Eczema...Eczema Investigations 1. measure the total IgE level 2. Secondary infection can be confirmed by taking swabs for culture and sensitivity 3. When dermatophyte infection is

Eczema

Dr Shawana Sharif

Dermatology department BBH

Eczema

Eczema means to boil, is a clinical and histological pattern of inflammation of the skin

seen in a variety of dermatoses with widely diverse aetiologies

all eczema is dermatitis, but not all dermatitis is eczema.

There remain cases of eczema that do not fit any of the described patterns. These are not

uncommon and have been termed ‘unclassified eczema’. These patients may have a

poor prognosis, with a tendency for the disease to become chronic.

Eczema

Eczema

Exogenous eczemas

• Allergic contact eczema• Dermatophytid• Eczematous polymorphic light eruption• Infective dermatitis• Irritant eczema• Photoallergic contact eczema• Post‐traumatic eczema

Endogenous eczemas

• Asteatotic eczema• Atopic eczema • Chronic superficial scaly dermatitis• Eyelid eczema• Hand eczema• Juvenile plantar dermatosis• Nummular dermatitis• Pityriasis alba• Metabolic eczema or eczema associated with systemic disease• Seborrhoeic eczema• Venous eczema

Eczema

Age and Sex

Most cases of eczema in infants and young children are atopic.

Pompholyx and atopic eczema are less common in elderly people.

Nummular dermatitis occurs particularly in elderly males in winter.

Eczema

Pathophysiology

The interaction of trigger factors, keratinocytes and T lymphocytes seems particularly

important in most eczema types.

Three predominant processes occurring in irritant dermatitis are disturbed barrier function,

epidermal cell change and release of inflammatory mediators and cytokines.

Certain irritants may provoke a chronic reaction in which an effect on epidermal cell

turnover predominates, leading to lichenification; whereas in acute irritant reactions

inflammatory mediators cytokine release is similar to that seen in acute allergic contact

dermatitis

Both intracellular and intercellular oedema are visible throughout the epidermis at 3–6 h,

and within 24 h there may be epidermal necrosis, with cellular vacuolation and nuclear

pyknosis. In severe forms, the primary epidermal damage may progress to subepidermal

blister formation.

mutations of the fillaggrin gene.

Eczema

Presentation

Acute eczema presents as an eruption that is typically oedematous, vesicular and may be

exudative.

Chronic eczema, these features give way to a more stable picture of erythema, scaling,

excoriation and lichenification.

Eczema

Secondary Dissemination

A characteristic feature of eczematous inflammation is its tendency to spread far from its

point of origin and to become generalized. This phenomenon is often termed

autosensitization or, more specifically, autoeczematization.

Eczema

Complications and co‐morbidities

A reduction in skin barrier function increases the risk of both bacterial and viral secondary skin

infection.

Prognosis

Eczema tends to follow a chronic relapsing remitting course.

Eczema

Investigations

1. measure the total IgE level

2. Secondary infection can be confirmed by taking swabs for culture and sensitivity

3. When dermatophyte infection is suspected, a potassium hydroxide preparation

4. Microscopy, or dermoscopic examination of the skin

5. Biopsy

6. immunofluorescence can help identify less common conditions such as dermatitisherpetiformis

7. Patch testing in eczema - important in atypical or asymmetrical eruptions, and especiallyin dermatitis affecting the face, hands and feet.

Eczema

Treatment

First line

• Avoidance of irritants and allergens, emollients and soap substitutes

Second line

• Topical corticosteroids and topical calcineurin inhibitors

Third line

• Phototherapy, oral immunosuppressants and steroids

Seborrheic dermatitis

Nummular dermatitis

Definition and nomenclature

Nummular dermatitis is characterized by a single, non‐specific morphological feature, namely

circular or oval plaques of eczema with a clearly demarcated edge.

Synonyms

• Discoid eczema

• Nummular eczema

Nummular dermatitis

Nummular dermatitis

Age

women in early adulthood

Men in the older age groups.

Associated diseases

Atopy

Nummular dermatitis

Environmental factors

1. underlying allergic contact dermatitis, reacting to rubber chemicals, formaldehyde,

neomycin, chrome and nickel .

2. excessive alcohol intake

3. Nummular dermatitis has occurred rarely as a result of sensitivity to aloe, depilating creams

and mercury, and in patients taking methyldopa. In addition, oral gold therapy.

Nummular dermatitis

Presentation

The diagnostic lesion of nummular dermatitis is a coin‐shaped plaque of closely set,

thin‐walled vesicles on an erythematous base.

This arises, quite rapidly, from the confluence of tiny papules and papulovesicles. These

may occur, in the phase of very acute dissemination, as individual lesions on the trunk or

limbs at the same time as localized plaques are being formed.

In the acute phase the lesions are dull red, very exudative or crusted and highly pruritic.

They progress towards a less vesicular and more scaly stage, often with central clearing,and peripheral extension, causing ring‐shaped or annular lesions.

As they fade, they leave dry, scaly patches. After any period of between 10 days andseveral months, secondary lesions occur, often in a mirror‐image configuration on the

opposite side of the body.

Asteatotic eczema

Definition

This is eczema developing in very dry skin, usually in the elderly.

Synonyms

• Eczéma craquelé

• Winter eczema

Asteatotic eczema

Asteatotic eczema

Presentation

The condition occurs particularly on the legs, arms and hands. The asteatotic skin is dry andslightly scaly. The surface of the backs of the hands is marked in a criss‐cross fashion. The fi

nger pulps are dry and cracked, producing distorted prints and retaining a prolonged

depression after pressure (‘parchment pulps’). On the legs the pattern of superficial markingsis more marked and deeper (‘crazy‐paving’ pattern or eczéma craquelé).

Asteatotic eczema

Environmental factors

1. central heating

2. cold, dry winter

3. Drugs – Diuretics, Cimetidine, topical corticosteroids.

Associated diseases

1. Myxoedema

2. zinc deficiency

Asteatotic eczema

Predisposing factors

At present, the relevant factors in the production of asteatotic eczema can be considered to be:

(i) a naturally ‘dry’ skin and a lifelong tendency to chapping;

(ii) a further reduction in lipid with age, illness, malnutrition or hormonal decline;

(iii) increased transpiration relative to the environmental water content;

(iv) loss of integrity of the water reservoir of the horny layer;

(v) chapping and degreasing by industrial or domestic cleansers or solvents;

(vi) low environmental humidity and dry, cold winds increasing convection loss; and

(vii) repeated minor trauma leading to inflammation and further disorganization of the surfaceaqueous/lipid balance.

Dermatitis and eczema of the hands

Hand eczema: aetiological possibilities to be considered

Exogenous

• Contact irritants:

• Chemical (e.g. soap, detergents, solvents)

• Physical (e.g. friction, minor trauma, cold dry air)

• Contact allergens:

• Delayed hypersensitivity (type IV) (e.g. chromium,

rubber)

• Immediate hypersensitivity (type I) (e.g. seafood)

• Ingested allergens (e.g. drugs, possibly nickel,

chromium)

• Infection (e.g. following bacterial infection of hand

wounds)

• Secondary dissemination (e.g. dermatophytide reaction to tineapedis)

Endogenous

• Idiopathic (e.g. discoid,

hyperkeratotic palmar eczema)

• Immunological or metabolic

defect (e.g. atopic)

• Psychosomatic: stress aggravates,

but may not be causative

• Dyshidrosis: increased sweating

aggravates, but may not beCausative


Morphological patterns of hand eczema

Apron eczema

Chronic acral dermatitis

Nummular dermatitis (discoid eczema)

Fingertip eczema

‘Gut’ eczema

Hyperkeratotic palmar eczema

Pompholyx

Recurrent focal palmar peeling

Ring eczema

‘Wear and tear’ dermatitis (dry palmar eczema)

Other patterns (e.g. patchy vesiculosquamous)





Clinical variants

Hyperkeratotic palmar eczema.

Pompholyx. - Pompholyx is a form of eczema of the palms and soles in which oedema fluidaccumulates to form visible vesicles or bullae.

Apron eczema - This condition is a type of hand eczema that involves the proximal palmar aspect of

two or more adjacent fingers and the contiguous palmar skin over the metacarpophalangeal joints,

thus resembling an apron.

Chronic acral dermatitis- This is a distinctive syndrome affecting patients in middle age. A chronic,

intensely pruritic, hyperkeratotic, papulovesicular eczema of the hands and feet, is associated with

grossly elevated IgE levels in subjects with no personal or family history of atopy. The condition

responds to oral corticosteroids,but the response to topical therapy is poor.


Nummular dermatitis.

Fingertip eczema - Two patterns may be distinguished. The first and most common involves most or all

of the fingers, mainly those of the dominant hand, and particularly the thumb and forefinger. The

condition is usually worse in the winter and generally improves on holiday. Fingertip eczema is usually

a cumulative irritant dermatitis in which degreasing agents combine with trauma as causative

factors; patch tests are typically negative or not relevant. The second pattern involves preferentially

the thumb, forefinger and third finger of one hand. This is usually occupational and may be either

irritant (e.g. in newspaper delivery employees) or allergic (e.g. to colophony in polish). The condition

usually involves the dominant hand, but there may be allergy to onions, garlic and other kitchenproducts held in the non‐dominant hand when being cut. In these cases, patch testing and 20 min

contact tests) may be rewarding.


Clinical variants

‘Gut’/slaughterhouse eczema. Workers who eviscerate and clean pig carcasses are at risk of

developing vesicular eczema which starts in the fi nger webs and spreads to the sides of the fingers.This is a mild, self‐limiting condition, which clears in a week or two, even if the patient remains at work,

but it can recur at intervals.

Patchy vesiculosquamous eczema. In a large group of cases, a mixture of irregular, patchy,vesiculosquamous lesions occur on both hands, usually asymmetrically. In contrast to the lesions of

discoid hand eczema, the degree of activity and distribution of the lesions vary. Nail changes are

common if the nail folds are affected.


Clinical variants

Recurrent focal palmar peeling.- keratolysis exfoliative

Ring eczema - This characteristic pattern particularly affects young women, rarely men. The conditionusually starts soon after marriage or childbirth. An irritable patch of eczema begins under a ring –

usually a broad wedding ring


Prognosis

Atopic hand eczema probably has the worst prognosis of all types of hand eczema

eczema on the dorsa of the hands clears more readily, and is less likely to recur than palmar

eczema.

Pompholyx, - about one‐third of patients experience no further episodes, one‐third suffer from

recurrent episodes and in the remainder the condition develops into a chronic, possibly

hyperkeratotic phase.

Investigations

scrapings should be examined for fungus

patch testing


Treatment ladder

First line

Hand care advice

Irritant and allergen avoidance

Emollients

Soap substitute

Second line

Potent or very potent topical corticosteroids

Third line

Alitretinoin/PUVA/azathioprine/ciclosporin/methotrexate

Dermatitis and eczema of the lower legs

Definition

1. venous eczema,

2. stasis dermatitis

3. allergic contact dermatitis.

Lower limb venous eczema encompasses the skin changes that result from venous hypertension.

Stasis dermatitis relates to the skin changes that result from reduced lower leg venous fl ow.



Age

Middle age or Elders

Sex

Females due to

1. Hormonal Effects

2. DVT

Predisposing factors

1. previous DVT

2. Obesity

3. Immobility

4. previous cellulitis


Causative organisms

Staphylococcus and

Streptococcus

Presentation

Venous eczema and stasis dermatitis are both erythematous, scaly and often exudative eruptions

usually seen around the ankle and lower leg.

Occasionally, similar changes occur at other sites of venous hypertension such as the pendulous skin

over an obese abdomen or in association with an arteriovenous fistula in the upper limb.

The eczema is often accompanied by other manifestations of venous hypertension, including

dilatation or varicosity of the superficial veins, oedema, purpura, haemosiderosis and ulceration or

small patches of white, atrophic, telangiectatic scarring (‘atrophie blanche’)

.Leashes of dilated venules around the dorsum of the foot or ankle are particularly common.


Treatment ladder

First line

Skin care, including leg elevation, emollients and topical corticosteroids

Second line

Compression hosiery

Third line

Referral to vascular surgeon to consider surgical intervention

Juvenile plantar dermatosis

Definition

This condition is characterized by shiny, dry, fissured dermatitis of the plantar surface of the forefoot.

Synonyms

Forefoot eczema

Peridigital dermatosis

Dermatitis plantaris sicca

Atopic winter feet


Age

3-14 Years

Sex

Male Children

Associated Diseases

Atopy

Pathophysiology

Mild Non-specific Eczema

Blockage of Sweat Glands

Environmental Factors

Resulting changes in composition of children socks and shoes due to frictions & sweating



Clinical features

The presenting features of juvenile plantar dermatosis are redness and soreness on the plantar surface

of the forefoot, which assume a shiny, ‘glazed’ and cracked appearance. The condition is mostsevere on the ball of the foot and toe pads, and tends to spare the non‐weight‐bearing instep. The

toe clefts are normal and this helps to distinguish the condition from tinea pedis. The symmetry of the

lesions is a striking feature.

Investigations

Clinical

Skin Scraping

Patch test


Treatment ladder

First line

Change to leather footwear and cotton socks/open sandals

Second line

Emollients, including urea‐containing preparations

Third line

Lassar’s paste/tar/tacrolimus ointment

Pityriasis alba

Definition

This is a pattern of dermatitis in which hypopigmentation is the most conspicuous feature. Some

erythema and scaling usually precede the development of hypopigmentation but these are often

relatively mild.

Age

Children 3-16 years

Sex

Equal

Associated Diseases

Atopic Eczema

Pityriasis alba

Pityriasis alba

Clinical Features

The individual lesion is a rounded, oval or irregular hypopigmented patch that is usually not wellmarginated. Lesions are often slightly erythematous and have fine scaling.

There are usually several patches ranging from 0.5 to 2 cm in diameter, but they may be larger,especially on the trunk. In children the lesions are often confined to the face, and are mostcommon on the cheeks and around the mouth and chin. In 20% of affected children the neck,arms and shoulders are involved as well as the face.

Differential Diagnosis

Vitiligo

Naevus depigmentosus

Nummular dermatitis

Psoriasis

Mycosis fungoides

Pityriasis alba

Prognosis

The course is extremely variable. Most cases persist for some months, and some may still show

hypopigmentation for a year or more after all scaling subsides. Recurrent crops of new lesions may

develop at intervals. The average duration of the common facial form in childhood is a year or more.

Treatment ladder

First line

Emollient

Second line

Mild topical corticosteroids

Third line

Topical tacrolimus or pimecrolimus

Chronic superficial scaly dermatitis

Definition

This is a chronic condition characterized by the presence of round or oval erythematous, slightly scaly

patches on the limbs and trunk, which histologically show mild eczematous changes with little or no

dermal infiltrate.

Synonyms and inclusions

Digitate dermatosis

Persistent superfificial dermatitis

Small plaque parapsoriasis



Age

Middle Age

Sex

Men

Ethnicity

All

Pathophysiology

Unknown

Differential Diagnosis

Nummular Dermatitis

Poikiloderma

Ecezematides

Mycosis-fungoides


Prelymphomatous eruption Chronic superficial scaly dermatitis

Bizarre or angulated shape Regular, round or oval shape

Fine scale Coarser scale

May be irritable Little or no irritation

Progresses to cutaneous lymphoma Does not become malignant

Histology

Absence of epidermal eczema May be eczematous changes

Dermal infiltrate Little or no dermal infi ltrate


Prognosis

The patches are more prominent in winter than in summer, and may clear temporarily with

natural or artificial sunlight. They will also clear for a time with suitable topical medications but

recur in the same, or adjacent, areas when treatment is stopped. After extending they then

usually remain static and, with minor fluctuations, persist throughout life. In a few patients the

condition clears permanently.


Treatment ladder

First line

Emollient

Second line

Mild topical corticosteroids

Third line

Phototherapy (narrow‐band UVB/PUVA)

EXOGENOUS ECZEMAS

Contact Dermatitis

• The generic term applied to acute and chronic

inflammatory reactions to substances that come in

contact with the skin

Types of Contact Dermatitis

Irritant Contact Dermatitis

• An inflammatory reaction in the skin resulting from exposure to a substance that causes an eruption in most people who come in contact with it

although inflammatory and immunological mediators may be

activated, no antigen-specific reaction is involved

no previous exposure to the irritant is necessary

Allergic Contact Dermatitis

• An acquired delayed sensitivity to various substances that produce inflammatory reactions in only those who have been previously sensitized to the allergen

CONTACT DERMATITIS

Irritant contact dermatitis

Non immunological

caused by a chemical irritant

Allergic contact dermatitis

Immunological

caused by an antigen (allergen) that elicits a type IV(cell-

mediated or delayed) hypersensitivity reaction.

Photoallergic contact dermatitis

Exposure to sunlight required to elicit contact dermatitis

substances are transformed into irritants or sensitizers

(photosensitizers) after irradiation with UV

Phytophotodermatitis

Allergic contact dermatitis associated with plants

Differences between direct irritant and

allergic contact dermatitis Direct irritant Allergic contact

Prevalence Very common Much less common

Prior exposure

to substance Not required Essential

Affected sites Sites of direct contact Sites of contact

with little extension and distant sites

Susceptibility Everyone susceptible Only some patients susceptible

Timing Rapid onset 4~12 hours Onset generally 24 h

after contact or longer after exposure

Lesions develop at first No lesions on first

exposure exposure

DIFFERENCES BETWEEN IRRITANT AND ALLERGICCONTACT DERMATITIS

IRRITANT ALLERGIC


Erythema at contact sites


erythema、edema


Erythema 、papules at contact sites


Erythema and edema

at contact site


Erythema and papules at contact site

Red patch and scales

at contact sites



Red patch

at contact sites

Erythema and edema、blister and oozing

at contact sites



Erythema and edema at contact sites


erythema、blister and bulla at contact sites

Allergic contact dermatitis of

ear and neck: neomycin

Allergic contact dermatitis of

wrist: nickel

Allergic phytodermatitis of

leg: poison ivy

Linear vesicular lesions with erythema

and edema on the calf at sites of direct

contact of the skin 5 days after exposure

with the poison ivy leaf.

Allergic phytodermatitis of

face: poison ivy

Infective dermatitis

Infected eczema. Infected eczema shows erythema, exudation and crusting. The exudation may

be profuse, generating crusting, or slight, with the accumulation of layers of somewhat greasy,

moist scale, beneath which the surface is raw and red. The margin is characteristically sharply

defined, and the horny layer is often split to form an encircling collarette. There may be small

pustules in the advancing edge and, where a flexure is involved, it is often the site of a deep and

persistent fissure.


Infective eczema. Infective eczema usually presents as an area of advancing erythema,

sometimes with microvesicles. It is seen predominantly around discharging wounds or ulcers, or

moist skin lesions of other types. Infective dermatitis is relatively common in patients with venous

leg ulcers, but care must be taken to distinguish it from contact dermatitis due to the application

of topical medicaments.

chronic threadworm infestation

Pediculosis

Scabies

secondary impetigo

Molluscum- contagiosum



Pathophysiology

Bacterial antigens can promote a cytotoxic reaction in the skin, but this is perhaps more likely to

aggravate or perpetuate than to initiate the eczematous process. Bacterial superantigens such as

staphylococcal protein A and enterotoxin B may be profound immune stimulants and may

aggravate atopic eczema.

Eczematous reactions can occur as an allergic reaction to a fungal infection elsewhere in the skin.


Treatment ladder

First line

Treat primary cause (e.g. ulcer) or modify footwear if relevant

Second line

Topical antibiotics (for mild presentations)

Third line

Systemic antibiotics (also potassium permanganate soaks for forefeet variant)

THANKS

Documents

Eczema...Eczema Investigations 1. measure the total IgE level 2. Secondary infection can be confirmed by taking swabs for culture and sensitivity 3. When dermatophyte infection is