eczema rangeen

ECZEMA

RANGEEN CHANDRAN R

'Ekze', in Greek means “to boil over”.

Eczema is an inflammatory condition of the skin that is characterized by erythema, papulo-vesicles, oozing & crusting in the acute stages & lichenification in the chronic stages

CLASSIFICATIONENDOGENOUS EXOGENOUS COMBINED

Seborrheic dermatitis

Irritant dermatitis

Atopic dermatitis

Nummular dermatitis

Allergic dermatitis

Pompholyx

Lichen simplex chronicus

Photodermatitis

Pityriasis alba Radiation dermatitis

Stasis dermatitis

Infective dermatitis

Asteatotic eczema.

Exogenous eczemas Mediated by external trigger factors; inherited tendencies may play a part.

Endogenous eczemas Mediated by internal factors; that is, processes originating within the body.

Combined EczemasSome types of eczema are precipitated by both external and internal factors.

CLINICAL FEATURES

The inflammatory changes of eczema evolve through two stages:◦ Acute eczematous inflammation◦ Chronic eczematous inflammation

ACUTE ECZEMA

CLINICAL FEATURES-

Intense itching Intense erythema Oedema Papulovesicles Oozing

CHRONIC ECZEMA

CLINICAL FEATURES

Dryness of skin Excoriation Fissuring Lichenification

COMPLICATIONS

DERMATOLOGICAL Infections.

Ide eruption

Contact dermatitis

Erythroderma

PSYCHOSOCIAL Anxiety

Depressions

Social complications

Wage loss

Debility

Social ostracism

ITCH SCRATCH CYCLE

DIAGNOSIS OF ECZEMAS

Diagnosis in most cases, is clinical and based on a carefully taken history.

Total IgE level to assess if the individual is atopic.Swabs for culture and sensitivity (Bacterial

resistance)Microscopy: to rule out dermatophyte infection/

scabies

PATCH TEST

 Relies on the principle of a type IV hypersensitivity reaction.

Method used to determine if a specific substance causes allergic inflammation of the skin.

Commonest antigen used-Nickel.

TECHNIQUE-

Antigens in standardised dilutions applied to the back and occluded.

Patches removed after 48hrs;read after half hour.

Another reading at 96hr detects delayed reaction.

PATCH TEST

INTERPRETATION

Clinical findings

Grading

No reaction Normal skin 0

Weak reaction Palpable erythema,infiltration

1+

Strong reaction Infiltration,erythema,papules and vesicles

2+

Extreme reaction Intense erythema,papules and vesicles.

3+

Irritant reaction Cauterization IR

COMBINED ECZEMAS

ATOPIC DERMATITIS

Endogenous eczema triggered by exogenous agents

Characterised by

Pruritic,recurrent,symmetric eczematous lesions

Characteristic site of involvement

Personal/family historyof atopic diathesis.

Increased ability to form IgE.

ATOPIC TRIAD

AsthmaAllergic Rhinitis

Atopic Dermatitis

ETIOLOGY

Strong genetic predisposition.

Raised IgE level.

Contributing factors

1. Anxiety.

2. Temperature change.

3. Decreased humidity

4. Contact with irritants

5. Allergens

6. Microbial agents

CLINICAL FEATURES

Shows 3 distinct patterns

1. Infantile phase.

2. Childhood phase.

3. Adult phase.

INFANTILE PHASE

3 months-2years.

Itchy papules and vesicles,becoming exudative.

Begins on face;can involve rest of body.

Spares diaper area.

CHILDHOOD PHASE

2-12 years.

Dry,leathery and itchy plaques.

Charecteristic feature-Lichenification.

Site-elbow and knee flexors.

Pallor of the face is common; erythema and scaling occur around the eyes

ADULT PHASE

12 years onwards.

Lesions become more diffuse with an underlying background of erythema.

Face and flexural areas are commonly involved and is dry and scaly.

Xerosis is prominent.

Lichenification may be present.

Dirty neck sign

COMPLICATIONS

1. Bacterial infections-Impetigo

2. Viral infections

Herpes simplex,molluscum contagiosum,HPV infection.

3. Fungal infections

4. Poor growth

5. Side effects of steroids.

Atopic dermatitis

Management First-line treatmentSecond-line treatmentThird-line treatmentCounselling; occupational advice

Management of Atopic dermatitis

First-line treatmentIdentify and control ‘flare factors’Topical treatments

◦ Bathing; Emollients; Humectants◦ Corticosteroids ◦ Calcineurin inhibitors: Pimecrolimus; tacrolimus ◦ Icthamol and tar

Management of Atopic dermatitis

First-line treatmentOral treatment

1. Antihistamines Sedative antihistamines preferred Promethazine; trimeperazine; hydroxyzine

2. Antibiotics3. Systemic steriods (in severe cases)

Management of Atopic dermatitis

Second-line treatmentIntensive topical therapy Wet wrap technique Allergy management

◦ Food◦ Inhalants◦ Contact allergy

Management of Atopic dermatitis

Third-line treatmentPhototherapyOral immunosuppresants

◦ Cyclosporine◦ Azathriopine◦ Thymopentine◦ α- Interferon

Desensitization

POMPHOLYX

Dyshydrotic eczema/acute vesiculobullous hand eczema

 It is a skin condition that is characterized by small blisters on the hands or feet.

CLINICAL FEATURES

Summer aggravation.

Recurrent episode of deep seated,bland looking vesicles(blisters)

Vesicles resolve gradually in 3 to 4 weeks, and may be followed by chronic eczematous changes.

Sites-fingers,palms and soles.

TREATMENT

Saline soaks followed by topical steroids.

Antibiotics in bacterial infection.

Sole dyshydrosis

Advanced stage of dyshidrosis on the palm showing cracked and peeling skin

EXOGENOUS DERMATITIS

CONTACT DERMATITIS

CONTACT DERMATITIS

Reaction of skin to contactants.

2 types-

IRRITANT CONTACT DERMATITIS

ALLERGIC CONTACT DERMATITIS.

ETIOLOGY

Occupational/recreational exposure.

Water

Detergents

Solvents

Abrasive dusts

Alkalis

Cutting oils

IRRITANT CONTACT DERMATITIS

PREDISPOSING FACTORS PATIENT FACTORS

Dry skin

Atopic individuals

ENVIRONMENTAL FACTORS

Persons in occupations of :◦ Hairdressing◦ Medical, dental,

veterinary◦ Food preparation,

catering, fishing ◦ Printing and painting,

metal work◦ Construction

SITES

Skin of face.

Scrotum

Back of hands.

CLINICAL FEATURES

Spectrum of features ranging from dryness,redness or chapping to an acute caustic burn.

Acute Exudative Lesions-

Exposure to a strong irritant.

Dry Dermatic Lesions-

Chronic repeated exposure to a weak irritant.

PATHOGENESIS

Chemical directly injures skin without involving immunologic pathway.

Develops in patients exposed to chemicals and develop with 1st exposure itself.

MANAGEMENT

PROPHYLAXIS Complete avoidance

Relative avoidance-

Gloves and clothing.

TREATMENT Topical steroids ointments

Emollients.

ALLERGIC CONTACT DERMATITIS

Allergic contact dermatitis (ACD) is a delayed type of induced sensitivity (allergy) resulting from cutaneous contact with a specific allergen to which the patient has developed a specific sensitivity.

This allergic reaction causes inflammation of the skin manifested by varying degrees of erythema, edema, and vesiculation.

ETIOLOGY

PLANTS Parthenium

METALS NickelChromates

Cosmetics ParaphenylenediamineFormaldehydeParabens

MEDICINES NeomycineBenzocaine

RUBBER Mercapto mixThiuram mix

PATHOGENESIS Type IV hypersensitivity reaction to exogenous antigens.

Antigen

Processed by antigen presenting cells

Processed antigen+Sensitised lymphocytes

Multiplication of lymphocytes

Release cytokines

Skin injury(inflammation,itching and rashes)

CLINICAL FEATURES

MORPHOLOGY ACUTE ECZEMA

o Progress from erythema to edema to papulovesiculation.

o Manifest as edema in eyelids and genitalia. CHRONIC ECZEMA

o Itchy lichenified plaques.

quaternium-15 hair dying

PHOTOCONTACT DERMATITIS

Eczematous condition triggered by an interaction between an unharmful or less harmful substance on the skin and ultraviolet light.

Distribution typically on the light exposed areas of the skin.

Two types:

1. Phototoxic

2. Photoallergic

PHOTOTOXIC PHOTOALLERGIC

Common Less Common

Non immunological TYPE IV Hypersensitivity

Sunburn Eczematous

Phototoxic reactions: Inducing agents

TopicalPerfumesDyesPsoralensTarsPlants (lime, celery)

SystemicPsoralenTetracyclinePhenothiazine

Perfumes (soaps, aftershave) Sunscreens (PABA) Neomycin Halogenated compoundsParthenium (congress grass)

SystemicNSAIDSPhenothiazine Thiazides

Photoallergic reactions: Inducing agents

 Papules that largely have become confluent to form plaques

INFECTIOUS ECZEMATOID DERMATITIS

Form of dermatitis caused by the spreading of purulent material that exudes from the site of an infection.

ETIOLOGY

Bacterial/Viral infection-Primary event

Eczema-Seconadary event

CLINICAL FEATURES

Seen around discharging wounds and ulcers

Presents as an area of advancing erythema sometimes with microvesicles at the edge around the lesion

DERMATOPHYTID

Eczematous reaction that occurs as an allergic response to a dermatophyte infection elsewhere on the skin

Most common dermatophytid is an inflammation in the hands resulting from a fungus infection of the feet.

Dermatophytid caused by Trichophyton rubrum

Diagnostic criteria

A proven focus of dermatophyte infection.A positive skin test to a group-specific trichophytin

antigen.Absence of fungi in the dermatophytid lesion.Clearing of the dermatophytid after the eradication

of the primary fungal infection.

ENDOGENOUS DERMATITIS

SEBORRHEIC DERMATITIS

Seborrheic dermatitis is a papulosquamous disorder patterned on the sebum-rich areas of the scalp, face, and trunk.

SITES-

Scalp,eyebrows,nasolabial folds,retroauricular area presternal and interscapular regions.

EPIDEMIOLOGY-

Age-

Onset at puberty;peaks at 40yrs.

Gender-

Common in males

ETIOLOGY

Microbial-

Overgrowth of Malassezia furfur

Genetic Predisposition

Immunodeficiency

Associated with psoriasis and Parkinson’s disease.

CLINICAL FEATURES

INFANTILE SEBORRHEIC DERMATITISCommonly affects within first 3 months of life; affects

both sexes equally. Begins as cradle cap.Lesions comprise tiny papules covered with yellow,

greasy scales; and redness in the diaper area and axillae.

CLINICAL FEATURES

ADULTS Affects hairy areas; mostly men (30 to 60 years). Scalp: Earliest sign is dandruff; later followed by greasy

scales and retroauricular fissuring. Face: Scaling; erythema of eyebrows, nasolabial folds;

and squamous blepharitis may occur.Trunk: Papules, greasy scales, petaloid pattern.Flexural areas: Marginated erythema, greasy scaling and

secondary infection.

TREATMENT

Topical therapy1. Topical antifungals

Topical ketoconazole,selenium sulphide and ciclopirox.

2. Topical steroids

Combined with antifungal agents in flexural and exudative lesions.

Combined with salicylic acid in recalcitrant lesions of scalp.

Systemic Therapy In extensive lesions and

HIV+ve patients.

Include antibiotics and antifungal agents(fluconazole/itraconazole)

LICHEN SIMPLEX CHRONICUS

Neurodermatitis.

Skin disorder characterized by chronic itching and scratching

CLINICAL FEATURES

Symptoms-extremely itchy

MORPHOLOGY-Single/multiple lichenified plaques

Lesion reappear after treatment is stopped

Commonly affects adults (30 to 50 years); often in atopics

SITES-Nape of neck in women,legs in men,anogenital area in both.

ETIOLOGY

Scratching in predisposed individuals.

Atopy.

TREATMENT

Topical steroids and keratolytic agents-to break itch-scratch cycle.

Antihistamines.

STASIS ECZEMA

Gravitational eczema/Venous eczema

Refers to the skin changes that occur in the leg as a result of "stasis" or blood pooling from insufficient venous return.

ETIOLOGY:

Secondary to venous hypertension.

Late sequel of previous deep vein thrombosis.

SITE-Lower third of leg(medial malleolus)

CLINICAL FEATURES

Begins with pedal edema around ankles.

Over period of time,brownish pigmentation appears(punctate initially and later confluent)

LIPODERMATOSCLEROSIS-

Long standing case presents with ivory white siderotic plaques with dilated capillary loops.

COMPLICATIONS

1. Ulceration

2. Bacterial infection-resulting in cellulitis,lymphangitis

3. Allergic contact dermatitis

4. Deformity-”inverted champagne” bottle appearance.

5. Malignant change

Leg elevation; weight reduction in obese patients. Compression by regular use of firm elastic bandage

or well fitting stockings. Sedative antihistaminesTopical steroids. Systemic antibiotics for secondary bacterial

infection.

Management

NUMMULAR ECZEMA

Discoid eczema.

Name comes from the Latin word “nummus," which means "coin.“

Characterized by round or oval-shaped itchy lesions

ETIOLOGY

Unknown in many case.

Frequent association with atopy

Reaction to bacterial antigens has been suspected.

Can also be worsened by stress and caffeine, which dehydrates the body and thus the skin

CLINICAL FEATURES

AGE/GENDER

Middle aged males.

SITES:

Extremities(distal parts)

MORPHOLOGY

Extremely itchy,multiple,sharply demarcated coin shaped vesicular/crusted plaques.

TREATMENT

SYMPTOMATIC:

Antihistamines

LOCALIZED LESIONS

Topical steroid+br.spectrum antibiotics

EXTENSIVE LESIONS:

PUVA sol/narrow band UVB

PITYRIASIS ALBA

Common skin condition mostly occurring in children and usually seen as dry, fine-scaled, pale patches on the face.

Characterized by asymptomatic, slightly elevated, hypopigmented, scaly patches; indistinct borders.

ETIOLOGY

Unknown.

Public swimming pools could be a factor.

Affects children (3 to 16 years) and disappears in early adulthood; may be a manifestation of atopic dermatitis.

SITES:Face, perioral area, chin and cheeks; lateral aspect of the upper arm; and thighs.

Hypopigmentation appears prominent in dark skinned patients and during summer as it stands out against the tanned skin

CLINICAL FEATURES

Individual lesions develop through 3 stages and sometimes are itchy:

Raised and red - although the redness is often mild and not noticed by parents

Raised and pale.

Smooth flat pale patches.

TREATMENT

ManagementSelf-limiting condition; hypopigmentation is not due

to vitiligo.Emollients to control scaling.Sunscreens.Short course of a topical steroid for actively

inflammed lesions.

ASTEATOTIC ECZEMA

Eczema craquelé

Form of eczema that is characterized by changes that occur when skin becomes abnormally dry, itchy, and cracked. 

Common in old people.

ETIOLOGY

Old age.

Dry skin

Low humidity

Hypothyroidism

Malignancy

CLINICAL FEATURES

Extremely itchy.

Skin is dry with fine reticulate red supericial fissures

Management

Advise to live in a warm room; avoid exposure to cold winds.

Wear woollen clothing over the cottons, avoid direct contact with wool.

Restrict bathing with very hot water; and use of soaps and detergents.

Application of emollient, immediately after bathing frequently thereafter to keep the skin moisturized.

Substituting aqueous cream for soap prevent recurrence.

DIFFERENTIAL DIAGNOSIS

PSORIASIS ECZEMA

Moderately itchy.Scratching results in bleeding

Very itchy.Scratching results in oozing.

Well defined indurated plaques.

Not so well defined and not indurated.

Surmounted with silvery scales.

Scale-crust.

Nail changes-Typical Variable.

Auspitz sign-Positive Negative

SCABIES IN INFANTS INFANTILE ECZEMA

Burrows Papulovesicles

On palms and soles;genitalia Spares palms and soles

Family history-positive Positive for atopic diathesis

DERMATOPHYTIC INFECTIONS

ECZEMA

Annular lesions(center relatively clear)

Discoid lesions

Exudation-Minimal/crusting Exudation/crusting/lichenification

KOH mount-+ve for fungus -ve