EczemasEczemas

MUDr. Nina BenákováMUDr. Nina BenákováDermatovenerologická klinika 1. LF UKDermatovenerologická klinika 1. LF UK

Eczemas - definitionEczemas - definition

eczema eczema ~~ dermatitis dermatitis

eczemaeczema = allergic= allergic chronical coursechronical coursedermatitisdermatitis = non allergic = non allergic acute courseacute course

dermatitis = more general termdermatitis = more general term

superficial noninfectious skin superficial noninfectious skin inflammationinflammation

irritative and/or allergic ethiologyirritative and/or allergic ethiologydisposition + exogenous and disposition + exogenous and

endogenous factors endogenous factors

Eczemas - characteristicsEczemas - characteristics

polymorphous and variable clinical polymorphous and variable clinical picture, characteristic morphologypicture, characteristic morphology

tendency to chronicitytendency to chronicity some dermatitis to generalization and erythrodermasome dermatitis to generalization and erythroderma

most frequent dermatosis most frequent dermatosis and occupational skin diseaseand occupational skin disease

psycho-social-economic consequencespsycho-social-economic consequences

Enviroment and skinEnviroment and skin

Physical

Chemical Biologic

Psychosocial

Reaction types of cutaneous neuroimmune system: irritative, reactive, allergic, atopic

Eczema /Dermatitis

Classification of eczemasClassification of eczemascourse: course: acute-subacute-chronicacute-subacute-chronic

morphology morphology eczema papulosum, vesiculosum, eczema papulosum, vesiculosum, squamosum, squamosum, hyperkeratoticum, rhagadiforme,..hyperkeratoticum, rhagadiforme,..

localization localization eczema faciei, palmoplantare, flexurarumeczema faciei, palmoplantare, flexurarum

ethiologyethiology

contemporary clinical classification = contemporary clinical classification = ethiological - morphologicalethiological - morphological

Eczema/dermatitis overviewEczema/dermatitis overview

Dermatitis contacta irritativaDermatitis contacta irritativa Eczema contactum allergicumEczema contactum allergicum

Eczema microbiale/nummulareEczema microbiale/nummulare Eczema atopicumEczema atopicum Eczema dyshidroticumEczema dyshidroticum

Dermatitis seborrhoicaDermatitis seborrhoica

Stasis dermatitisStasis dermatitis

Dermatitis morphology Dermatitis morphology

Polymorphous picturePolymorphous picture acute:acute: erythema, edema, papules, vesicles erythema, edema, papules, vesicles

- bullas, madidation, crusts- bullas, madidation, crusts chronic:chronic: hyperkeratosis, desquamation, hyperkeratosis, desquamation,

lichenification, rhagadeslichenification, rhagades

acute chronic

Patophysiology of contact dermatitisPatophysiology of contact dermatitisactivated T cells

Th1 a Tc :IL-2, TNFα, INFγ

+ inflammatory cells

damage to keratinocytesIL-1, TNF, GMCSF

- intensity of reaction-apoptosis regeneration

Acute dermatitisspongiosis

↓kohesion keratinocytes→ vesiclesvasodilatation, permeability →edema

DERMIS

Chronic dermatitishyperproliferation→ hyperkeratosis → lichenification

allergen genetics

irritant

→ bulla, nekrosisEPIDERMIS

Dermatitis contacta irritativaDermatitis contacta irritativa

• Acute: Acute: one exposition is sufficient to elicit reactionone exposition is sufficient to elicit reaction

• Chronic:Chronic: cumulative-toxic cumulative-toxic →→ secondary sensitization secondary sensitization →→ eczema from „overused“ skineczema from „overused“ skin

AGENTS:AGENTS:

• ChemicalChemical: water, detergents, alcalies, acids, solvents: water, detergents, alcalies, acids, solvents

• PhysicalPhysical:: heat-frost, radiation, wetness-dryness, rubbing + heat-frost, radiation, wetness-dryness, rubbing + mechanical, incl. aerogenic irritants (airborne): dust, smokemechanical, incl. aerogenic irritants (airborne): dust, smoke

• BiologicBiologic:: microbes, vegetable or animal juices microbes, vegetable or animal juices

Eczema contactum allergicumEczema contactum allergicum• 1-10 % population1-10 % population• ethiology – contact allergensethiology – contact allergens• coupled allergy, group (cross-reaction) allergycoupled allergy, group (cross-reaction) allergy• often in occupation - occupational dermatosesoften in occupation - occupational dermatoses• especially hands and faceespecially hands and face

• metalls (Cr, Ni, Co), fragrances, drugs metalls (Cr, Ni, Co), fragrances, drugs (neomycin), rubber (MBT, thiuram), dyes (neomycin), rubber (MBT, thiuram), dyes (PPD), preservatives (parabens, Kathon), (PPD), preservatives (parabens, Kathon), plants (primula), cosmetics (Peru balsam)plants (primula), cosmetics (Peru balsam)

Sensitization and elicitation phase Sensitization and elicitation phase

EpidermisLangerhans cells, Keratinocytes

Lymphatic node

Epidermis –latent contact dermatitis

Langerhans cells,Homing T cells

I. allergen - first contactII. allergen contact after sensitization

II.I.

Epidermis –manifest contact d.

cytotoxic effect of T cells + nonspecific inflammationMasto, PMN, Baso, Eosino + mediators

I. allergen presentation to naive T-cells →→ memory T-cells

II. proliferation of specific T-cells =

effector →→ migration to epidermis

Eczema contactum allergicumEczema contactum allergicum

Eczema contactum allergicumEczema contactum allergicum

Jirásková 13

handrails in undergoundhandrails in undergoundrubberrubber

Frequent causes of contact allergyFrequent causes of contact allergy

14

lepidla, plnicí perotužky, zapalovačapod.

oleje na vlasybrilantiny apod .

páska klobouku

brýle

telefonní sluchátko

holicí mýdla a krémy,kolínské vody apod.

šle dezinfekční roztokyna teploměry

hodinky, náramky

tiskařská čerň,tabák, rukavice aj.

podvazky, guma podkolenek

gumové holinky

barevné ponožky, gumové lepidlo a krémy na obuv

zápalky v kapse aj.

Obr. 42. Nejčastější příčiny kontaktního alergického ekzém u u m uže (m im o příčiny profesionální)

líčidla, kosmetika

kožešiny

barevné šaty,svetry

páska do stroje pletací dráty vlna aj.

výplachy, mužem i ženoupoužívané amtikomcepční prostředky

šampony, barviva na vlasy, na řasy a na obočí

brýle

rtěnky, ústní vody a zubní pasty

náhrdelníky

potítka, depilatoria

bokovky podvazkové pásy

hodinky, náramky

krémy, kosmetika,líčidla, lak na nechty

niklované a chromovanépřezky i guma podvazková

depilatoria

gumová lepidla z obuvi,krémy na obuv, přezůvky

lak na nechty

Obr. 43. Nejčastější příčiny kontaktního alergického ekzému ženy (m imo příčiny profesionální)

Location is often clue to detect possible agent

Examining Examining • careful, targeted history careful, targeted history occupation, hobbiesoccupation, hobbies

• patch tests, principle - provocation DHRpatch tests, principle - provocation DHR• standard and special panels/seriesstandard and special panels/series• allergens in testing patches/tapeallergens in testing patches/tape• don´t test in acute stage – false don´t test in acute stage – false

positivitypositivity• readings in 48, 72readings in 48, 72• occupationaloccupational

dermatoses-criteriasdermatoses-criterias

Reactions in patch testsReactions in patch testsReaction+, ++, +++

Allergicdelayed hypersensitivity

Irritativebarrier damage

ManifestationManifestation only disponed individuals all exponed

Time to elicitationTime to elicitation 24 - 48 hours immediately or in 24 hours

MorphologyMorphology evolution polymorphousnot demarcated, spreading

evolution monomorphousdemarcated, not spreading

Reaction intensity Reaction intensity concentration, timeconcentration, time

increases doesn´t play role

decreases plays role

Subjective Subjective symtpomssymtpoms

itch burning, pain

DispositionDisposition?, > 3000 cont. allergens

atopy, phototype I, age

Atopic dermatitis ADAtopic dermatitis AD

AtopyAtopy = = disposition disposition 30 - 4030 - 40 % Europe % Europe Atopic dermatitisAtopic dermatitis = 20 % = 20 % Europe Europe 70% AD onsets< 6 yrs, max. in 1-3 yrs of age70% AD onsets< 6 yrs, max. in 1-3 yrs of age ± asthma, allerg. rhinoconjunctivitis± asthma, allerg. rhinoconjunctivitis genetics – positive family history of atopy genetics – positive family history of atopy

(mother)(mother)

hand dermatitis - in 50-60% is of atopic originhand dermatitis - in 50-60% is of atopic origin

Atopic dermatitisAtopic dermatitisG e n e t i c

d i s p o s t i o n

Neuroimmunologic dysbalance

Barrier

dysfunction

M A N I F E S T A T I O N

phenotypic heterogenity

Skin hyperreactivity

Endogenous triggerring factors

Exogenous triggering factors

Charakteristic features of ADCharakteristic features of AD

Clinical picture is varied and variable

1. dermatitis

2. dryness

3. itch

4. chronic course

5. ± positivity of specific IgE („intrinsic“ AD)

6. ↑skin infections: staphylococci, warts, herpes

AD forms

Infants

< 2 yrs

Children

2-12 yrs

Adults

> 12 yrs

White dermographism

Ichthyosiform xerosis

Jirásková 22

Papilomatous conjunctivitis

Jirásková 23

Eczema herpeticatumEczema herpeticatum

Eczema child without sensitization

intrinsic phase

adult sensitized to external allergens

adult sensitized 1/4 to autologous proteins = autoimmunity

Early therapyEarly therapy = reduction of manifest or latent inflammation blocs its fixation, prevents sensitiization, incl. systemic one

Eczema child sensitized < 3 yrs 28%, < puberty 80%

extrinsic phase

Atopic evolution- atopic marchAtopic evolution- atopic march

Eczema microbiale/ nummulareEczema microbiale/ nummulare• alergic reaction to bacteria ? alergic reaction to bacteria ? • X colonization, impetiginizationX colonization, impetiginization

• often in terrain of atopy, contact or varicous often in terrain of atopy, contact or varicous dermatitisdermatitis

• lower leg, periorificial, perifocallower leg, periorificial, perifocal• coin shapedcoin shaped• spreads, id reactions (following irritation)spreads, id reactions (following irritation)• Dif.dg.Dif.dg.: atopic, asteatotic and contact allergic : atopic, asteatotic and contact allergic

dermatitis, mycosis fungoides, neurodermitis, dermatitis, mycosis fungoides, neurodermitis, tinea, para-, psoriasistinea, para-, psoriasis

Eczema microbiale, nummulareEczema microbiale, nummulare

-id reacton

Eczema dyshidroticumEczema dyshidroticum

deep seated vesicles on palms and soles deep seated vesicles on palms and soles - - pompholyxpompholyx, often hyperhidrosis, often hyperhidrosis

• polyethiologic reaction, not an entity :polyethiologic reaction, not an entity : atopic dermatitisatopic dermatitis id reaction (mycid, microbid)id reaction (mycid, microbid) contact dermatitis (alergic, irritative)contact dermatitis (alergic, irritative)drug reactiondrug reaction idiopatic (psychosomatic influences)idiopatic (psychosomatic influences)

Dif. Dg: scabies, lues, TBC-id, tinea, pyodermias, pustular psoriasis, Dif. Dg: scabies, lues, TBC-id, tinea, pyodermias, pustular psoriasis,

palmoplantar pustulosispalmoplantar pustulosis

Eczema dyshidroticumEczema dyshidroticum

Pompholyx

Stasis dermatitis Stasis dermatitis

• secondary in chronic venous incompetency secondary in chronic venous incompetency „„varicous eczema“ - varicous veins need not to be presentvaricous eczema“ - varicous veins need not to be present

• erythema, desquamation, erosions, crustserythema, desquamation, erosions, crusts• preeczematouse terrain preeczematouse terrain contact, microbialcontact, microbial

• Dif.dg.Dif.dg.: contact allergic, nummular, atopic, neurodermitis: contact allergic, nummular, atopic, neurodermitis, tinea, psoriasis,tinea, psoriasis,erysipelas (celullitis), trombophlebits, pressure edema erysipelas (celullitis), trombophlebits, pressure edema dermatitisdermatitis

Dermatitis at lower leg -exsiccative, Dermatitis at lower leg -exsiccative, stasis/microbial, contactstasis/microbial, contact

Dermatitis seborrhoicaDermatitis seborrhoica

• ethiology: ? Pityrosporum orbiculare, ethiology: ? Pityrosporum orbiculare, intercelullar lipids and keratinisation disturbance , intercelullar lipids and keratinisation disturbance , adaptive immunityadaptive immunity

• 5% population seek doctor5% population seek doctor• erythema, greassy, yellowish scaleserythema, greassy, yellowish scales• infants - scalp, intertriginous partsinfants - scalp, intertriginous parts• adults - seborhoeic predilection adults - seborhoeic predilection • seborhoea need not to be present seborhoea need not to be present

infants, atopicsinfants, atopics

atopic dermatitis

seborhoeic dermatitis

Only morphologic-difficult to differentiate

Therapy of eczema- complexTherapy of eczema- complex

1. education 1. education verbal and written verbal and written causes/triggering factors causes/triggering factors elimination – elimination – prophylaxisprophylaxis

2. emolients2. emolients hydratation, barrier renewalhydratation, barrier renewal

3. washing agents3. washing agents antiseptic, emolientantiseptic, emolient

4. corticosteroid 4. corticosteroid

± topical immunomodulator± topical immunomodulator reduction of inflammationreduction of inflammation

5. ± paste5. ± paste (ichthamol, tar) (ichthamol, tar) maintenance, prophylaxismaintenance, prophylaxis

6. ± wet dressing, sprays, medical baths 6. ± wet dressing, sprays, medical baths edema, madidationedema, madidation

7. antiseptic liquid 7. antiseptic liquid erosions, rhagades, erosions, rhagades, impetiginizat.impetiginizat.

8. ± antihistamines (itch in AD 8. ± antihistamines (itch in AD ~ ~ IL-31)IL-31) itch, respiratory atopyitch, respiratory atopy

9. ± phototherapy9. ± phototherapy chronic eczemas - UVBchronic eczemas - UVB

10. ± psychotherapy10. ± psychotherapy

Stepwise therapy of eczemaStepwise therapy of eczema

emolients, prophylaxis X exsiccation, irritation

+ antiseptics, antipruritics + moderate CS and/or TIM

+ moderate to strong CS

Systemic therapy CS, CsA, MTX, alitretinoin

Phototherapy

IV. severe eczema perzistent, chronic

III. moderate

II. mild

I. dry skin

A. Acute – rescue, reliev

B. Chronic - maintenance, stabilization