eczema & psoriasis dr. jerald e. hurdle kennebec medical consultants waterville, me 04901
TRANSCRIPT
Eczema & PsoriasisEczema & Psoriasis
Dr. Jerald E. HurdleKennebec Medical Consultants
Waterville, ME 04901
Dr. Jerald E. HurdleKennebec Medical Consultants
Waterville, ME 04901
Learning ObjectivesLearning Objectives
To familiarize you with the many presentations of eczema & psoriasis,
To understand how to get the most out of topical therapies, and
To recognize newer therapies now becoming available.
To familiarize you with the many presentations of eczema & psoriasis,
To understand how to get the most out of topical therapies, and
To recognize newer therapies now becoming available.
EczemaEczema
From the Greek “to boil over”
Eczema = Dermatitis
Wastebasket term for many undiagnosed rashes
Histology shows edema or spongiosis
From the Greek “to boil over”
Eczema = Dermatitis
Wastebasket term for many undiagnosed rashes
Histology shows edema or spongiosis
Eczema is itchy!Eczema is itchy!
Acute: Vesicles
Sub acute: Sub acute: Juicy PapulesJuicy Papules
Chronic: LichenificationChronic: Lichenification
Lesions tend to have Lesions tend to have indistinct bordersindistinct borders
Acute: Vesicles
Sub acute: Sub acute: Juicy PapulesJuicy Papules
Chronic: LichenificationChronic: Lichenification
Lesions tend to have Lesions tend to have indistinct bordersindistinct borders
Eczema is itchy!Eczema is itchy!
Acute: VesiclesAcute: Vesicles
Sub-acute: Juicy PapulesSub-acute: Juicy Papules
Chronic: LichenificationChronic: Lichenification
Lesions tend to have Lesions tend to have indistinct bordersindistinct borders
Acute: VesiclesAcute: Vesicles
Sub-acute: Juicy PapulesSub-acute: Juicy Papules
Chronic: LichenificationChronic: Lichenification
Lesions tend to have Lesions tend to have indistinct bordersindistinct borders
Eczema is itchy!Eczema is itchy!
Acute: VesiclesAcute: Vesicles
Sub acute: Sub acute: Juicy PapulesJuicy Papules
Chronic: LichenificationChronic: Lichenification
Lesions tend to have Lesions tend to have indistinct bordersindistinct borders
Acute: VesiclesAcute: Vesicles
Sub acute: Sub acute: Juicy PapulesJuicy Papules
Chronic: LichenificationChronic: Lichenification
Lesions tend to have Lesions tend to have indistinct bordersindistinct borders
Lesions tend to have Lesions tend to have indistinct bordersindistinct borders
Lesions tend to have Lesions tend to have indistinct bordersindistinct borders
New patients presenting to a dermatology clinic
New patients presenting to a dermatology clinic
Types of Dermatitis Essential: 11.4% Contact: 2.8% Atopic: 2.6% Seborrheic: 3.7% Stasis: 0.4% Lichen Simplex Chronicus (LSC): 0.8%
Types of Dermatitis Essential: 11.4% Contact: 2.8% Atopic: 2.6% Seborrheic: 3.7% Stasis: 0.4% Lichen Simplex Chronicus (LSC): 0.8%
Source: Hershey Medical Center Dermatology Clinic
Essential DermatitisEssential Dermatitis
Pruritus
Eczematous lesions not conforming to other patterns of dermatitis
Pruritus
Eczematous lesions not conforming to other patterns of dermatitis
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Essential DermatitisEssential Dermatitis
Dyshidrotic
AutosensitizationAutosensitization
XeroticXerotic
NummularNummular
Dyshidrotic
AutosensitizationAutosensitization
XeroticXerotic
NummularNummular“tapioca” on lateral borders of fingers
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Essential DermatitisEssential Dermatitis
DyshidroticDyshidrotic
Autosensitization
XeroticXerotic
NummularNummular
DyshidroticDyshidrotic
Autosensitization
XeroticXerotic
NummularNummularHypersensitivity to a substance produced by local dermatitis
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Essential DermatitisEssential Dermatitis
DyshidroticDyshidrotic
AutosensitizationAutosensitization
Xerotic
NummularNummular
DyshidroticDyshidrotic
AutosensitizationAutosensitization
Xerotic
NummularNummular • “crazy paving" appearance:
• affects elderly particularly in winter
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Essential DermatitisEssential Dermatitis
DyshidroticDyshidrotic
AutosensitizationAutosensitization
XeroticXerotic
Nummular
DyshidroticDyshidrotic
AutosensitizationAutosensitization
XeroticXerotic
Nummular
Coin-shaped lesions
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Contact DermatitisContact Dermatitis
Irritant vs. Allergic
Only affects area of contact
Rx : avoid contactant
Irritant vs. Allergic
Only affects area of contact
Rx : avoid contactant
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Contact DermatitisContact Dermatitis
Cosmetics
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Contact DermatitisContact Dermatitis
Nickel
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Contact DermatitisContact Dermatitis
Poison Oak
or
Poison Ivy
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Contact DermatitisContact Dermatitis
Irritant
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Atopic DermatitisAtopic Dermatitis
Triad of atopic disease
Pruritus
Waxing/waning course
Hands/face/neck common in adults
Triad of atopic disease
Pruritus
Waxing/waning course
Hands/face/neck common in adults
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Seborrheic DermatitisSeborrheic Dermatitis
Dandruff on the body
Hypersensitivity to yeast
Rx: Anti yeast & steroids
Dandruff on the body
Hypersensitivity to yeast
Rx: Anti yeast & steroids
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Stasis DermatitisStasis Dermatitis
Eczema overlying edematous legs
Chronic
: Compression
Beware of Ulcers
Eczema overlying edematous legs
Chronic
: Compression
Beware of Ulcers
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Lichen Simplex ChronicusLichen Simplex Chronicus
Localized chronic dermatitis
Occluded steroids may help
Localized chronic dermatitis
Occluded steroids may help
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Scratch
Scratch
Itch
Itch
Treatment Of EczemaTreatment Of Eczema
Gentle skin care
↓ Frequency of washing
Cooler Water
Avoid Soap
Gentle skin care
↓ Frequency of washing
Cooler Water
Avoid Soap
Treatment Of EczemaTreatment Of Eczema
Use cream based emollients as soap
Encourage greasiest
Copious quantities
Use cream based emollients as soap
Encourage greasiest
Copious quantities
increasing greasiness
Treatment Of EczemaTreatment Of Eczema
Topical Steroids
Ointments > Cream
Use lowest effective potency
BID
Topical Steroids
Ointments > Cream
Use lowest effective potency
BID
clobetasol
fluocinonide
triamcinolone
aclomethasone
hydrocortisone
Potency
PsoriasisPsoriasis
PsoriasisPsoriasis
2-5% Caucasians
Onset at any age
2 peaks in 20s & 50s
May be pruritic
2-5% Caucasians
Onset at any age
2 peaks in 20s & 50s
May be pruritic
Psoriasis: precipitantsPsoriasis: precipitants Genetics
Stress
Infections -- i.e. Strep
Trauma (Koebner)
Medications: Lithium, β Blockers
Obesity (insulin resistance)
Alcohol
Genetics
Stress
Infections -- i.e. Strep
Trauma (Koebner)
Medications: Lithium, β Blockers
Obesity (insulin resistance)
Alcohol
Chronic Plaque Chronic Plaque
Commonest
Extensor surfaces
Stable disease
Commonest
Extensor surfaces
Stable disease
Guttate Guttate
Explosive onset
May be preceded by Strep infection
Consider other Dx: Pityriasis Rosea & syphilis
Explosive onset
May be preceded by Strep infection
Consider other Dx: Pityriasis Rosea & syphilis
Palmar Plantar PustulosisPalmar Plantar Pustulosis
Commoner in smokers
Tends to be difficult to treat
Groups of sterile pustules
Commoner in smokers
Tends to be difficult to treat
Groups of sterile pustules
Erythrodermic PustularErythrodermic Pustular Rare
Skin often painful
Pustules tiny (look close)
Later get lakes of pus
Need to admit patient to stabilize
Rare
Skin often painful
Pustules tiny (look close)
Later get lakes of pus
Need to admit patient to stabilize
Nail PsoriasisNail Psoriasis
Commoner in pts with Ps arthritis
Pitting
Oil spots
Onycholysis
Difficult to Rx
Commoner in pts with Ps arthritis
Pitting
Oil spots
Onycholysis
Difficult to Rx
TreatmentsTreatments
Remember Koebner
Point to a scar
Remember Koebner
Point to a scar
Emollients
Topical Agents
UV light
Systemics
Biologics
Emollients
Topical Agents
UV light
Systemics
Biologics
TreatmentsTreatments
Corticosteroids (potent & super potent)
Vit D Analogue (Dovonex)
Tars (LCD)
Anthralin (Dithrocream)
Corticosteroids (potent & super potent)
Vit D Analogue (Dovonex)
Tars (LCD)
Anthralin (Dithrocream)
Emollients
Topical Agents
UV light
Systemics
Biologics
Emollients
Topical Agents
UV light
Systemics
Biologics
TreatmentsTreatments
Immunosuppressant
UVB (Narrow band vs. broadband
PUVA: Psoralen + UVA
Treatment course 3x weekly for 6 weeks
Beware of skin cancer!
Immunosuppressant
UVB (Narrow band vs. broadband
PUVA: Psoralen + UVA
Treatment course 3x weekly for 6 weeks
Beware of skin cancer!
Emollients
Topical Agents
UV light
Systemics
Biologics
Emollients
Topical Agents
UV light
Systemics
Biologics
TreatmentsTreatments
Retinoids: Acitretin monitor LFTs & Lipids (avoid in ♀ of childbearing potential)
Methotrexate (once weekly) monitor LFTs & CBC
Cyclosporine : monitor BP & Renal function : great rescue drug but need exit strategy!
Retinoids: Acitretin monitor LFTs & Lipids (avoid in ♀ of childbearing potential)
Methotrexate (once weekly) monitor LFTs & CBC
Cyclosporine : monitor BP & Renal function : great rescue drug but need exit strategy!
Emollients
Topical Agents
UV light
Systemics
Biologics
Emollients
Topical Agents
UV light
Systemics
Biologics
TreatmentsTreatments
Anti-TNF: Etanercept, infliximab & adalumimab
IL 12/23 blockers
Watch out for TB/infections
No long term safety data
$$$$
Not Better than CyA or MTX
Anti-TNF: Etanercept, infliximab & adalumimab
IL 12/23 blockers
Watch out for TB/infections
No long term safety data
$$$$
Not Better than CyA or MTX
Emollients
Topical Agents
UV light
Systemics
Biologics
Emollients
Topical Agents
UV light
Systemics
Biologics
TreatmentsTreatments
Avoid systemic corticosteroids!!! Avoid systemic corticosteroids!!!
Snowbird
Eczema: Key PointsEczema: Key Points
Appearance varies from blisters to scaling plaques
Itching is prominent
Distribution can be localized or generalized
Appearance varies from blisters to scaling plaques
Itching is prominent
Distribution can be localized or generalized
Psoriasis: Key PointsPsoriasis: Key Points
Well demarcated erythematous, silvery, scaling plaques
Elbows, knees & scalp are typically involved
Inflammation and epidermal proliferation
Well demarcated erythematous, silvery, scaling plaques
Elbows, knees & scalp are typically involved
Inflammation and epidermal proliferation
Learning ObjectivesLearning Objectives
To familiarize you with the many presentations of eczema & psoriasis,
To understand how to get the most out of topical therapies, and
To recognize newer therapies now becoming available.
To familiarize you with the many presentations of eczema & psoriasis,
To understand how to get the most out of topical therapies, and
To recognize newer therapies now becoming available.
And Remember…And Remember…
For scaling rashes of uncertain etiology…
“if it scales, scrape it!”
For scaling rashes of uncertain etiology…
“if it scales, scrape it!”