eczema...eczema investigations 1. measure the total ige level 2. secondary infection can be...
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Eczema
Dr Shawana Sharif
Dermatology department BBH
Eczema
Eczema means to boil, is a clinical and histological pattern of inflammation of the skin
seen in a variety of dermatoses with widely diverse aetiologies
all eczema is dermatitis, but not all dermatitis is eczema.
There remain cases of eczema that do not fit any of the described patterns. These are not
uncommon and have been termed ‘unclassified eczema’. These patients may have a
poor prognosis, with a tendency for the disease to become chronic.
Eczema
Eczema
Exogenous eczemas
• Allergic contact eczema• Dermatophytid• Eczematous polymorphic light eruption• Infective dermatitis• Irritant eczema• Photoallergic contact eczema• Post‐traumatic eczema
Endogenous eczemas
• Asteatotic eczema• Atopic eczema • Chronic superficial scaly dermatitis• Eyelid eczema• Hand eczema• Juvenile plantar dermatosis• Nummular dermatitis• Pityriasis alba• Metabolic eczema or eczema associated with systemic disease• Seborrhoeic eczema• Venous eczema
Eczema
Age and Sex
Most cases of eczema in infants and young children are atopic.
Pompholyx and atopic eczema are less common in elderly people.
Nummular dermatitis occurs particularly in elderly males in winter.
Eczema
Pathophysiology
The interaction of trigger factors, keratinocytes and T lymphocytes seems particularly
important in most eczema types.
Three predominant processes occurring in irritant dermatitis are disturbed barrier function,
epidermal cell change and release of inflammatory mediators and cytokines.
Certain irritants may provoke a chronic reaction in which an effect on epidermal cell
turnover predominates, leading to lichenification; whereas in acute irritant reactions
inflammatory mediators cytokine release is similar to that seen in acute allergic contact
dermatitis
Both intracellular and intercellular oedema are visible throughout the epidermis at 3–6 h,
and within 24 h there may be epidermal necrosis, with cellular vacuolation and nuclear
pyknosis. In severe forms, the primary epidermal damage may progress to subepidermal
blister formation.
mutations of the fillaggrin gene.
Eczema
Presentation
Acute eczema presents as an eruption that is typically oedematous, vesicular and may be
exudative.
Chronic eczema, these features give way to a more stable picture of erythema, scaling,
excoriation and lichenification.
Eczema
Secondary Dissemination
A characteristic feature of eczematous inflammation is its tendency to spread far from its
point of origin and to become generalized. This phenomenon is often termed
autosensitization or, more specifically, autoeczematization.
Eczema
Complications and co‐morbidities
A reduction in skin barrier function increases the risk of both bacterial and viral secondary skin
infection.
Prognosis
Eczema tends to follow a chronic relapsing remitting course.
Eczema
Investigations
1. measure the total IgE level
2. Secondary infection can be confirmed by taking swabs for culture and sensitivity
3. When dermatophyte infection is suspected, a potassium hydroxide preparation
4. Microscopy, or dermoscopic examination of the skin
5. Biopsy
6. immunofluorescence can help identify less common conditions such as dermatitisherpetiformis
7. Patch testing in eczema - important in atypical or asymmetrical eruptions, and especiallyin dermatitis affecting the face, hands and feet.
Eczema
Treatment
First line
• Avoidance of irritants and allergens, emollients and soap substitutes
Second line
• Topical corticosteroids and topical calcineurin inhibitors
Third line
• Phototherapy, oral immunosuppressants and steroids
Seborrheic dermatitis
Nummular dermatitis
Definition and nomenclature
Nummular dermatitis is characterized by a single, non‐specific morphological feature, namely
circular or oval plaques of eczema with a clearly demarcated edge.
Synonyms
• Discoid eczema
• Nummular eczema
Nummular dermatitis
Nummular dermatitis
Age
women in early adulthood
Men in the older age groups.
Associated diseases
Atopy
Nummular dermatitis
Environmental factors
1. underlying allergic contact dermatitis, reacting to rubber chemicals, formaldehyde,
neomycin, chrome and nickel .
2. excessive alcohol intake
3. Nummular dermatitis has occurred rarely as a result of sensitivity to aloe, depilating creams
and mercury, and in patients taking methyldopa. In addition, oral gold therapy.
Nummular dermatitis
Presentation
The diagnostic lesion of nummular dermatitis is a coin‐shaped plaque of closely set,
thin‐walled vesicles on an erythematous base.
This arises, quite rapidly, from the confluence of tiny papules and papulovesicles. These
may occur, in the phase of very acute dissemination, as individual lesions on the trunk or
limbs at the same time as localized plaques are being formed.
In the acute phase the lesions are dull red, very exudative or crusted and highly pruritic.
They progress towards a less vesicular and more scaly stage, often with central clearing,and peripheral extension, causing ring‐shaped or annular lesions.
As they fade, they leave dry, scaly patches. After any period of between 10 days andseveral months, secondary lesions occur, often in a mirror‐image configuration on the
opposite side of the body.
Asteatotic eczema
Definition
This is eczema developing in very dry skin, usually in the elderly.
Synonyms
• Eczéma craquelé
• Winter eczema
Asteatotic eczema
Asteatotic eczema
Presentation
The condition occurs particularly on the legs, arms and hands. The asteatotic skin is dry andslightly scaly. The surface of the backs of the hands is marked in a criss‐cross fashion. The fi
nger pulps are dry and cracked, producing distorted prints and retaining a prolonged
depression after pressure (‘parchment pulps’). On the legs the pattern of superficial markingsis more marked and deeper (‘crazy‐paving’ pattern or eczéma craquelé).
Asteatotic eczema
Environmental factors
1. central heating
2. cold, dry winter
3. Drugs – Diuretics, Cimetidine, topical corticosteroids.
Associated diseases
1. Myxoedema
2. zinc deficiency
Asteatotic eczema
Predisposing factors
At present, the relevant factors in the production of asteatotic eczema can be considered to be:
(i) a naturally ‘dry’ skin and a lifelong tendency to chapping;
(ii) a further reduction in lipid with age, illness, malnutrition or hormonal decline;
(iii) increased transpiration relative to the environmental water content;
(iv) loss of integrity of the water reservoir of the horny layer;
(v) chapping and degreasing by industrial or domestic cleansers or solvents;
(vi) low environmental humidity and dry, cold winds increasing convection loss; and
(vii) repeated minor trauma leading to inflammation and further disorganization of the surfaceaqueous/lipid balance.
Dermatitis and eczema of the hands
Hand eczema: aetiological possibilities to be considered
Exogenous
• Contact irritants:
• Chemical (e.g. soap, detergents, solvents)
• Physical (e.g. friction, minor trauma, cold dry air)
• Contact allergens:
• Delayed hypersensitivity (type IV) (e.g. chromium,
rubber)
• Immediate hypersensitivity (type I) (e.g. seafood)
• Ingested allergens (e.g. drugs, possibly nickel,
chromium)
• Infection (e.g. following bacterial infection of hand
wounds)
• Secondary dissemination (e.g. dermatophytide reaction to tineapedis)
Endogenous
• Idiopathic (e.g. discoid,
hyperkeratotic palmar eczema)
• Immunological or metabolic
defect (e.g. atopic)
• Psychosomatic: stress aggravates,
but may not be causative
• Dyshidrosis: increased sweating
aggravates, but may not beCausative
Dermatitis and eczema of the hands
Morphological patterns of hand eczema
Apron eczema
Chronic acral dermatitis
Nummular dermatitis (discoid eczema)
Fingertip eczema
‘Gut’ eczema
Hyperkeratotic palmar eczema
Pompholyx
Recurrent focal palmar peeling
Ring eczema
‘Wear and tear’ dermatitis (dry palmar eczema)
Other patterns (e.g. patchy vesiculosquamous)
Dermatitis and eczema of the hands
Dermatitis and eczema of the hands
Dermatitis and eczema of the hands
Dermatitis and eczema of the hands
Clinical variants
Hyperkeratotic palmar eczema.
Pompholyx. - Pompholyx is a form of eczema of the palms and soles in which oedema fluidaccumulates to form visible vesicles or bullae.
Apron eczema - This condition is a type of hand eczema that involves the proximal palmar aspect of
two or more adjacent fingers and the contiguous palmar skin over the metacarpophalangeal joints,
thus resembling an apron.
Chronic acral dermatitis- This is a distinctive syndrome affecting patients in middle age. A chronic,
intensely pruritic, hyperkeratotic, papulovesicular eczema of the hands and feet, is associated with
grossly elevated IgE levels in subjects with no personal or family history of atopy. The condition
responds to oral corticosteroids,but the response to topical therapy is poor.
Dermatitis and eczema of the hands
Nummular dermatitis.
Fingertip eczema - Two patterns may be distinguished. The first and most common involves most or all
of the fingers, mainly those of the dominant hand, and particularly the thumb and forefinger. The
condition is usually worse in the winter and generally improves on holiday. Fingertip eczema is usually
a cumulative irritant dermatitis in which degreasing agents combine with trauma as causative
factors; patch tests are typically negative or not relevant. The second pattern involves preferentially
the thumb, forefinger and third finger of one hand. This is usually occupational and may be either
irritant (e.g. in newspaper delivery employees) or allergic (e.g. to colophony in polish). The condition
usually involves the dominant hand, but there may be allergy to onions, garlic and other kitchenproducts held in the non‐dominant hand when being cut. In these cases, patch testing and 20 min
contact tests) may be rewarding.
Dermatitis and eczema of the hands
Clinical variants
‘Gut’/slaughterhouse eczema. Workers who eviscerate and clean pig carcasses are at risk of
developing vesicular eczema which starts in the fi nger webs and spreads to the sides of the fingers.This is a mild, self‐limiting condition, which clears in a week or two, even if the patient remains at work,
but it can recur at intervals.
Patchy vesiculosquamous eczema. In a large group of cases, a mixture of irregular, patchy,vesiculosquamous lesions occur on both hands, usually asymmetrically. In contrast to the lesions of
discoid hand eczema, the degree of activity and distribution of the lesions vary. Nail changes are
common if the nail folds are affected.
Dermatitis and eczema of the hands
Clinical variants
Recurrent focal palmar peeling.- keratolysis exfoliative
Ring eczema - This characteristic pattern particularly affects young women, rarely men. The conditionusually starts soon after marriage or childbirth. An irritable patch of eczema begins under a ring –
usually a broad wedding ring
Dermatitis and eczema of the hands
Prognosis
Atopic hand eczema probably has the worst prognosis of all types of hand eczema
eczema on the dorsa of the hands clears more readily, and is less likely to recur than palmar
eczema.
Pompholyx, - about one‐third of patients experience no further episodes, one‐third suffer from
recurrent episodes and in the remainder the condition develops into a chronic, possibly
hyperkeratotic phase.
Investigations
scrapings should be examined for fungus
patch testing
Dermatitis and eczema of the hands
Treatment ladder
First line
Hand care advice
Irritant and allergen avoidance
Emollients
Soap substitute
Second line
Potent or very potent topical corticosteroids
Third line
Alitretinoin/PUVA/azathioprine/ciclosporin/methotrexate
Dermatitis and eczema of the lower legs
Definition
1. venous eczema,
2. stasis dermatitis
3. allergic contact dermatitis.
Lower limb venous eczema encompasses the skin changes that result from venous hypertension.
Stasis dermatitis relates to the skin changes that result from reduced lower leg venous fl ow.
Dermatitis and eczema of the lower legs
Dermatitis and eczema of the lower legs
Age
Middle age or Elders
Sex
Females due to
1. Hormonal Effects
2. DVT
Predisposing factors
1. previous DVT
2. Obesity
3. Immobility
4. previous cellulitis
Dermatitis and eczema of the lower legs
Causative organisms
Staphylococcus and
Streptococcus
Presentation
Venous eczema and stasis dermatitis are both erythematous, scaly and often exudative eruptions
usually seen around the ankle and lower leg.
Occasionally, similar changes occur at other sites of venous hypertension such as the pendulous skin
over an obese abdomen or in association with an arteriovenous fistula in the upper limb.
The eczema is often accompanied by other manifestations of venous hypertension, including
dilatation or varicosity of the superficial veins, oedema, purpura, haemosiderosis and ulceration or
small patches of white, atrophic, telangiectatic scarring (‘atrophie blanche’)
.Leashes of dilated venules around the dorsum of the foot or ankle are particularly common.
Dermatitis and eczema of the lower legs
Treatment ladder
First line
Skin care, including leg elevation, emollients and topical corticosteroids
Second line
Compression hosiery
Third line
Referral to vascular surgeon to consider surgical intervention
Juvenile plantar dermatosis
Definition
This condition is characterized by shiny, dry, fissured dermatitis of the plantar surface of the forefoot.
Synonyms
Forefoot eczema
Peridigital dermatosis
Dermatitis plantaris sicca
Atopic winter feet
Juvenile plantar dermatosis
Age
3-14 Years
Sex
Male Children
Associated Diseases
Atopy
Pathophysiology
Mild Non-specific Eczema
Blockage of Sweat Glands
Environmental Factors
Resulting changes in composition of children socks and shoes due to frictions & sweating
Juvenile plantar dermatosis
Juvenile plantar dermatosis
Clinical features
The presenting features of juvenile plantar dermatosis are redness and soreness on the plantar surface
of the forefoot, which assume a shiny, ‘glazed’ and cracked appearance. The condition is mostsevere on the ball of the foot and toe pads, and tends to spare the non‐weight‐bearing instep. The
toe clefts are normal and this helps to distinguish the condition from tinea pedis. The symmetry of the
lesions is a striking feature.
Investigations
Clinical
Skin Scraping
Patch test
Juvenile plantar dermatosis
Treatment ladder
First line
Change to leather footwear and cotton socks/open sandals
Second line
Emollients, including urea‐containing preparations
Third line
Lassar’s paste/tar/tacrolimus ointment
Pityriasis alba
Definition
This is a pattern of dermatitis in which hypopigmentation is the most conspicuous feature. Some
erythema and scaling usually precede the development of hypopigmentation but these are often
relatively mild.
Age
Children 3-16 years
Sex
Equal
Associated Diseases
Atopic Eczema
Pityriasis alba
Pityriasis alba
Clinical Features
The individual lesion is a rounded, oval or irregular hypopigmented patch that is usually not wellmarginated. Lesions are often slightly erythematous and have fine scaling.
There are usually several patches ranging from 0.5 to 2 cm in diameter, but they may be larger,especially on the trunk. In children the lesions are often confined to the face, and are mostcommon on the cheeks and around the mouth and chin. In 20% of affected children the neck,arms and shoulders are involved as well as the face.
Differential Diagnosis
Vitiligo
Naevus depigmentosus
Nummular dermatitis
Psoriasis
Mycosis fungoides
Pityriasis alba
Prognosis
The course is extremely variable. Most cases persist for some months, and some may still show
hypopigmentation for a year or more after all scaling subsides. Recurrent crops of new lesions may
develop at intervals. The average duration of the common facial form in childhood is a year or more.
Treatment ladder
First line
Emollient
Second line
Mild topical corticosteroids
Third line
Topical tacrolimus or pimecrolimus
Chronic superficial scaly dermatitis
Definition
This is a chronic condition characterized by the presence of round or oval erythematous, slightly scaly
patches on the limbs and trunk, which histologically show mild eczematous changes with little or no
dermal infiltrate.
Synonyms and inclusions
Digitate dermatosis
Persistent superfificial dermatitis
Small plaque parapsoriasis
Chronic superficial scaly dermatitis
Chronic superficial scaly dermatitis
Age
Middle Age
Sex
Men
Ethnicity
All
Pathophysiology
Unknown
Differential Diagnosis
Nummular Dermatitis
Poikiloderma
Ecezematides
Mycosis-fungoides
Chronic superficial scaly dermatitis
Prelymphomatous eruption Chronic superficial scaly dermatitis
Bizarre or angulated shape Regular, round or oval shape
Fine scale Coarser scale
May be irritable Little or no irritation
Progresses to cutaneous lymphoma Does not become malignant
Histology
Absence of epidermal eczema May be eczematous changes
Dermal infiltrate Little or no dermal infi ltrate
Chronic superficial scaly dermatitis
Prognosis
The patches are more prominent in winter than in summer, and may clear temporarily with
natural or artificial sunlight. They will also clear for a time with suitable topical medications but
recur in the same, or adjacent, areas when treatment is stopped. After extending they then
usually remain static and, with minor fluctuations, persist throughout life. In a few patients the
condition clears permanently.
Chronic superficial scaly dermatitis
Treatment ladder
First line
Emollient
Second line
Mild topical corticosteroids
Third line
Phototherapy (narrow‐band UVB/PUVA)
EXOGENOUS ECZEMAS
Contact Dermatitis
• The generic term applied to acute and chronic
inflammatory reactions to substances that come in
contact with the skin
Types of Contact Dermatitis
Irritant Contact Dermatitis
• An inflammatory reaction in the skin resulting from exposure to a substance that causes an eruption in most people who come in contact with it
although inflammatory and immunological mediators may be
activated, no antigen-specific reaction is involved
no previous exposure to the irritant is necessary
Allergic Contact Dermatitis
• An acquired delayed sensitivity to various substances that produce inflammatory reactions in only those who have been previously sensitized to the allergen
CONTACT DERMATITIS
Irritant contact dermatitis
Non immunological
caused by a chemical irritant
Allergic contact dermatitis
Immunological
caused by an antigen (allergen) that elicits a type IV(cell-
mediated or delayed) hypersensitivity reaction.
Photoallergic contact dermatitis
Exposure to sunlight required to elicit contact dermatitis
substances are transformed into irritants or sensitizers
(photosensitizers) after irradiation with UV
Phytophotodermatitis
Allergic contact dermatitis associated with plants
Differences between direct irritant and
allergic contact dermatitis Direct irritant Allergic contact
Prevalence Very common Much less common
Prior exposure
to substance Not required Essential
Affected sites Sites of direct contact Sites of contact
with little extension and distant sites
Susceptibility Everyone susceptible Only some patients susceptible
Timing Rapid onset 4~12 hours Onset generally 24 h
after contact or longer after exposure
Lesions develop at first No lesions on first
exposure exposure
DIFFERENCES BETWEEN IRRITANT AND ALLERGICCONTACT DERMATITIS
IRRITANT ALLERGIC
Allergic contact dermatitis
Erythema at contact sites
Allergic contact dermatitis
erythema、edema
Allergic contact dermatitis
Erythema 、papules at contact sites
Allergic contact dermatitis
Erythema and edema
at contact site
Allergic contact dermatitis
Erythema and papules at contact site
Red patch and scales
at contact sites
Allergic contact dermatitis
Allergic contact dermatitis
Red patch
at contact sites
Erythema and edema、blister and oozing
at contact sites
Allergic contact dermatitis
Allergic contact dermatitis
Erythema and edema at contact sites
Allergic contact dermatitis
erythema、blister and bulla at contact sites
Allergic contact dermatitis of
ear and neck: neomycin
Allergic contact dermatitis of
wrist: nickel
Allergic phytodermatitis of
leg: poison ivy
Linear vesicular lesions with erythema
and edema on the calf at sites of direct
contact of the skin 5 days after exposure
with the poison ivy leaf.
Allergic phytodermatitis of
face: poison ivy
Infective dermatitis
Infected eczema. Infected eczema shows erythema, exudation and crusting. The exudation may
be profuse, generating crusting, or slight, with the accumulation of layers of somewhat greasy,
moist scale, beneath which the surface is raw and red. The margin is characteristically sharply
defined, and the horny layer is often split to form an encircling collarette. There may be small
pustules in the advancing edge and, where a flexure is involved, it is often the site of a deep and
persistent fissure.
Infective dermatitis
Infective eczema. Infective eczema usually presents as an area of advancing erythema,
sometimes with microvesicles. It is seen predominantly around discharging wounds or ulcers, or
moist skin lesions of other types. Infective dermatitis is relatively common in patients with venous
leg ulcers, but care must be taken to distinguish it from contact dermatitis due to the application
of topical medicaments.
chronic threadworm infestation
Pediculosis
Scabies
secondary impetigo
Molluscum- contagiosum
Infective dermatitis
Infective dermatitis
Pathophysiology
Bacterial antigens can promote a cytotoxic reaction in the skin, but this is perhaps more likely to
aggravate or perpetuate than to initiate the eczematous process. Bacterial superantigens such as
staphylococcal protein A and enterotoxin B may be profound immune stimulants and may
aggravate atopic eczema.
Eczematous reactions can occur as an allergic reaction to a fungal infection elsewhere in the skin.
Infective dermatitis
Treatment ladder
First line
Treat primary cause (e.g. ulcer) or modify footwear if relevant
Second line
Topical antibiotics (for mild presentations)
Third line
Systemic antibiotics (also potassium permanganate soaks for forefeet variant)
THANKS