• The word ‘eczema’ comes from the

Greekfor ‘boiling’ – a reference to

the tiny vesicles (bubbles) that are

often seen in the early acute

stages of the disorder

• In the acute stage, oedema in the epidermis (spongiosis) progresses to the formation ofintra-epidermal vesicles, which may coalesce into larger blisters or rupture.

• The chronic stages of eczema show less spongiosis and vesication but more thickening of the prickle cell layer (acanthosis) and hornylayers (hyperkeratosis and parakeratosis).

• variable degree of vasodilatation andinfiltration with lymphocytes

Acute eczema

Acute eczema is recognized by its:

• weeping and crusting

• blistering – usually with vesicles but, in many cases, withlarge blisters

• redness, papules and swelling

Chroniceczema

Chronic eczema may show all of the above changesbut in general is:

• less vesicular and exudative

• more scaly, pigmented and thickened;

• more likely to show lichenification– a dry leathery thickened state, with increased skin markings, secondary to repeated scratching or rubbing;

1. Heavy bacterial colonization is common in all typesof eczema , overt infection is most troublesome in the seborrhoeic, nummular and atopic types.

2. Local superimposed allergic reactions to medicaments can provoke dissemination, especially in gravitational eczema.

3. a huge effect on the quality of life.

4. An itchy sleepless child can wreck family life.

5. Eczema can interfere with work, sportingactivities and sex lives. Jobs can be lost through it

Exogenous eczema

Patch testing

• to identify the allergens.

• In patch testing, standardized non-irritating concentrations of common allergens are applied to the normal skin of the back. If the patient is allergic to the allergen, eczema will develop at the site of contact after 48–96h.

Photopatch testing

• A chemical is applied to the skin for 24 h and then the site is irradiated with a suberythemal dose of ultraviolet irradiation;the patches are inspected for an eczematous reaction 48 h later.

• Total and specific IgE antibodies are measured by a radio-allergosorbent test RAST test as it carries no risk of anaphylaxis, is easier to perform and is less time consuming

• Cultures for bacteria and Candida if theeczema is worsening despite treatment, or if there is much crusting

• This accounts for more than 80% of all cases of contactdermatitis, and for the vast majority of industrial cases

Cause

• Strong irritants elicit an acute reaction after brief contact but prolonged exposure, sometimes over years, is needed for weak irritants tocause dermatitis

• Detergents, alkalis, solvents, cutting oils andabrasive dusts are common culprits.

• Past or present atopic dermatitis doubles the risk of irritant hand eczemadeveloping

Complications

• The condition may lead to loss of work.

Differential diagnosis• It is often hard to differentiate irritant fromallergic contact

dermatitis, and from atopic eczema of the hands

Investigations• Patch testing with irritants is not helpfuland may be misleading

Treatment

• based upon avoidance of the irritants

• reduced exposure by the use of protective gloves andclothing.• Moderately potent topical corticosteroids and emollients are

valuable• Prevention is better than cure because, once started, irritant eczema

can persist long after contact with offending substanceshas ceased, despite the vigorous use of emollients and topical corticosteroids

Cause

• The mechanism is that of delayed (typeIV) hypersensitivity,

It has the followingfeatures.

1. Previous contact is needed to induceallergy.

2. It is specific to one chemical and its close relatives.

3. After allergy has been established, all areas ofskin will react to theallergen.

4. Sensitization persists indefinitely.

5. Desensitization is seldom possible

Allergens

• Are variable• Their ability to sensitize varies – from substances

that can do so after a single exposure (e.g. poison ivy) to those that need prolonged exposure (e.g. chrome – bricklayers take an average of 10 years to become allergic to it).

Presentation and clinical course

• Allergic contact dermatitis should be suspected if:1.certain areas are involved (e.g. the eyelids,

external ear, hands or feet, and aroundgravitational ulcers)

2.there is known contact with theallergens

mentioned3.the individual’s work carries a high risk (e.g.

hairdressing, working in a flower shop, ordentistry)

Investigations

Patch testing• Some allergies are more common than others, nickel top of

the list, with a positive reaction in some 15% of those tested; fragrance allergy usually comes second.

• It is important to remember that positive reactions are not necessarily relevant to the patient’s current skin problem;some are simply ‘immunological scars’ left behind by previous unrelated problems

Treatment• avoidance of the relevant allergen is most important, Job

changesare sometimes needed

• Reducing exposure is usually not enough

• Topical corticosteroids give temporary relief

• The word ‘atopy’ comes from the Greek(a-topos meaning ‘without aplace’).

• Atopy is a state in which an exuberantproduction of IgE occurs as a response to common environmental allergens.

• Atopic subjects may, or may not, develop one ormore of the atopic diseases such asasthma, hayfever, eczemaand food allergies

• Several environmental factors that reduce therisk of developing atopic disease are: having many older siblings, growing up on a farm, having childhood measles and gut infections.

• A strong genetic component is obvious, although affected children can be born to clinically normalparents.

• The concordance rates for atopic eczema in monozygotic and dizygotic twins are around 80% and 22%, respectively

• Atopic diseases tend to run a specific type within each family. In some, most of the affected members will have eczema; in others, respiratory allergy will predominate.

• There is also a tendency for atopic diseases to beinherited more often from the mother than the father, and if both parents have atopic eczema, a child has a 75% chance of developing the disease.

• It affects at least 3% of infants

Onset

• 75% of cases of atopic eczema begin before the age of 6 months, and 80–90% before the age of5 years.

• the onset may be delayed until childhood oradult life.

• 60–70% of children with atopic eczemawill clear by their early teens, although subsequent relapses are possible.

• The distribution and character of the lesions vary withage but a generaldryness of the skin may persist throughoutlife.

In infancy

• atopic eczema tends to be vesicular

• often starts on the face with a non-specific distributionelsewhere.

In childhood

• the eczema becomes leathery and dry

• affecting mainly the elbow and knee flexures, wrists andankles.

• A stubborn ‘reverse’ pattern affecting the extensor aspects of the limbsis also recognized.

In adults

• the distribution is as in childhood with a marked tendency towards lichenification and a more widespread but low-grade involvement of the trunk, face andhands.

• The cardinal feature of atopic eczema is itching, and scratching may account for most of the clinical picture.

• Affected children may sleep poorly, be hyperactiveand sometimes manipulative, using the state of their eczema to get what they want from their parents.

• The condition remits spontaneously before the age of10 years in at least two-thirds of affected children, butit may come back at times ofstress.

• Eczema and asthma may seesaw, so that while one improves the other may getworse.

Complications

• Overt bacterial infection

• Viral infections, most dangerously with widespreadherpes simplex.

• Growth impairment because of impaired sleep dueto itching and absorption of topical steroids cancontribute

Investigations

• The value of prick testing in atopic eczema remainscontroversial. Often the finding of multiple positivereactions, and a high IgE level, does little more thansupport adoubtful clinicaldiagnosis.

• Avoidance of exacerbating factors such as irritants (e.g. woollen clothing next to the skin) and avoid extremes of temperature, andcontact with soaps anddetergents.

• Emollients used regularly. Those with an associated ichthyosis should generally use ointments rather thancreams.

• Occlusive bandaging (e.g. with a 1% ichthammol paste bandage).

Topical steroids.• A technique useful for extensive and troublesome

eczema, particularly in children, is that of ‘wetwrap’dressings

• Tacrolimus is an immunosuppressant, now available as an ointment for topical use in eczema unresponsive to conventional therapy.

• Best used for treatment of resistant eczema on sensitive sites,such as the face, or in patients requiring constant use of topicalsteroids.

• Local infection might be troublesome and concerns remainaboutthe development of skin cancer or lymphoma in the longterm.

• Patients should be advised to avoid excessive exposure tosunlight or UV lamps while using tacrolimus.

Sedative antihistamines (e.g. trimeprazine or hydroxyzine)

• are of value if sleep is interrupted, but histamine release is not the main cause of the itching, so the newer non-sedative antihistamines help less than might beexpected.

Antibiotics

• Acute flares are often induced by the surface proliferation of staphylococciA month’s course of a systemic antibiotic (e.g. erythromycin) may then behelpful.

Allergen avoidance

In stubborn cases:

• UVB, UVA-1 (340–400 nm) or even PUVA

• Ciclosporin

• Azathioprine

Other

• Chinese herbal remedies

Presentation and course

• mainly affecting hairy areas

• often showing characteristic greasy yellowish

scales

• These patterns may merge together1. A red scaly or exudative eruption of the scalp, ears and face.

• May be associated with otitis externa.2. Dry scaly ‘petaloid’ lesions of the presternal

andinterscapular areas.• There may also be extensive follicular papules on

the trunk.3. lesions of the umbilicus or groins.

• often affecting those with a tendency todandruff

• overgrowth of the pityrosporum yeast skin commensals plays an important part in the development of seborrhoeic eczema. This fits wellwith the fact that seborrhoeic eczema is often an early sign of AIDS, and that it responds to anti-yeast agents such as topical ketoconazole shampoo or cream.

• Seborrhoeic eczema may affect infants but is mostcommon in adult males.

• In infants it clears quickly but in adults itscourse is unpredictable and may be chronic or recurrent

Areas most

often affected

byseborrhoeic

eczemaAreas

most often

affected

byseborrhoeic

eczema

Complications

• Furunculosis

• Candida infection iscommon.

Investigations

• None are usually needed, but bear possible

HIV infection and Parkinson’s disease in mind.

• Therapy is suppressive rather than curative.

• Topical imidazoles are perhaps the first lineof treatment.

• 2 % sulphur and 2% salicylic acid in aqueous cream , It may be used on the scalpovernight

• Shampoo contain ketoconazole, tar, salicylicacid, sulphur, zinc or seleniumsulphide

• For intertriginous lesions, a weak steroid – antisepticor steroid – antifungal combination is ofteneffective.

• For severe and unresponsive cases a short course of oral itraconazole may behelpful.

Cause

• cause is usually unknown, but is sometimes provoked by heat or emotional upsets or small amounts of nickel in food, in subjects allergic tonickel

Presentation and course

• It is tiresome and sometimes very unpleasant formof eczema

• recurrent bouts of vesicles or larger blisters appear on the palms, fingers and/or the soles of adults.

• Bouts lasting a few weeks recur at irregularintervals.

• Secondary infection are arecurrent problem

Investigations• Sometimes a pompholyx like eruption of the

handscan follow acute tinea pedis (an ‘idereaction’).

• Swabs from infected vesicles should be cultured for bacterial pathogens.

Treatment

• Aluminium acetate or potassiumpermanganate, followed by applications of avery potent corticosteroid cream, are oftenhelpful.

• Appropriate antibiotics should be given forbacterial infections.

Cause

• Poor circulation, often accompanied by obvious

venous insufficiency.

Presentation and course

• A chronic patchy eczematous condition of the lower

legs, sometimes accompanied by varicose veins,

oedema and haemosiderin deposition

Complications

• Sensitization to local antibiotic applications or to the

preservatives in medicated bandages.

• Ulcer

Treatment

• elimination of oedema by elevation,pressure bandages or diuretics.

• A moderately potent topical steroid may be helpful, but stronger ones are bestavoided.

• It is liable to persist, despite surgery to the underlying veins.

Cause• The skin is damaged as a result of repeated

rubbing or scratching, as a habit or in response tostress, but there is no underlying skin disorder.

Presentation and course

• A single, fixed, itchy• Lesions may resolve with treatment but tend to

recur either in the same place or elsewhere.Treatment• Potent topical steroids or occlusive bandaging,

where feasible,help to break the scratch–itchcycle.

• Tranquillizers are often disappointing.

Cause• This condition is thought to be related to the

impermeability of modern socks and shoe linings with subsequent sweat gland blockage, and sohas been called the ‘toxic sock syndrome’!

Presentation and course• The skin of the weight-bearing areas of the feet, particularly

undersides of the toes, becomes dry and shiny with deep painful fissures thatmake walking difficult.

Treatment

• wear cotton or woolsocks.• An emollient such as emulsifying ointment or 1%

ichthammol paste, or anemollient containing lactic acid, is as good as a topicalsteroid.

Cause• The most common type of napkin eruption is irritant in

origin, and is aggravated by the use ofwaterproof plastic pants.

• The mixture of faecal enzymes and ammonia produced by urea-splitting bacteria, if allowed to remain in prolongedcontact with the skin, leads to a severe reaction.

Presentation• The moist and sore erythema.Complications• Superinfection with Candidaalbicans is common.• Differential diagnosis

• infantile seborrhoeic eczema

• candidiasis.

• It is never easy tokeep this area clean and dry, but this is the basis of all treatment.

• superabsorbent diaper is best and should be changed regularly, especially in the middle of thenight.

• The area should be cleaned at each nappy change with aqueous cream andwater.

• Protective ointments (e.g. zinc and castor oil ointment)

• Potent steroids should be avoided but combinations of hydrocortisone with antifungals or antiseptics areoften useful

Tony had inflamed, red patches on the insides

of his elbows, around the back of his neck and

behind his knees.

The affected areas looked sore and were

excoriated in places. Tony repeatedly

attempted to scratch the affected areas. The

GP diagnosed atopic eczema.

How is the diagnosis of atopic eczema

established?

What factors are thought to contribute to the

development of atopic eczema?

What are typical trigger factors for atopic

eczema?

Outline a pharmaceutical care plan for Tony.