Dermatitis

Skin made easy.

1. DERMATITIS / ECZEMA Dr. Angelo Smith M.D WHPL

2. Effect on Quality of Life (Burden of Disability) 10-15% children suffer from atopic dermatitis Asteototic dermatitis is becoming more and more common in the elderly Hand dermatitis is a major cause of absence from work

3. Critical components of the physical exam of the skin should include: Type Color Shape Arrangement Duration Distribution

4. Adequate history should include: Skin symptoms Constitutional symptoms Travel/Occupation Systems review Self care

5. Shapes of Lesions The shape of a lesion frequently gives clues to the etiology of the skin lesion. Shapes include lesions that are: round, polygonal, polycyclic, annular, iris, serpiginous , umbilicated,and target. Margination is also important – are the lesions well or ill defined Arrangement – are the lesions grouped or disseminated

6. Distribution of Lesions A significant number of skin diseases are limited to specific regions of the body Are the lesions isolated, localized, regional, or generalized Are the lesions symmetrical; limited to exposed areas, sites of pressure, or intertriginous areas

7. Classification of Eczema / Dermatitis Historically Endogenous (occurring from within) dermatitis was given the name “ eczema” Exogenous dermatitis (occurring from without) was termed “ dermatitis”

8. Classifications of Eczema Endogenous Atopic or IgE Seborrheic Discoid or nummular Pompholyx Venous Asteatotic Juvenile plantar Erythoderma Exogenous Allergic Toxic irritant contact Photosensitive

9. Eczema - Common Definitions Any itching rash Any red itching rash Any red itching rash that has scales or is dry The itch that rashes Any rash that cannot otherwise be identified

10. Eczema-Dermatological Definition An acute, subacute but usually chronic pruritic inflammation of the epidermis and the dermis, often occurring in association with a personal family history of hay fever, asthma, allergic rhinitis or atopic dermatitis. 1 1 Color Atlas and Synopsis of Clinical Dermatology

11. Characteristics of Acute Eczema Well demarcated plaques of erythema and edema on which are superimposed and closely spaced small vesicles filled with clear fluid with punctate erosions and crusting Distribution may be isolated and localized or general

12. Acute Eczema ( Note the erythema, vesicles and swelling) Term dyshidrotic is a misnomer as sweat glands are not involved Also known as pompholyx

13. Characteristics of Subacute Eczema Plaques of mild erythema with small dry scales and or superficial desquamation, sometimes associated with small red, pointed or round papules Distribution may be isolated and localized or general

14. Subacute Eczema Note erythema, swelling and desquamation

15. Dermatitis Commonly misdiagnosed as tinea

16. Characteristics of Chronic Eczema Plaques of lichenification with deepening of the skin lines with satellite, small, firm flat or round top papules, excoriations and pigmentations or mild erythema Distribution – isolated and localized or generalized

17. Chronic Eczema Note lichenification , scaling and fissuring

18. Dermatitis Commonly misdiagnosed as psoriasis

19. Acute - Subacute - Chronic Swelling and erythema Punctate erythema , desquamation Lichenification

20. Atopic Dermatitis 10-20% of population Primary symptom: itch Location, location, location Associated with atopic background Periorbital pallor

21. Atopic / IgE Eczema Characteristics: 60% have onset in the first year of life Influenced by genetics and environmental factors More common in males that females Ethnicity may be a factor –less common in Asians; more common in Westerners and higher socioeconomic families Theory is - manifestation of well nourished immune system rarely challenged by infection Rare to have adult onset 2/3 of patients have family history of asthma, hay fever or allergic rhinitis

22. May persist months to years All patients have dry skin Exacerbations caused by allergens, stress, hormones, climate, skin dehydration Physical characteristic may include all phases Distinctive Characteristics: Lesions are usually bilateral Located frequently in skin folds/creases and flexor surfaces

23. Distribution Note: Bilateral Skin folds and flexor surfaces

24. Triggers: Irritants Dry skin; bathing without moisturizing Harsh/perfumed soaps, detergents Disinfectants Contact with wool, occupational chemicals/fumes Allergens Dust mites Pet dander (cat more allergenic than dog) Pollens, seasonal and molds Foods- strawberries, carrots

25. Infections Bacterial Viral Cold and other URI viruses GI viruses Fungal Environmental Extremes in temperature and/or humidity Perspiration Stress

26. D / D Confused with: Scabies, seborrhea, psoriasis and, contact dermatitis

27. Infantile Phase (patients 2 months to 2 years of age) Eruption may become generalized, in most cases it first manifests with severe “cradle cap” or severe intertriginous rashes (groin, neck, axillae ). As the patient approaches age 2 years, the flexor creases become involved. Lesions consist of scaly, red, and occasionally oozing plaques that tend to be symmetric. Occurs on the scalp face, particularly cheeks neck chest extensor extremities

28. Childhood Phase (patients aged 2 years to 12 years of age) These patients tend to be less acute and lesions less exudative than those seen in infancy. Inflamed lesions become lichenified (especially in Asian and African-American patients) secondary to chronic rubbing and scratching. Lesions tend to occur symmetrically, with characteristic distribution in the flexural folds. Occurs on the: Antecubital and popliteal fossae Neck, wrists, and ankles May occur on the eyelids, lips, scalp, and postauricular areas

29. Adolescent and Adult Phase (patients 12 years and older) Post inflammatory hyper or hypo pigmented changes tend to be seen. The appearance of atopic dermatitis may change to a more poorly defined, itchy, erythematous rash, possibly with papules and/or plaques. Lichenified plaques of atopic dermatitis are typically less well demarcated than are the plaques seen in psoriasis. These plaques tend to blend into surrounding normal skin.

30. Characteristics: Positive family history is common Seen in all age groups equally May occur on presternal area and mid upper back Stress may increase symptoms Pityrosporum ovale may be causative factor Distinctive Characteristics: Red greasy scaling rash consists of patches and plaques with indistinct margins and an underlying red glazed look to the skin Most commonly located in the hairy areas, nasolabial folds, retroauriclar folds Excoriations from scratching are rare SEBORRHEIC DERMATITIS

31. Redness and flakes appear in the head. Eruptions on scalp may appear. Treated with shampoos containing ketokonazole or hydrocortisone

32. Allergic (Contact ) Eczema Characteristic: Delayed, cell mediated hypersensitivity Strong sensitizer results in reaction soon after exposure Weak sensitizer my take months or years to develop reaction Age does not influence capacity for sensitization but more common in adults Black skin is less susceptible Important cause of disability in industry Non seasonal

33. Characteristics: usually clears quite rapidly on withdrawal of offending agent may appear as erythematous papules, vesicles or bullous more common where epidermis is thinner Distinctive Characteristics : Initial lesions usually limited to contact area not bilateral lesions with sharp borders or angles are pathognomonic

34. Causes Metals- nickel, platinum (10% of women) Detergents Plants and fibers Chemicals and dyes Polyethylene glycol and polysorbate 60 Topical antibiotics and medications Animal keratin

35. Distribution

36. Note: distribution

37. Note: Linear distribution with satellite lesions

38. Allergic Contact Dermatitis Poison Ivy/Oak/Sumac linearity

39. Allergic Contact Dermatitis Potassium Dichromate in Leather

40. Allergic Contact Dermatitis Latex Cleaning products Cosmetics Occupational exposures Check the feet and nails!!!

41. Allergic Contact Dermatitis

42. Allergic Contact Dermatitis Contact dermatitis with Nickel. Reddish marking and itching will occur.

43. Irritant Contact Dermatitis Prevention is key!

44. Lip licker dermatitis

45. Nummular Dermatitis Coin shaped patches and plaques Secondary to xerosis cutis Primary symptom itch Notice the surrounding xerosis

46. Characteristics: usually - personal or family history of allergy, especially asthma, hay fever, and childhood eczema Distinctive Characteristics - Coin-shaped papulovesicular patches that develop in to scaling and crusting lesions; lesions may be as large as 4-5cm in diameter with distinct margins, initial eruptions on arms and legs; intense itching; tends to be chronic

47. Characteristics: Most severe during winter; may be aggravated by systematic administration of iodine or bromine; secondary bacterial infections are common Treatment: skin hydration, topical corticosteroids, intralesional injection, coal tar ointments, UVB treatment, treat secondary infection

48. Note: Coin shaped lesions dorsal surface arms bilateral

49. Asteatotic Dermatitis Extreme case of xerosis Riverbed type cracking

50. Xerotic Eczema, “Winter Itch ” Characteristics: Seen mainly in elderly Worse in the winter Precipitated by excessive washing Treatment: Avoid excessive washing and use of soap Emollients Increase humidity in the environment Topical steroids for a short periods of time

51. Stasis Dermatitis Venous hypertension Full spectrum of timing Id reaction common Complicated by ulceration

52. Pseudokaposi’s (acroangiodermatitis) Venous ulceration Dispigmentation (chronic) Lipodermatosclerosis

53. Id reaction Superimposed allegic contact Do: 1) dry weeping lesions 2) cover for infection Don’t: 1) apply neosporin 2) just hope steroids will fix it

54. Localized Neurodermatitis (known as Lichen Chronicus Simplex) Characterisitcs: Origin often small patch of dermatitis or insect bite starting the itch –scratch- itch cycle Condition unrelated to allergies or family history More common in women Nonseasonal aggravated by stress worse at night may be secondary to atopic eczema, contact dermatitis, lichen planus, psoriasis, or insect bite

55. Distinctive Characteristics: Lesions lichenified or excoriated usually limited to a single patch at hairline of nape of neck or on wrists, ankles, ears, or anal area Not bilateral Llichenification of dark skin develops a “follicular pattern”

56. Lichen simplex chronicus Prurigo simplex No fungus on the scrotum!

57. Butterfly sign Prurigo Nodularis Consider screening

58. Stepped Approach to Treatment of Eczema Conservative Therapy Education - prevention Use of astringents and emollients/moisturizers OTC products (hydrocortisone, Benadryl, Calamine, etc.) Low to mid potency steroid creams High potency steroid creams Coal Tar PUVA therapy (phototherapy)

59. Prevention Checklist Moisturize daily Wear cotton, avoid wool and tight clothes Take lukewarm showers, using mild soap or nonsoap cleansers Pat dry – do not rub Apply moisturizer within 3 min. to “lock in” moisture Avoid extremes of heat / humidity and perspiration Learn triggers and how to avoid them Keep fingernails short Remove carpets and pets from the home

60. Avoidance Irritants: Recommend non-irritant fabric, such as cotton. Wool may induce itching Overheating and sweating: Excess dryness or humidity should be avoided. An air conditioner or humidifier in a child’s bedroom may help to avoid the dramatic changes in climate that may trigger outbreaks. Allergens: Environmental elimination of airborne substances may bring lasting relief.

61. Soap Free Cleansers Cetaphil Aquanil Aveeno Daily Mositurizer Eucerin Gentle Hydrating Cleanser Lobana Body Shampoo Moisturel pHisoderm Indications: For use in those eczema patients who may be sensitive to one or more of the various potential sensitizers in soaps and shampoos. To cleanse, reduce irritation (if sensitive to soaps), and reduce dryness (thereby increase absorption of other topicals ).

62. Emollients / Moisturizers Aquaphor Balmex Daily AmLactin Cutemol DML Forte Eucerin Original Hydrisinol Lanolor Indication: To soften and soothe rough, dry skin and increase absorbability of topical medications Directions: Apply as necessary or as prescribed; generally after showering/bathing and pat drying; apply liberally to affected areas Neutrogena Norwegian Formula Lac-Hydrin Aveeno Pen-Kera Curel Lubriderm Advanced Therapy Minerin

63. Astringents Astringents – reduce secretions (by causing contraction of tissues) and are antibacterial Best used in eczema where vesicular or draining lesions are present Acetic Acid 5% (white vinegar) – especially useful in Pseudomonas infections Burow’s Solution (Domeboro and others) Potassium Permanganate

64. Points to Remember Topical Steroids should be applied only to inflamed skin (active disease). When Topical Steroids are applied immediately after bathing their penetration and potency are increased. Low-potency topical steroids are recommended for use on the face and in skin folds.

65. Coal Tar Preparations Tegrin cream and lotion Medotar ointment PsoriGel gel Polytar and Tegrin soaps Tegrin , T/Gel, and other shampoos Indication: to relieve and control itching, and flaking skin associated with psoriasis and seborrhea as well as eczema Directions: Depending on product 1-4 times daily

66. Contraindications : Hypersensitivity Precautions: Do not use on broken skin, genital or rectal area except on the advise of your health care provider. Photosensitivity x 24hr after application May stain light colored hair Warning: High concentrations of some chemicals in coal tar may cause cancer. Concentrations of 0.5% to 5% appear to be safe.

67. PUVA Therapy Indications : Psoriasis, eczema, pruritic rashes of other causes Consists of psoralen (photosensitizing agent) followed by UVA phototherapy Must avoid sunlight for 24h after psoralen Sessions are 3d/wk, may be from 12-30 sessions, increasing in duration Side effects are redness, burning, occasional nausea