Eczema - A Case Presentation (by Dr. Julius King Kwedhi)

Eczema: Come from the Greek name for boiling, a reference to the tiny vesicles (bubbles) that are commonly seen in the early acute stage of the disease
An immune-mediated inflammation of the skin arising from an interaction between genetic (e.g. epidermal barrier function, immune system) and environmental factors (foods, airborne allergens, Staphylococcus aureus colonization on skin due to deficiencies in endogenous antimicrobial peptides, topical products)
The eczemas are a disparate group of diseases, but unified by the presence of itch and, in the acute stages, of oedema (spongiosis) in the epidermis

1. A Case Presentation Eczema

2. Definition Eczema: Come from the Greek name for boiling, a reference to the tiny vesicles (bubbles) that are commonly seen in the early acute stage of the disease An immune-mediated inflammation of the skin arising from an interaction between genetic (e.g. epidermal barrier function, immune system) and environmental factors (foods, airborne allergens, Staphylococcus aureus colonization on skin due to deficiencies in endogenous antimicrobial peptides, topical products) The eczemas are a disparate group of diseases, but unified by the presence of itch and, in the acute stages, of oedema ( spongiosis ) in the epidermis

3. Dermatitis: means inflammation of skin, it’s a broader term than eczema which is only a type of several skin inflammations

4. Etiology Endogenous Factors Exogenous Factors Irritant Allergic Photodermatitis Localization: Face, Neck, Scalp, Extremities, Abdomen etc

5. Types of Eczema Infantile (Atopic) Eczema Irritant Contact Eczema Allergic Contact Eczema Occupational Eczema Seborrhoeic Eczema (on upper part of the body) Discoid (Nummular) Eczema Juvenile plantar dermatosis Napkin dermatitis Photodermatitis Pompholyx Gravitational Asteatotic

6. Classic Presentation of Eczema Erythema ( Macules ) Oozing Papulus Vesicles Crusting Scaling Healing

7. Pathogenesis Similar in all types involving similar inflammatory mediators (prostaglandins, leukotriens , cytokines) Helper T cells sometimes activated by superantigens from Staph. aureus Epidermal cytokines help to produce spongiosis & that their secretion by keratinocytes elicited by T lymphocytes, irritants, bacterial products, & other stimuli

8. Histology Acture stage: Spongiosis Intraepidermal vesciles & blisters Chronic stage: Less spongiosis & vesication Acanthosis Hyperkeratosis & parakeratosis These changes accompanied by various degree of vasodiletation & lymphocyte infiltration

9. Clinical Presentation In Acute Phase Erythema ( macules ) [Redness) Weeping and crusting; blistering – usually with vesicles but, in fierce cases, with large blisters; Papules and swelling – usually with an ill-defined border; and scaling.

10. In Chronic Phase Less vesicular & exudation Numular skin lesions Lichenification More scaly and epithelial disruption Fissures

11. Complications Heavy bacterial colonization esp. in seborrhoeic , atopic, nummular Local superimposed allergic reaction to medicaments can provoke dissemination Interfere with sleep Interfere with work Interfere with sporting, activiteis

12. Differential Diagnosis Separated from other skin conditions that look like it. NB: Eczemas are scaly, with poorly defined margins. Exhibit features of epidermal disruption such as weeping, crust, excoriation, fissures and yellow scale (because of plasma coating the scale). Papulosquamous dermatoses , such as psoriasis or lichen planus , are sharply defined and show no signs of epidermal disruption. Occasionally, a biopsy is helpful in confirming a diagnosis of eczema, but it will not determine the cause or type. Once the diagnosis of eczema becomes solid, look for clinical pointers towards an external cause. This determines both the need for investigations and the best line of treatment. Sometimes, an eruption will follow one of the well known patterns of eczema, such as the way atopic eczema picks out the skin behind the knees, and a diagnosis can then be made readily enough. Often, however, this is not the case, and the history then becomes especially important.

13. Differential Diagnosis Psoriasis: sharply marginated , very scaly, involve knee & elbow Scabies: itchy contacts, face spared, burrows, affect nipple & genitalia Lichen planus : mouth lesion, violaceous flat topped papules Fungal infection: annular lesions with active edge Palmoplantar pustulosis : obvious pastules on palm & sole Angiodema & erysipelas: Unusually swollen, on face

14. Investigations Patch test Photopatch test Total & specific IgE antibodies RAST

15. Treatment Systemic Corticosteroids Mycophenolate Mofetil Antihistaminics Sedatives Diuretics Calcineurine inhibitors Topical Corticosteroids Antiseptics Keratolitics Tacrolimus Emollients

16. Treating Acute weeping Eczema Rest & liquid application Nonsteroidal preparation Daily 10 min soaks in cool 0.65% aluminium acetate solution Saline or tap water & soaks followed by a smear of corticosteroid cream or lotion Potassium permanganate Calamine lotion Magenta paint Wet wrap dressing: esp. in children a bath followed by steroid application covered with double layers of tubular dressing

17. Treating Subacture Eczea Steroid lotions or creams Vioforms , bacitracin Fucidic acid, mupirocin , neomycin

18. Patient Patient presented with: Itchy back , feet, hands, arms, on face and under shin Scales on palms of hands Itchy around 20:00-22:00 pm 4 months ago patient has accident: Cuts on hands and knees Dr prescribed medication (antibiotics), Appearance of vesicles and later on oozing, followed by crusting and scaling on right hand and area of trauma ( Koebner Phenomenon) Later given treatment for eczema

19. Anamnesis 10 yrs ago patient was pierced with a knife on right arm After taking medication eczema appeared Given treatment and eczema was treated But after he ate chocolate, it appeared again Current condition was aggrevated by energy drinks and diet

20. Treating Chronic Eczema Steroid in ointment base Icthamole Zinc c Nothing stronger than 0.5-1% hydrocortisone oint . On face or in anfants Mild potency corticosteroids not more than 200g/wk Moderate potency corticosteroids not more than 50g/wk Potent corticosteroids not more than 30g/ wkream or paste

21. Systemic Therapy Systemic steroid ( prednisolone ) Hydroxyzine Doxepin Trimeprazine Systemic antibiotics

22. Common Patterns of Eczema Irritant Contact Dermatitis 80% of dermatitis cases Mostly industrial Usually on hands & forearm Acute reaction elicited after brief contact Commonly by detergents, alkalis, solvents May lead to loss of work DDX: allergic contact dermatitis, atopy Patch test with irritants is not helpful & may be misleading Rx: avoid irritants, use protective measures, barrier creams, topical steroids & emollients, change of job

23. Allergic Contact Dermatitis The mechanism is delayed type 4 Hypersensetivity Previous contact is needed Its specific to one chemical usually Remote areas may be affected Sensetization is persists indefinitely Most allergens are simple chemicals that bind to a protein to become complete antigen Areas involved eyelids, external auditory meatus , hands & feet

24. Allergic Contact Dermatitis (cont…) High risk individuals are hair dressing, working in flower shop, dentisty Common allergens: chrome, nickle , cobalt, lanolin, neomycin, rubber, poison ivy & oak Jewellery , bra clips, jeans stud are common causes Patch test is recommended Treatment: Avoid allergens, topical steroid, adding ferrous sulphate to cement to reduce its water soluble chromate content

25. Atopic Eczea Means without place in greek Is a state in which exuberant production of IgE occurs as a response to common environmental allergens Atopic patient develop one or more of atopic diseases as asthma, aczema , hay fever, & food allergies Concordance rate in monozygotic twins is 86%, in dizygotic is 21% 75% begin before 6 months, 80-90% before 5 years, totally affect 3% of infants 60-70% will clear by their early teens

26. Atopic Eczema has 3 Phases Infantile: vesicular, weeping, start at face Childhood: leathery, dry, excoriated, affects elbow, knee flexures, wrist ankle Adults: lichenification , more wide spread, white dermographism is striking

27. Atopic Dermatitis Cardinal feature is itching If there is no itching, it is probably not eczema Diagnostic criteria: Must have: Chronically itchy skin Plus 3 or more of the following: History of itching in skin creases History of asthma or hay fever General dry skin Visible flexural eczema Onset in first 2 years of life

28. Complications: bacterial infections, widespread Herpes simplex, M. contagiosum Prick test used to show type 1 reaction Treatment: Explanation, reassurance, avoid exacerbating factors, topical steroids, tacrolimus , sedative antihistamines, antibiotics, UVA, UVB, cyclosporin

29. Seborrhoeic Eczema common eczema of the hairy areas show characteristic greasy yellowish scales Red scaly exudative or dry scaly or intertriginous Affects scalp, ears, eyebrows, face, presternal area, armpits, umblicus , groin May be familial (hereditary), affect those with dandruff (a scaly flake formed on and shed from the scalp) There may be overgrowth of of pityrosporum yeasts May be early sign of AIDS Mainly affect adults, usually recurrent May associated with furunculosis , or superadded candida infection Treatment: topical imidazole , sulphur , salicylic acid, topical steroids, ketoconazole shampoo

30. Discoid (Nummular) Eczema Common endogenous eczema Affects limbs of middle age males Reaction to bacterial antigen is suspected Multiple coin shaped vesicular crusted itchy plaques Treatment: topical steroid & antibiotics

31. Pompholyx Recurrent bouts of vesicles or blisters on palms, fingers & or sole of adults Cause is unknown,may provoke by stress or heat or may be allergy to nickle Recurrent infection & lymphangitis is a recurrent problem, it may follow acute Tinea pedis Treatment: antibiotics, aluminium acetate, potassium permanganate, steroids

32. Gravitational (stasis) Eczema Usually accompanied by venous insufficiency, haemosidrin deposition Chronic patches of eczema on lower legs Patient may become sensetized to local antibiotics or to preservatives in medicated bandages Treatment: eliminate oedema , topical steroids, zinc cream

33. Asteatotic Eczema Itchy eczema patches on lower legs of elderly Contributory factors: Dry skin in old, low humidity in winter, cental heating, diuretics, hypothyroidism Treatment: Steroids, restrict bathing, daily use of emollients

34. Localized Neurodermatitis (Lichen Simplex) Single fixed itchy lichenified plaque on nape of neck in women, legs in men & anogenital area in both sexes Skin damaged from repeated rubbing or scratching as a habit in response to stress Treatment: topical steroid with occlusion, tranquilizers are with little effect

35. Juvenile Plantar Dermatosis May be related to modern socks & shoe lining With subsequent sweat gland blockage Also referred to as toxic sock syndrome Forefeet & undersides of toes become dry shiny with deep painful fissures Treatment: use of cork insole in shoes, cotton or wool socks, emmolients , icthammol , steroid

36. Napkin (Diaper) Dermatitis Irritant in nature aggravated by waterproof plastic pants, feces, urine Moist glazed sore erythema of napkin area sparing skin folds (which diff. it from seborrhoeic eczema) Candida superinfection is common appears as erythematous vesicopustules on periphery Treatment: keep this area clean & dry, use disposal diapers, topical zinc, caster oil, silicone, mild steroid-antifungal combination The child should be allowed to be free of napkins as much as possible

37. Patient Case Was admitted to hospital for trauma injuries due to arm injury After treatment, he noticed vesicles The itchy vesicles healed but returned after he ate something Diagnosis was eczema and it was treated successfully

38. Current Condition Motorbike accident 4 months ago He noticed itchy vesicles in the region of the trauma to the skin (knee and hands) Itchy skin on hands, feet, back and all arms, face, underneath the shin First course of treatment was successful Condition returned after he drank energy drink, and it was successfully treated again He then ate chocolate afterwards and the condition returned and how he Is on third course of medication

39. Clinical Manifestation Scaly skin on hands and knee, at sight of trauma Papules on back and hand Itchy skin all over the body Fluid-filled vesicles: they first appeared red and later burst open and begun to heal Itch aggravates at around 20:00-22:00 Cold temperature helps

40. Scales on Hands

41. Papules On The Back

42. Areas of Trauma

43. Possible diagnosis Probably patient has “ allergic contact eczema ”

44. Reference Richard P.J.B., et al (2008) Clinical Dermatology, Fourth Edition,