPrick test used to show type 1 reaction

Rx: explanation, reassurance, aviod Rx: explanation, reassurance, aviod exacerbating factors, topical steroids, exacerbating factors, topical steroids, tacrolimus, sedative antihistamines, tacrolimus, sedative antihistamines, antibiotics, UVA, UVB, cyclosporinantibiotics, UVA, UVB, cyclosporin

Seborroeic dermatitisSeborroeic dermatitis common eczema of the hairy areas show common eczema of the hairy areas show

characteristic greasy yellowish scalescharacteristic greasy yellowish scales

Red scaly exudative or dry scaly or Red scaly exudative or dry scaly or intertriginousintertriginous

Affects scalp, ears, eyebrows, face, Affects scalp, ears, eyebrows, face, presternal area, armpits, umblicus, groinpresternal area, armpits, umblicus, groin

May be familial, affect those with dandruffMay be familial, affect those with dandruff

there may be overgrowth of of there may be overgrowth of of pityrosporum yeasts pityrosporum yeasts

May be early sign of AIDSMay be early sign of AIDS

Mainly affect adults, usually recurrentMainly affect adults, usually recurrent

May associated with furunculosis, or May associated with furunculosis, or superadded candida infectionsuperadded candida infection

Rx: topical imidazole, sulphur, salicylic Rx: topical imidazole, sulphur, salicylic acid, topical steroids, ketoconazole acid, topical steroids, ketoconazole shampooshampoo

Discoid (nummular ) eczemaDiscoid (nummular ) eczema Common endogenous eczemaCommon endogenous eczema

Affects limbs of middle age malesAffects limbs of middle age males

Reaction to bacterial antigen is Reaction to bacterial antigen is suspectedsuspected

Multiple coin shaped vesicular Multiple coin shaped vesicular crusted itchy plaquescrusted itchy plaques

Rx: topical steroid & antibioticsRx: topical steroid & antibiotics

pompholyxpompholyx Recurrent bouts of vesicles or blisters on Recurrent bouts of vesicles or blisters on

palms, fingers & or sole of adultspalms, fingers & or sole of adults

Cause is unknown,may provoke by stress Cause is unknown,may provoke by stress or heat or may be allergy to nickleor heat or may be allergy to nickle

Recurrent infection & lymphangitis is a Recurrent infection & lymphangitis is a recurrent problem, it may follow acute recurrent problem, it may follow acute Tinea pedisTinea pedis

Rx: antibiotics, aluminium acetate, Rx: antibiotics, aluminium acetate, potassium permanganate, steroidspotassium permanganate, steroids

Gravitational (stasis) eczemaGravitational (stasis) eczema Usually accompanied by venous Usually accompanied by venous

insufficiency, haemosidrin depositioninsufficiency, haemosidrin deposition

Chronic patches of eczema on lower legsChronic patches of eczema on lower legs

Patient may become sensetized to local Patient may become sensetized to local antibiotics or to preservatives in antibiotics or to preservatives in medicated bandagesmedicated bandages

Rx: eliminate oedema, topical steroids, Rx: eliminate oedema, topical steroids, zinc creamzinc cream

Asteatotic eczemaAsteatotic eczema Itchy eczema patches on lower legs Itchy eczema patches on lower legs

of eldrlyof eldrly

Contributory factors: Dry skin in old, Contributory factors: Dry skin in old, low humidity in winter, cental low humidity in winter, cental heating, diuretics, hypothyroidismheating, diuretics, hypothyroidism

Rx: steroids, restrict bathing, daily Rx: steroids, restrict bathing, daily use of emollientsuse of emollients

Localized neurodermatitis Localized neurodermatitis (lichen simplex)(lichen simplex)

Single fixed itchy lichenified plaque Single fixed itchy lichenified plaque on nape of neck in women, legs in on nape of neck in women, legs in men & anogenital area in both sexesmen & anogenital area in both sexes

Skin damaged from repeated rubbing Skin damaged from repeated rubbing or scratching as a habit in response or scratching as a habit in response to stressto stress

Rx: topical steroid with occlusion, Rx: topical steroid with occlusion, tranquilizers are with little effecttranquilizers are with little effect

Juvenile plantar dermatosisJuvenile plantar dermatosis May be related to modern socks & shoe May be related to modern socks & shoe

lining withsubsequent sweat gland lining withsubsequent sweat gland blockageblockage

Called toxic sock syndromeCalled toxic sock syndrome

Forefeet & undersides of toes become dry Forefeet & undersides of toes become dry shiny with deep painful fissures shiny with deep painful fissures

Rx: use of cork insole in shoes, cotton or Rx: use of cork insole in shoes, cotton or wool socks, emmolients, icthammol, wool socks, emmolients, icthammol, steroidsteroid

Napkin (diaper) dermatitisNapkin (diaper) dermatitis Irritant in nature aggravated by Irritant in nature aggravated by

waterproof plastic pants, feces, urinewaterproof plastic pants, feces, urine

Moist glazed sore erythema of napkin Moist glazed sore erythema of napkin area sparing skin folds (which diff. it area sparing skin folds (which diff. it from seborrhoeic eczema)from seborrhoeic eczema)

Candida superinfection is common Candida superinfection is common appears as erythematous appears as erythematous vesicopustules on peripheryvesicopustules on periphery

Rx: keep this area clean & dry, use Rx: keep this area clean & dry, use disposal diapers, topical zinc, caster disposal diapers, topical zinc, caster oil, silicone, mild steroid-antifungal oil, silicone, mild steroid-antifungal combination combination

The child should be allowed to be The child should be allowed to be free of napkins as much as possiblefree of napkins as much as possible