eczema rangeen
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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