Dermatitis (Eczema) PDF

Dermatitis By Dr. Zeyad Al-Dabbagh Assistant Professor of Dermatology Duhok College of Medicine  LECTURE OBJECTIVES n Understand the Pathogenesis and Causes of Eczema n Get Familiar with the Different Types of Eczema and Their Manifestations n Understand the manag...

Dermatitis By Dr. Zeyad Al-Dabbagh Assistant Professor of Dermatology Duhok College of Medicine  LECTURE OBJECTIVES n Understand the Pathogenesis and Causes of Eczema n Get Familiar with the Different Types of Eczema and Their Manifestations n Understand the management strategy for patients with eczema  TERMINOLOGY ECZEMA=DERMATITIS Dermatitis = Dermat + itis refers to skin means “inflamed” (thus, inflamed skin) n Greek- meaning n (ec-) over Is a type of non-papulosquamous n (-ze) out skin disorder, accounts for 25% of dermatological cases n (-ma) boiling The Many Faces of Eczema  The Many Faces of Eczema ill defined lesions, unlike psoriasis  Eczema: A Working Classification n Mainly Caused by exogenous (contact) factors. n Other types of Eczema  Exogenous Eczema n Irritant contact dermatitis n Allergic contact dermatitis n Photosensitive dermattitis -Photo-Irritant -Photo-Allergic  Other Types of Eczema n Atopic dermatitis n Seborrheic dermatitis n Nummular eczema n Dyshidrosis n Lichen simplex chronicus(NeuroDermatitis) n Asteatotic dermatitis n Stasis Eczema(Gravitational) n Pityriasis alba n Juvenile plantar dermatitis  Morphology None Papulo-Squamous Group  Eczema Stages. Eczema/dermatitis may be presented as Acute, subacute or chronic. In the acute eczema, erythema, edema, oozing and papulovesicular eruptions are the presenting features. In the sub-acute eczema, the lesion shows less erythema, edema and oozing with scaling and crusting. In the chronic eczema, the lesion shows dryness and thickening (lichenification).  Histology n (Acute Stage) : Spongiosis, Itraepidermal vesicles, Blisters. n Chronic Stage : Less spongiosis and More thickening of the epidermis (Acanthosis, Hyperkeratosis and Parakeratosis) n Eosinophiles Maybe seen.  ATOPIC DERMATITIS  Atopic dermatitis § prevalence of 16.5% § 10-20% of referrals to dermatology § 30% of dermatological GP consultations  Pathogenesis Multifactorial : § Genetic Factors § Impaired Epidermal Barrier : Decreased Filaggrin protein Mutated flaggrin is the most important genetic predisposing factor § Environmental factors § Immune Dysregulation : TH1-TH2 Imbalance The Atopic Triad  Effects on Life n Intractable itch n Sleep depravation n Disruption to family life n School/work absenteeism n Chronic disease n Low self esteem Growth failure: GH is released during sleep and these patients can’t sleep because of itching. Here in our locality, they receive steroids from paramedics which impairs growth also. What aggravates eczema?  AD – 3 Stages n Infantile 2 months to 2 years n Childhood 2 years to 10 years n Adult adolescence to adulthood Infantile AD Childhood AD Adult Atopic Dermatitis  Infection n Pts w/ AD more prone to certain cutaneous infx n Staph aureus – 90% of chronic lesions n Eczema herpeticum – generalized herpes simplex infection. Young children usually. Eczema herpeticum: typical vesicular lesions on the hand, around the eye, and on the face  Management STEP 1: Complete STEP 2: Identification Emollient therapy & avoidance of allergens triggers Education Education These same steps are applied for all forms of eczema not only atopic STEP 3: Treatment of one, with some modification according to each disease flare with topical corticosteroids / calcineurin inhibitors Sedating antihistamines (first generation H1 blockers) Education preferred in children to decrease itching and improve sleeping  Treatment n The first step is to break the “itch-scratch cycle” n Avoidance of triggers n Control of exacerbating factors in the environment n Restoration of skin barrier function and skin hydration with emollients  Treatment options 1. Topical corticosteroids 2. Topical immunosuppressants  Principles of treatment with topical corticosteroids. n Use the weakest Cs that controls the eczema effectively n Review their use regularly n Consider calcineurin inhibitors in children with long term Treatment  Treatment n Topical calcineurin inhibitors (TCI) have anti-inflammatory effects without the side effect profile of topical corticosteroids.  Other Eczema n Atopic dermatitis n Seborrheic dermatitis n Nummular eczema n Dyshidrosis n Lichen simplex chronicus(NeuroDermatitis) n Asteatotic dermatitis n Stasis Eczema(Gravitational) n Pityriasis alba n Juvenile plantar dermatitis Lichen Simplex Chronicus Neurodermatitis  Etiology n Chronic repetitive rubbing, scratching and piking skin Picking n Skins Thickens (lichenification) n Eventually itching becomes a habit. This something similar to obsessive compulsive disorder (OCD). Dermatitis + OCD → neurodermatitis (patient scratches their skin repeatedly and does not let it heal so the skin thickens). Note: patient does not feel itchy skin when having fun time, playing but when stressed or alone will feel itch (atopic dermatitis is always itchy) Lichen simplex chronicus  Treatments n Avoid scratching, rubbing n Highly potent topical steroid n Keratolytics n Intralesional steroid injection Moisturizers May need referral to a psychiatrist Pityriasis alba  Pityriasis alba n Unknown etiology n Start as a Mild Itchy Pink Patch with Slight Scales That Eventually turn inot a hypo pigmented Patch n May be the variant of AD but also found in non AD patients Pityriasis alba  Treatments n Mild potent topical steroid n Emollient cream n Sunblock Reassurance: patches will re-pigment spontaneously Seborrheic dermatitis  Seborrhoeic Dermatitis n Mainly affecting hairy areas, often showing characteristic greasy yellowish scales , interscapular areas and Intertriginous lesions of the armpits, umbilicus. n On The Face typically involve the inner thirds of the eyebrows and NLF (Nasolabial folds) Scalp, central chest/back Inside & behind ear  Seborrheic dermatitis Etiology : n Pityrosporum ovale (Malassezia furfur) is a species of fungal yeast that is naturally found on the skin. Also causes pityriasis (tinea) versicolor n Sebaceous gland activity n Seen more commonly in Parkinson and HIV patients.  Seborrheic dermatitis Greasy yellow (golden) scale  Specific forms Dandruff is a mild form seen in adults Cradle cap in infants  Treatments n Mild-Moderate topical steroids n Shampoo : Tar, 2% selenium sulfide, Ketoconazole , Ciclopirox olamine, Pyrithione zinc. n Topical Antifungal : Cotrimazole , Micanazol cream. n Systemic Antifungal Medications in sever cases: Itraconazole , Fluconazole.  Stasis eczema (Gravitational Eczema )  Pathogenesis n Venous Hypertension/Venous insufficiency n Increased intravascular pressure lead to changes in the dermis, including dilated capillaries with leucocyte accumulation, hemosiderin deposits, and hyperplastic venules. n Chronic inflammation induced by venous hypertension is central in the pathogenesis of stasis dermatitis.  Clinical Features n Start suddenly or insidiously with pitting edema around the ankle disappear at night, n Trauma and scratching lead to eczematous reaction start dry then becomes exudates if secondary infection occur the end result will be ulceration ( Venous/Stasis Ulcer) n In the chronic cases the skin firm, non pitting woody. n Recurrent ulceration and fat necrosis lead to loss of the subcutaneous tissue and decrease in the lower leg circumference (Inverted bottle leg). Stocking erythema may occur in elderly Management n Doppler US to confirm the diagnosis and rule out arterial insufecciency. n Elimination of the oedema by elevation and elastic stockings. n Moderately potent topical steroids. n Topical and Systemic Antibiotics for secondary infection Dyshidrotic Dermatitis Pompholyx n recurrent vesicular eruption limited to the hands (most often the sides of the digits) and sometimes the feet. n The etiology is unknown; no causal relationship with sweating has been shown n he lesions are extremely pruritic. n Small, tense, clear, fluid-filled vesicles on the medial or lateral aspects of the digits,  Treatment n Avoidance and treatment of the precipitating factors. n Potassium permanganate soaks n Potent corticosteroid creams. n Topical or systemic Antibiotics for secondary bacterial infection. n Systemic immunosuppressives in sever recurrent cases.  Juvenile plantar dermatosis n Affect age 3 to puberty. n Symmetrical lesions on weight bearing area n Virtually always resolve after puberty Lesions due to non breathable shoes + humidity + immature stratum corneum (children) *non-weight bearing areas are spared  Asteatotic Eczema, n Winter itch, eczema craquelé n Anterior shins, extensor arms n Elderly person predisposed. 70onceyears elderly should only bath per 7-10 days to prevent this. n Use of bath oils in bath water is recommended n Moisturizers – urea or lactic acid. n Topical Steroids. Adults can get the same lesions with retinoid dermatosis (causes dry skin) Nummular(Discoid) Eczema  Nummular eczema n More Common in older Males n Rare in children, esp. under 1 yr n Maybe a sign of an ID reaction.  Clinical features n Round or coin-shaped, erythematous, scaly plaques, often with minute fissures, round erosions, or crusts located within. n Plaques may begin as papules or vesicles that then coalesce. n The dorsum of the hand, forearm, feet and legs are sites of predilection  Nummular eczema This is the only type of eczema that is well defined and scaly (exception)  Treatments n Emollients. n Topical steroids. n Topical calcineurin inhibitors n Phototherapy n Antihistamines Antibiotics if it is an ID reaction  Diaper (Napkin) Dermatitis n Erythematous, papulovesicular dermatitis n Irritation caused by bacteria, change in the environment (moisture, Higher lower PH, feces) n Candida albicans occurs as a 2ndry infection. Treatment is by zinc- rich ointments, low potent topical steroid, antifungal, change diaper, or not use it Exogenous eczema  Contact dermatitis n Irritant contact dermatitis n Allergic contact dermatits n Phototoxic contact dermatits n Photoallergic contact dermatitis  Contact Dermatitis The generic term applied to acute and chronic inflammatory reactions to substances that come in contact with the skin 77 Regional Sites of Predilection 78  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 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 It is a type 4 hypersensitivity reaction 79  Irritant Contact Dermatitis Pathogenesis n The irritants cause cell damage if applied for sufficient time and in adequate concentration. 80  Pathogenesis of ICD n Denaturation of epidermal keratins n Disruption of the permeability barrier n Damage to cell membranes n Direct cytotoxic effects  Irritant Contact Dermatitis Acute Irritant Contact Dermatitis n Burning, stinging, painful sensations can occur immediately within seconds after exposure or may be delayed up to 24 hour 82  Allergic Contact Dermatitis Pathogenesis 83 Nickel Dermatitis Allergic contact dermatitis Neomycin Sulfate 13 year old boy developed an itchy allergic contact dermatitis from a topical antibiotic. www.dermatlas.org Fragrance Mix Mixed perfume of 8 substances  Quaternium-15 n Preservative that is an effective biocide against Pseudomonas, as well as other bacteria and fungi n Most common preservative to cause ACD n Found in shampoos, moisturizers, conditioners, Hand dermatititis due to and soaps quaternium-15 in a moisturiser Allergic contact dermatitis To rubber  Ear Eczema n Most frequently caused by seborrheic or atopic dermatitis n Earlobe is pathognomonic of nickel allergy  TREATMENT OF CONTACT DERMATITIS n Avoidance n Restore Skin Barrier. n Anti inflammatory medications. Because of shadow Questions?