Eczema Atopic Dermatitis
Contact Dermatitis
Fahad Al Sudairy , M.D.
ECZEMAAn inflammatory skin reaction to a variety
of agents characterized histologically by
spongiosis and clinically by a variety of
features, notably vesiculation
CLASSIFICATION
1) Endogenous Eczema
2) Exogenous Eczema
Endogenous Eczema
Atopic Eczema
Seborrhoeic Eczema
Discoid Eczema
Pityriasis Alba
Pompholyx
Gravitational Eczema
Asteatotic Eczema
Exogenous Eczema
Irritant Contact Dermatitis
Allergic Contact Dermatitis
Photo Allergic Contact Dermatitis
Infective Dermatitis
Stages of Eczema
Acute Eczema
Subacute Eczema
Chronic Eczema
Clinical Staging AcuteWeeping, papules, vesicles &
bullae
Chronic Dryness, redness, lichenification,
scaling & fissuring
Acute Eczema
ACUTE ECZEMA
Spongiosis
Intercellular edema of keratinocytes in the epidermis
ACUTE ECZEMA
ACUTE ECZEMA
Chronic Eczema
Chronic Eczema
Hyperkeratosis (thickening of the stratum corneum)Parakeratosis (retention of nuclei in the stratum corneum).Hypergranulosis (thickening of the stratum granulosum)Acanthosis (thickening of the stratum spinosum)
Thickening of the epidermis
Chronic Eczema
Atopic Eczema
Atopy – genetically determined increased
liability to form IgE
Aetiology – unknown
• inherently itchy & dry skin
• psychological
• climatic
• allergic factors
DIAGNOSTIC GUIDELINES FOR ATOPIC DERMATITIS
Must have: • An itchy skin condition (or parental report of scratching or
rubbing in a child) plus
Three or more of the following: • History of involvement of the skin creases such as folds of
elbows, behind the knees, fronts of ankles or around the neck (including cheeks in children under 10 years of age)
• A personal history of asthma or hay fever (or history of atopic disease in a first-degree relative in children under 4 years of age)
Cont’d
• A history of general dry skin in the last year
• Visible flexural eczema (or eczema involving the
cheek/forehead and outer limbs in children under 4 years of
age)
• Onset under 2 years of age (not used if child is under 4
years of age)
DIAGNOSTIC FEATURES OF ATOPIC DERMATITIS
Major features (3 of 4 present)• Pruritus • Typical morphology and distribution of skin lesions • Chronic or chronically relapsing dermatitis • Personal or family history of atopy
Minor features (3 of 23 present)• Xerosis • Ichthyosis / palmar hyperlinearity / keratosis pilaris • Immediate (type I) skin test reactivity • Elevated serum IgE
Cont’d
• Early age of onset • Tendency toward cutaneous infections / impaired cell-
mediated immunity • Tendency toward non-specific hand or foot dermatitis • Nipple eczema • Cheilitis • Recurrent conjunctivitis • Dannie-Morgan infraorbital fold • Keratoconus • Anterior subcapsular cataract • Orbital darkening
Cont’d
• Facial pallor / erythema • Pityriasis alba • Anterior neck folds • Pruritus when sweating • Intolerance to wool and lipid solvents • Perifollicular accentuation • Food intolerance • Course influenced by environmental / emotional factors • White dermographism / delayed blanch
PHASES OF ATOPIC DERMATITIS
infantile phase – 2-6 months
cheeks, forehead, scalp
child restless, sleepless
crawling – extensor aspect of knees
CONT’D
childhood phase - 18-24 months
elbows & knee flexures
sides of neck
wrists & ankles
reticulate pigmentation on neck
CONT’D
adult phase
lichenification of hands & flexures
photosensitivity
allergic hand eczema
TREATMENT
General measures
wear cotton clothes
avoid overheating rooms
avoid irritant soaps
reassurance
foods
CONT’D
Local emollients
topical steroids
tacrolimus ointment
Systemic antihistamines
oral corticosteroids
low dose cyclosporin
azathioprine
SEBORRHOEIC ECZEMA
occurs in sebaceous gland rich areas
Etiology - unknown, malassezia furfur
erythema, greasy yellowish scales
CONT’D
infants
cradle cap
face
flexures
CONT’D
adults
Scalp - dandruff
Retro-auricular area
Face, blephritis, conjunctivitis
Trunk
Severe recalcitrant to treatment – in HIV
CONT’D
Treatment
no permanent cure
keratolytics
mild topical steroids
antifungals
DISCOID ECZEMA
rounded plaques of eczema
clearly demarcated edge
sites - limbs
atopy, dry skin, allergic contact
emotional factors
POMPHOLYX
eczema of palms & soles characterized by
vesicles & bullae
hyperhidrosis, drugs, food allergies,
emotional stress
spontaneous remission – 2-7 weeks
PITYRIASIS ALBA
ill-defined erythematous scaly patches – leave
hypopigmentation
3-16 years, atopic eczema
face, neck, arms
Treatment - emollients, tar, 1% hydrocortisone
STASIS ECZEMA
eczema secondary to venous hypertension
often obese
lower legs
edema, varicosities, purpura, ulceration,
infection
CONTACT ECZEMA
IRRITANT CONTACT DERMATITIS
Irritant substance physical or chemical
which produces cell damage if applied for
sufficient length of time and in adequate
concentration
CONT’D
strong irritant – response immediate
weak irritant – repeated exposure
IRRITANT CONTACT DERMATITIS
First exposure gives response
Everyone exposed can develop
Strictly limited to area of contact
IRRITANT CONTACT DERMATITIS
Subjective irritant response
Immediate type stinging e.g. ethanol, chloroform
Delayed type stinging e.g. 5% lactic acid, phenol
Immediate non-immune contact
e.g. arthropods, caterpillar, capsaicin
Chronic irritant dermatitis e.g. hair dressers
Toxic burn e.g. strong acids
Caustic burn wet cement
Dermatitis eyelid volatile irritant
Irritant dermatitis in barber
Irritant finger web eczema
Dry irritant contact
Dry fingertip dermatitis
ALLERGIC CONTACT DERMATITIS
occurs in only those allergic to a contactant
mediated by lymphocytes (delayed hypersensitivity)
not dose related
MOST COMMON ALLERGENS
Rubber
Perfumes
Some Plants
Metals - nickel
Dyes
Cosmetics
Medicaments
Irritant Contact Dermatitis Allergic Contact Dermatitis
Accounts for approximately 80% of all contact dermatitis
Accounts for the remaining 20% of all contact dermatitis
Result from a local toxic effect It is a delayed-type hypersensitivity reaction of Th1 response
Affect every one ,no sensitization is required Prior sensitization is required
Reaction soon after contact -minutes to hours Reaction delayed for hours to days
Repeated or prolonged exposure is required, a dose-response relationship
Small amount of allergen is enough to elicit the reaction
No cross-reaction Cross-reaction can occur
Burning prominent Burning not prominent
Lesions are restricted to the area where the irritant damaged the tissue
Localized, but may be more diffuse
Negative patch test Positive patch test
CD TO RUBBER
CD TO RUBBER
CD TO PERFUME
CD TO PLANTS
CD TO PLANTS
COSMETICS - NAIL POLISH
COSMETICS - LANOLINE
HAIR DYE - PPD
SHOE CONTACT DERMATITIS
CD TO NICKLE
CD TO NICKLE
CD TO MEDICAMENTS
CD TO MEDICAMENTS
OCCUPATIONAL CD - ACRYLATE
NAPKIN DERMATITIS
DIAGNOSIS
History
Examination
Patch testing
Remove the causative agents
Treat the dryness (Emollients)
Choose the correct steroid for the site and
activity of disease
Antihistamines (Itching)
MANAGEMENT
TOPICAL STEROIDS
CLASSIFICATION
USES
COMPLICATIONS
TOPICAL STEROIDS POTENCY RANKING
Class 1 (Superpotent) Clobetasol propionate OINTMENT AND CREAM 0.05% (dermovate , temovate)
Betamethasone dipropionate OINTMENT (optimized vehicle) 0.05% (diprolene)
Class 2 (High Potency) Betamethasone diproprionate CREAM 0.05% (diprolene)
Betamethasone diproprionate OINTMENT 0.05% (diprosone)
Betamethasone diproprionate CREAM 0.05% (diprosone)
Mometasone furoate ointment 0.1% (elocom)
Cont’d
Class 3 (High Potency) Fluticasone proprionate OINTMENT 0.05% (cutivate)
Class 4 (Medium Potency) Hydrocortisone valerate OINTMENT 0.2% (Westcort)
Mometasone furoate CREAM 0.1% (elocom)
Triamcinolone acetonide OINTMENT 0.1% (Kenalog)
Hydrocortisone butyrate OINTMENT 0.1% (Locoid)
Cont’d
Class 5 (Medium Potency) Fluticasone proprionate CREAM 0.05% ( cutivate ) Hydrocortisone valerate CREAM 0.2% (Westcort) Hydrocortisone butyrate CREAM 0.1% (Locoid)
Triamcinolone acetonide CREAM 0.1% (Kenalog)
Class 6 (Low Potency) Alclometasone diproprionate OINTMENT 0.05% ( perderm ) Alclometasone diproprionate CREAM 0.05% ( perderm )
Class 7 (Low Potency) Topicals with hydrocortisone acetate 1 %
Important about topical steroidsWhat skin conditions are
topical corticosteroids used for?
Potency of topical corticosteroids
How safe are topical steroids?
Does the formulation of steroid make any difference?
Misuse of topical steroids How long should topical
steroids be used for?
How often should topical steroids be applied?
How much should be applied?
How much should be prescribed?
Can topical corticosteroids be used safely on infected skin?
Using topical steroids in children and geriatric group
Tachyphylaxix
SUGESSTED AMOUNT FOR TOPICAL THERAPY
AREA TREATED SINGLE APPLICATION (G) BID FOR I WEEK
FACE 1 15SCALP 2 30ONE HAND 1 15ONE ARM 3 45ANTERIOR TRUNK 4 60POSTERIOR TRUNK 4 60ONE LEG INCLUDING FOOT
5 70
ANOGENITAL AREA 1 15WHOLE BODY 30-40 450-500
Topical Steroids in Adults
Area of skin to be treated (adults)
Size is roughly: FTUs each dose (adults)
A hand and fingers (front and back)
About 2 adult hands 1 FTU
A foot (all over) About 4 adult hands 2 FTUs
Front of chest and abdomen
About 14 adult hands 7 FTUs
Back and buttocks About 14 adult hands 7 FTUs
Face and neck About 5 adult hands 2.5 FTUs
An entire arm and hand About 8 adult hands 4 FTUs
An entire leg and foot About 16 adult hands 8 FTUs
Regional differences in penetration
1. mucous membranes
2. scrotum
3. eyelids
4. face
5. chest and back
6. upper arms and legs
7.lower arms and legs
8. dorsa of hands and feet
9.palmar and plantar skin
10. nails
Skin absorption of topical steroids
Steroids are absorbed at different rates from different parts of the body.
A steroid that works on the face may not work on the palm. But a potent steroid may cause side effects on the face.
Forearm absorbs 1% Armpit absorbs 4% Face absorbs 7% Eyelids and genitals absorb 30% Palm absorbs 0.1% Sole absorbs 0.05%
Thank You