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