DERMATITIS -Eczema

DERMATITIS -Eczema A common type of inflamation of skin ( epidermo- dermatitis ) which is not caused by micro-

organism. Itching is the most symptom

Some types appear to be due to as yet unidentified constitutional abnormalities, while others are more obviously the result of some external set of circumstance

Constitutional : eg Atopic dermatitis

External : eg Contact dermatitis

Eflorescense of Dermatitis-Eczema

Erythem

Papule

Vesicle

Pustule

“Oozing”

Crust

Squama

Several types of Derm- ecz

Atopic dermatitis Contact dermatitis Seborrhoic dermatitis Statis dermatitis Neurodermatitis Nummular eczema Dishidrosis Asteatotic eczema Infective Eczematoid Dermatitis

Atopic dermatitis /Eczema

A.D may divided into three stages, namely :

• Infantile ( 2 months – 2 years)

• Childhood ( 2 years – 10 years)

• Adult

Infantile Usually begins as an itchy erythema of cheeks followed

by development of vesicle, rupture and produce moist crusted areas

The eruptions may rapidly extend to other parts of the body, chiefly the scalp, the neck, the forehead, the wrist and the extremities

The buttocks and diaper area are often involved

The eruption may become generalized with erythroderma

Infantil AD

Childhood AD

The lesion to be less exudative, drier, and more papular

The classic locations are the antecubital, and the popliteal spaces, the wrist, eyelids, and the face and in collarette about the neck

The other area, however, are frequently affected

Itching

There is a decrease in the frequency of sensitization to egg, wheat and milk, but an increase in sensitization to nonigested substances, particulary wool, cat hair, dog hair, and pollens

Childhood AD

Adolescent and adult AD

Usually the eruption involves the antecubital and popliteal fossae, the front and sides of the neck, the forehead and the are about the eyes

Hands dermatitis occurs more frequently in atopic individuals, and eczematous lessions of the dorsum are usual

Pruritus : paroxysm, nocturnal, triggered by acute emotional stress Trigger factors : rough clothing, wool irritation, foods or tension.

Adolescent and Adult AD

Associated features

Cutaneous stigmata : Dennie-Morgan fold, Keratosis pilaris, and Hertoghe’s sign

Vascular stigmata : White dermographism Personality traits : Nervous tension Ophthamologic abnormalities : cataracts, keratoconus.

Susceptibility to infection : S.aureus, generalized Herpes simplex or vaccinia virus

infections to produce Kaposi’s varicelliform eruption

Immunology : elevated serum IgE, decreased T-supressor cells, decreased chemotaxis and activations of PMN leucocyte.

Diagnosis

Hanifin & Rajka , Svenson, SCORAD criterias

Hanifin & Rajka criteria :

Major criteria 1. Pruritus2. Typical morphology and distribution3. Tendency toward chronics or chronically relapsing dermatitis4. Personal or family history of atopic diseases (asthma, allergic

rhinitis, AD)

Minor criteria :1. Xerosis / ichthyosis/ hyperlinear palms2. Pityriasis alba3. Keratosis pilaris4. Facial pallor / infraorbital darkening5. Elevated serum IgE6. Keratoconus7. Tendency to non spesific hand eczema8. Tendency to repeat cutaneous infections

Differential diagnosis

• Nummular Dermatitis

• Seborrhoic Dermatitis

• Contact Dermatitis

• Psoriasis

• Scabies

General management

1. In infancy and childhooda. It should be avoided :

External irritation Sudden change of temperature, excessive

bathing, insufficient cleanless especially in the diaper region, local infections

b. Food elimination ( with special attention)

b. Antihistamin systemically

c. Olive oil on absorbent cotton may used with gentle patting for cleansing to avoide rubbing the affected patrs. Particular attention should be given the genitals and buttocks and the diapers should be changed

d. Weak topical corticosteroid.

2. In adults :

a. The emotional stress should be controlled

b. Avoid extremes cold and heat

c. Hydrated xerotic skin

d. Antihistamin

e. Topical steroid ( be aware of the potentiality)

f. Antiobiotics ( if needed)

Contact Dermatitis (CD)

An exogenous dermatitis which develops as a reaction of the skin to contact with a foreign substance / an environmental agent, either a primary irritant ( Irritant CD) or an allergen (allergic CD)

It may be affected by exposure to UV-light, resulting into two variant reaction : Photoallergic & Phototoxic CD

Allergic Contact Dermatitis (ACD)

Occur in predisposed individual Sensitization occurs within a week after contact with a

substance (allergen), but there are no visible skin changes Subsequent contact with allergen, even in small amounts,

causes an dermatitis Once established, sensitivity may persists for months,

years, or even a lifetime

Irritant Contact Dermatitis

Occure in any individual provided the chemical irritant is applied in a potent enough concentration for a sufficient length of time

Inflamation of the skin develops at the site of contact

There is non allergic mechanism involved, the damage result from direct chemical action

Irritants: strong irritant severe inflamation at the first

contact Weak irritants: less toxic substances which require

repeated or prolinged conatact to cause inflamation (detergent, organic solvents, excessive exposure to water)

Incidence: The incidence of cases of ICD (each type)

depending mainly on the degree of exposure and the causative agent

In patients with atopic dermatitis there is a relatively high incidence of ICD

Sign

Allergic dermatitis

Based on erythematous skin there are : edema, papules, vesicles and occasionally bullae. Patches are single / multiple, and of various size and shape. Strong irritant burns, ulcer and necrosis

Patch Test

Treatment Preventive :

Once the causative agent has been identified, further contact should be avoided

Topical therapy :

in acute state : wet dressing : Burowi solution 1/20 –1/40, Permanganate 1/10.000, followed by topical steroid.

in chronic state : moderate topical steroid Systemic therapy :

Antihistamin (severe pruritus) and steroid (severe /

ex tensive eruption

Contact Dermatitis

Seborrhoic dermatitis

Two distinct subset of patients :

* The Infantile form * Characterized by large yellowish scale mainly on the scalp,

face, axilla and napkin rash May cause confusion with Infantile Atopic Dermatitis No link between the infantile and adult form No pruritus eat & sleep well

“Infantil form” Seborrhoeic Dermatitis

Cradle Cap

* The adult form * Affect the face, scalp, anterior chest, axilla, sub

mammary fold, groins, external ear Facial lesion, particularly in the nasolabial fold, in

men, maybe very persistent the scalp is frequently involved presenting

complaint, esp severe and persistent dandruff Eyebrow/ eyelid stickness of the eyelid in

early morning

Differential diagnosis :

Contact dermatitis, psoriasis and Pityriasis versicolor

Treatment : Tends to recure whatever treatment is chosen Topical : imidazol antifungal ketokonazol

(cream/shampoo) , weak potency topical steroid

“Adult form” Seborrhoeic Dermatitis

Stasis dermatitis

dermatitis on the lower legs, commonly seen in association with venous insufficiency

many cases seen in obese, female patients have a degree of venous insufficiency

inner aspects of boths lower legs above and around the medial malleous are chiefly involved

the skin is shinny, atrophic and large numbers of small blood vessels clearly visible, purpura, pigmentation (due to haemosiderin)

pruritus may be severe and cause scratch marks which are slow to heal

Treatment :treatment of underlying varicose veins, topical steroid (weak) be ware of side effects atrophy

Stasis Dermatitis

Neurodermatitis(liken simplex chronicus)

a well demarcated are of chronic lichenified dermatitis which is not due to either external irritants or identified allergens

In predisposed persons, the lesions are induced by continual scratching or rubbing of a localized area of itching skin

stress / emotional disturbance pruritic stimulus scratch itch-scratch-itch cycle stimulate a reactive hyperplasia, recognized clinically as lichenification

clinically, neurodermatitis are seen as a well-circumscribe, lichenified, slightly elevated plaque, seen on the nape of neck, forearm, or the legs

Treatment :

Reduce pruritus, topical steroid (ointment/ intra lesion)

Neurodermatitis

Asteatotic aczema(eczema craquele)

The dry irritable skin seen mainly on the limbs of elderly patients.

The skin is dry and has large scale with a “crazy-paving” appearance.

Treatment : - lubrication - steroid topical should be avoided (skin is already thin and fragile)

Asteatotic Eczema

Dishydrotic (eczema dishydrosticum)

a very characteristic pattern of intensely itchy vesicles of the skin of the hands and occasionally the feet and also the side of finger

Deep-seated vesicle : often easier to feel than to see The cause is not understood ( contact dermatitis /

stress? ) Treatment : systemic antihistamins ( control the need

to scratch) prevent secondary infection, potent topical steroid ( a short time) ; for the moist lesion calamine lot.

Dishydrotic

Nummular or Discoid dermatitis

a chronic, recurrent pattern of dermatitis with discrete coin-shape lesions tending to to involve the limbs

Usually affects adults (many of whom will have a past history of AD) ; The aetiology is unknown

Clinically : subacute with erythema, edema, vesiculation; the surface may be moist and appear infected bacterial eczema

Pruritus is variable Treatment : topical steroid + antibiotic

Nummular or Discoid Dermatitis

INFECTIVE ECZEMATOID DERMATITIS

IED is exogen in nature, can be defined as fluid/ exudate which originates from inflammation or disorders such as: OMP, sinusitis, chronic ulcers, etc

IED is thought as autosensitisation dermatitis which occurs from skin’s sensitivity toward chemical substances originating from tissues/ bacteria in the body’s own exudate

Clinical appearances : Erythema & exudation In a dry state, there is crust. If crust is peeled, we would

see erythema & often pustules on the edgesExamples : The earlobes of children suffering from OMP. The area around the nose of maxilaris sinusitis sufferers

Therapy : Rivanol 1/1000, Betadine dressing When cleared Hidrocortisone 1 % or combination with

antibiotic

Infective Eczematoid Dermatitis