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WHAT IS ECZEMA?
Dr Diana Purvis
Paediatric Dermatologist
What is eczema?
• Clinical features
• Epidemiology
• Prognosis
• Etiology and pathogenesis
• Immunology
• Skin barrier
Eczema
• From the Greek: ‘to boil over’
Eczema
• From the Greek: ‘to boil over’
• Pruritic papulovesicular dermatitis characterised by
erythema, oedema and a serous exudate in the
epidermis, an inflammatory infiltrate in the dermis, oozing
and vesiculation, and crusting and scaling; and later by
lichenification, thickening, signs of excoriations and
altered pigmentation. • TheFreeDictionary.com
Eczema
• From the Greek: ‘to boil over’
• Pruritic papulovesicular dermatitis characterised by
erythema, oedema and a serous exudate in the
epidermis, an inflammatory infiltrate in the dermis, oozing
and vesiculation, and crusting and scaling; and later by
lichenification, thickening, signs of excoriations and
altered pigmentation. • TheFreeDictionary.com
• “The itch that rashes”
• Itchy skin condition plus three of
• History of involvement of the creases
• Personal history of atopy (or 1st degree relative if <4 years)
• Generally dry skin
• Visible flexural eczema
• Onset under 2 years of age • UK Working Party, BJD 1994
Diagnostic criteria for atopic eczema
Features of eczema
Major features: • Pruritis
• Rash
• face and extensors in infants
• flexural in older children
• Chronic or chronically relapsing
• Personal or family history of other atopic disease
Other common features: • Dryness
• Dennie-Morgan folds
• Allergic shiners
• Facial pallor
• Pityriasis alba
• Keratosis pilaris
• Icthyosis vulgaris
• White dermatographism
• Conjunctivitis
• Keratoconus and cataracts
• Elevated serum IgE
• Skin prick test positivity
Eczema - subtypes
• Eczema / atopic dermatitis
• Seborrhoeic dermatitis
• Discoid, nummular eczema
• Dyshidrotic eczema / pompholyx
• Contact dermatitis
• Varicose eczema
• Asteatotic eczema
Infant Child/adolescent Adult
Prognosis
• Outcome of any individual is difficult to predict
• Spontaneous resolution in 40-60% of infants, especially with mild
disease
• 20% have resolved by adolescence, 65% less severe
• Prevalence is 2 – 3% in adults
• Adults whose childhood eczema has remitted can present with
hand dermatitis
• Poor prognosis:
• Generalised eczema
• Associated asthma and hayfever, high IgE levels
• Family history of troublesome eczema
• Early age of onset
Epidemiology of eczema
• Prevalence of has increased three-fold since 1960s
• 10-20% of children in industrialised countries eg Europe, USA
• 1-3% of adults
• Lower prevalence in agricultural economies eg China, Africa
• Environmental factors seem critical in disease expression
• Risk factors include:
• Small family size
• Increased income and education
• Migration from rural to urban environments
• Increased use of antibiotics
The hygiene hypothesis
• The ‘Western lifestyle’ predisposes to allergic disease
• Lack of early childhood exposure to infectious agents, symbiotic
microorganisms and parasites
• Suppresses the natural development of Th1 predominant
immune response
• Promotes a Th2 dominant or allergic response
• Supported by reduced risk of eczema with:
• owning a pet
• attending daycare
• use of probiotics
The atopic march
How atopic is atopic eczema?
• Up to 50% of hospital eczema patients are not sensitised,
even higher in community settings
• Population attributable risk for allergic sensitisation
causing eczema <50% in affluent countries, as low as
zero in non-affluent countries (ISAAC)
• Genetic risk
• “atopic disease” asthma, eczema, allergic rhinitis do tend to cluster
in families
H Williams, C Flohr J All Clin Imm 2006
Pathogenesis of eczema
Two hypotheses:
1) Inside-out
Immunological disturbance causes IgE-
mediated sensitisation, epithelial barrier
dysfunction is secondary
2) Outside-in
Epidermal barrier dysfunction allows
irritants and allergens into the skin, with
immunological disturbance secondary
Itch
Scratch
Leaky skin barrier
Inflammation
Immune dysfunction
Eczema Soap
Irritants
Infection
Allergens
House dust mite
Cat/dog fur
Itch
Scratch
Leaky skin barrier
Inflammation
Immune dysfunction
Eczema Soap
Irritants
Infection
Allergens
House dust mite
Cat/dog fur
Itch
Scratch
Leaky skin barrier
Inflammation
Immune dysfunction
Eczema Soap
Irritants
Infection
Allergens
House dust mite
Cat/dog fur
The skin as a barrier
The skin as a barrier
The stratum corneum
The skin barrier
• Skin barrier function maintained by:
• Regular desquamation
• Intercellular lipid bilayers
• Natural Moisturising Factors
• Production of antimicrobial peptides
The skin barrier is impaired in eczema
• Genetic defects • Filaggrin gene mutation in 30% of eczema patients
• Filaggrin involved in production of natural moisturising factors
• Other genes affecting stratum corneum function eg SPINK5, loricrin
• Reduced ceramides and water binding
• Decreased sebaceous secretion
• Impaired production of antimicrobial peptides • Defensins and cathelicidins
• Staphylococcus aureus colonisation in 90%
• Increased viral infections
The skin in eczema
1. Irvine et al. J Invest Dermatol 2006; 126: 1200–02. 2. Bieber T. N Engl J Med 2008; 358: 1483–94.
Gene-environment interaction
Genetic
background
Environmental
factors
Skin
barrier
Immune
system
Microbiological
agents (bacteria, virus, etc,)
Stress
Allergens (inhalative, food, contact)
Climate
Irritants
New discovery: filaggrin gene mutation
Itch
Scratch
Leaky skin barrier
Inflammation
Immune dysfunction
Eczema Soap
Irritants
Infection
Allergens
House dust mite
Cat/dog fur
What causes eczema?
Itch
Scratch
Leaky skin barrier
Inflammation
Immune dysfunction
Eczema Soap
Irritants
Infection
Allergens
House dust mite
Cat/dog fur
What causes eczema?
Itch
Scratch
Leaky skin barrier
Inflammation
Immune dysfunction
Eczema Soap
Irritants
Infection
Allergens
House dust mite
Cat/dog fur
What causes eczema?
Triggers
3/26/09 41
Brick => Corneocyte
Mortar => Lipid Lamellae
Cork MJ, Hunter LW & Danby SG; Academic Unit of Dermatology Research, The University of Sheffield.
Brick wall model of
the skin
The Normal Skin Barrier
3/26/09 42 Cork MJ, Hunter LW & Danby SG; Academic Unit of Dermatology Research, The University of Sheffield.
2/10/2015 43
Irritants &
allergens
Cork MJ, Hunter LW & Danby SG; Academic Unit of Dermatology Research, The University of Sheffield.
The skin barrier in atopic dermatitis
3/26/09 44
Broken
mortar
in AD
Cork MJ, Hunter LW & Danby SG; Academic Unit of Dermatology Research, The University of Sheffield.
TEWL
2/10/2015 The Academic Unit of Dermatology Research, The University of Sheffield. 45
Irritants &
allergens
46
Emollients
Cork MJ, Hunter LW & Danby SG; Academic Unit of Dermatology Research, The University of Sheffield.
NO itch
NO scratching
Effective skin barrier
NO inflammation
NO immune dysfunction
NO eczema
Emollients, treat inflammation
Avoid soap
and irritants,
treat
infection,
treat with
steroids,
immuno-
suppressant
Address allergens
minimise exposure,
immune modulation
Treat
inflammation,
cool,
antihistamines
Treat itch,
physical
barriers,
distraction