Dermatitis (Eczema)

Lecture Notes

Hendrik Kunta Adjie, Dermatovenereologist

Copyright-2011
 What is Dermatitis ?
• Literally means “ inflamation of the skin”
• Dermatologist use the terms to refer to a specific
group of inflamatory skin disease
• “wastebasket”
• Clinical presentation :
– Pruritic, erythematous lesions with or without distinct
margins.
• Phases :
– Acute (vesicular)
– Subacute (Scaling and Crusting)
– Chronic (acanthotic with thick epidermis)
• Primary lesions :
– Macules, papules, vesicles, or plaques
• Secondary lesions :
– Oozing, crusting, scaling, fissuring, and
lichenification
• Primary histologic events :
– Spongiosis (intercellular epidermal edema)
with lymphocytic and / or eosinophilic
infiltrates in the epidermis and dermis
Why is Dermatitis so important ?
• Up to 25% of all patients presenting with a
new skin disease have a form of
dermatitis.
• PRURITUS  Patients desperate for relief
 Classified as dermatitis
• Contact Dermatitis ( Irritan or allergic)
• Atopic Dermatitis
• Pompholyx (dyshydrosic dermatitis)
• Seborrheic dermatitis
• Autosensitization dermatitis (Id reaction)
• Statis dermatitis ( a vascular disorder)
• Lichen simplex chronicus ( a psychocutaneous
numular disorder)
• Generalized exfoliative dermatitis (erythroderma)
Contact Dermatitis
 Definition
• Is an inflammatory reaction of the skin
precipitated by an exogenous chemical
• 2 type : irritant and allergic
• Irritant : produce by a substance that has
a direct toxic effect on the skin
• Allergic : triggers an immunologic reaction
that causes tissue inflamation
 Comparison of Irritant and Allergic Contact
Dermatitis

Irritant Allergic
Examples Water, soap Nickle, fragnance, hair dye

Number of Many Fewer

compounds
Distribution of localized May spread beyond area of
reaction maximal contact and become
generalized
Concentration of High Can be minute
agent needed to
elicit reaction
Time course Immediate to late Sensitization in 2 weeks;
elicitation takes 24-72 h
Immunology Nonspecific Specific type IV delayed
hypersensitivity reaction
Diagnostic test None Patch
• Allergic contact dermatitis is a cell
mediated, delayed, type IV reaction
• The most common causes of allergic
contact dermatitis are :
– Poison ivy
– Paraphenylenediamine
– Nickel
– Rubber compounds
– Ethylenediamine
 Physical Examination
• Acute or chronic
• Lesions depends upon the nature of the
exposure
• Streaks of vesicles are characteristic fo
contact dermatitis to plants
• The location of the dermatitis often
provides a clue as to the nature of the
contactant
• Diferential Diagnosis
– Eczematous erptions
– Fungal infections
– Bacterial cellulitis
• Laboratory :
– Patch test help in identifying the respnsible
allergen(s)
 Therapy
• The ideal therapy is avoidance
• Topical steroids
• acute severe generalized :
– Systemic steroids
– wet dressing or baths
• Systemic antihistamine
Atopic Dermatitis
• “Atopos” means “ strange, unusual, out of
place”
• Is a chronic, pruritic, eczematous condition
of the skin that associated with a personal
or family history of atopic disease (asthma,
allergic rhinitis, atopic dermatitis)
• Incidence :
– predominantly a disease of childhood
 Criteria to Diagnose
• The Hanifin – Rajka Criteria ( 3 of 4) :
– Pruritus – the primary symptom
– Typical morphology and distribution of lessions for age
– Chronic or chronically relapsing course
– Personal or family history of asthma, allergic rhinitis or
atopic dermatitis
• Which come first the itch or the rash ?
– “ atopic disease is an itch, which when scratched,
erupts”
– If there is no friction or scratching, there is no eruption
Presentation of atopic dermatitis at
different ages
1. Infantile (2 months-2 years)
• Distribution : Cheeks, face & scalp,
extensor surfaces of extremities, and trunk

• Morphology : erythema, papules, vesicles,

oozing, and crusting

• Clearing : clears in half of the patients by

three years of age
2. Childhood (3-11 years)
• Distribution : Wirst, ankle, back of the tighs,
buttocks, and antecubital and popliteal fossae

• Morphology : Chronic, lichenified scaly patches

adan plaques that may have crusting and oozing

• Clearing : two thirds of patients clear by age 18

3. Adolescent / Young Adult (12-20 years)
• Distribution : face, neck, arms, back, and
flexures

• Morphology : Thick, dry, lichenified plaques

without weeping, crusting, or oozing

• Clearing : 90% of patients clear by age 18

4. Adult (>20 years)
• Distribution : Most commonly involves the
hands, sometimes the neck, and rarely
diffuse areas
• Morphology : Lichenified plaques, fissures
on the hands, occasional vesicular
outbreaks, one subset of “sensitive skin”
patients
 Physical findings associated with
atopic dermatitis
• Pruritus
• Dry skin
• Keratosis pilaris
• Pytiriasis alba
• Hyperlinear palm and sole creases
• Mild to moderate erythema at face
• Perioral palor
• Dennie-Morgan lines
• Vascular abnormality
 Factors provoke or exacerbate
• Excessive washing without appropriate skin
lubrication
• Repeat water exposure
• Topical irritants : wools, synthetic fabrics, poorly
fitting clothes, solvent, sand
• Airborne particles : tobacco smoke, animal ,
dander, mold, house dust, mites
• Foods induce atopic dermatitis
– Allergies to milk, eggs, nuts, soybean products,
wheat, and seafood
 Differential diagnosis
• Nonspecific eczematous eruptions
• scabies
 Laboratory
• The diagnosis atopic dermatitis is made
clinically
• Skin biopsy : eczematous dermatitis
• Serum Ig E is frequently elevated
Atopic dermatitis can’t be cured but
a variety of measures can control it
• Avoid
• Moisturize
• Limit soap use
• Wear cotton clothing
• Acute inflamed  wet to dry compressed
• Subacute or chronic  topical corticosteroid
• Calcineurin inhibitors (tacrolimus, pimecrolimus)
• Resistant occlusion of topical corticosteroid and
calcineurin inhibitors
• Secondary infection : antibiotic therapy
• Severe  systemic treatment ( cyclosporin, azathioprine)
Pompholyx (dyshydrosic dermatitis)
• “buble”
• Exacerbation by sweating, emotional stress
• “episodic vesiculobullous eczema of the palm and soles”
• “ Hand and Foot eczema”
• Clinically :
– crops of clear, deep seated, tapiocalike vesicles on
the palms and sides of the fingers in 80% cases
– Erythema is often absent, heat and prickling
sensation may precede attack
– Nails may become dystrophic
 Causes
• Nobody knows for sure
• Diferential diagnosis :
– Nummular dermatitis
– Contact dermatitis
– Oral allergy to metals
– Infections
– Id reactions
– Pemphigus or pemphigoid
 Management
• Most attacks resolve spontaneously within
1-3 weeks
• Hand protection : emollients
• Large blister : drained
• Infection : antibiotic
• Potent topical corticosteroid
• methotrexate
Seborrheic dermatitis
 Definition
Is a chronic, superficial, inflammatory
process affecting the hairy regions of the
body, especially the scalp, eyebrows, and
face
• Etiology is unknown
• Dandruff is scaling of the scalp without
inflammation
• Incidence : seborrheic dermatitis is a
common problem
 History
• The occurrence parallels with the
increased of the sebaceous gland activity
occuring in pregnancy and after puberty
• Newborn baby and age 18-40
 Physical examination
• Predilections :
– Hairy regions of the skin ( scalp, eyebrows, eyelids,
nasolabial creases, ears, chest, intertriginous areas–
the axilla, groin, buttocks,& inframammary folds
• Pityriasis Sicca and pityriasis steatoides
• In its most mild form, dandruff, there is fine
whitish scaling without erythema.
• The patches and plaques characterized by
indistinct margins, mild to moderate erythema,
and yellowish, greasy scalling.
• Uncommon to have hair loss
 Differential Diagnosis
• Psoriasis
• Psoriasis inversa
• Candidosis
• Otomikosis
 Therapy
• Antiseborrheic shampoos ( sulfur, salicylic
acid, coal tar, selenium sulfide, & Zinc
pyrithione.
– R/ 2%ketoconazole shampoo
• Low potency glucocorticoid solution, lotion
or gel
• Pimecrolimus 1% cream
• Hydrocortisone cream for non hairy skin
Statis dermatitis
 Definition
• Is an eczematous eruption of the lower
legs secondary to peripheral venous
disease
• Venous incompetence causes increased
hydrostatic pressure and capillary damage
with extravasation of red blood cells and
serum.
• Incidence : adults, predominantly of midle
and old age.
• History :
– chronic, pruritic eruption of the lower legs
preceded by edema and swelling
– thrombophlebitis
 Physical Examination
• Charactized By :
– Edema
– Brown pigmentation
– Petechiae
– Subacute and chronic dermatitis
 Differential Diagnosis
• Contact dermatitis
• Peripheral arterial disease
• Superficial fungal infection
• Bacterial cellulitis
 Therapy
• Prevention of venous stasis and edema
• Topical steroid
• Wet compresses if there is oozing or
crusting
Lichen simplex chronicus
 Definition
• “Neurodermatitis”
• Is a chronic eczematous eruption of the
skin that is the result of scratching.
• Pruritus precedes the scratching and its
precipitated by frustation, depression, and
stress
• The “itch-scratch-itch” cycle
• Emotional, psychiatric problems
• Nervous habits
 Physical Examination
• Anxious
• Pruritic area of skin that is scratched,
producing a plaque of chronic dermatitis
• The lichenified plaque always occurs
within reach of scratching
 Differential Diagnosis
• Delusions of parasitosis
• Neurotic excoriations
 Treatment
• Tranquilizer and antidepressant
• Topical and intralesional steroids
Nummular Dermatitis
• “Coin like” , range in size 1-10 cm in
diameter
• Lesions :
– occur most commonly on the extensor
surfaces or the lower extremities
– are often bilaterally symmetrical
– May recur at sites of previous involvement
– Typically intensely pruritic
• Age of onset : men 55-65 years, women
15-25 years
• Causes : unknown,
– 95% of the patients have S.aureus colonizing
or infecting lessions may be a
hypersensitivity reaction to the bacteria
 Treatment
• Limiting baths and soap exposure
• Avoiding irritants
• Frequent use of emollients
• Topical corticosteroid
• Avoiding dry environments
• Antihistamine
• Antibiotic : dicloxacillin or cephalexin
Algorithm
 Eczematous lesions
See next algoritm
Young children

Yes
No

localization

elsewhere

Hands/feet Legs Body fold

• Rectilinear
•Outdoor exposure
• Neck antecubitals and
yes
See next algoritm popliteals
• Varicose veins No
• H/o atopy Allergic
• H/o Phlebitis •Lichenified
• family history Contanct
• pedal edema •Chronic
No yes Dermatitis
Atopic •Stress related
dermatitis No
yes Lichen simplex yes
Rectilinear
H/o outdoor exposure Groins and/or chronicus No
Statis axillae
yes dermatitis • Recurs in same location
No yes • Heals with
Lichenified No hyperpigmentation
• +/- arms Allergic contact Refer toDerm • drug exposure
• cracked chins or dermatitis yes
yes No
parched earth No
appearance
• eldery Lichen Simplex • beely red Fixed drug Generalized
•winter chronicus • satelite papules eruption
yes and pustules yes
Xerotic eczema yes
No No
Candida • Spares scalp and face
No Refer to
• Burrows
• central clearing dermatologist
• coin shaped • Mite & eggs in
• scale at edge Skin scrappings
• arms or face
• hyphae on KOH prep
• young adults
yes Non-specific
No No
yes Eczematous
yes
Nummular Tinea • acute onset Dermatitis
No eczema •Contact to sensitizer Scabies
yes
No
Allergic contact •Treat symps
Refer to Derm dermatitis
Refer to Derm •Refer to derm
Treat symps