ECZEMA Dr. Sharon Crichlow Consultant Dermatologist Luton and Dunstable NHS Foundation Trust 22/02/2011

Definition Controversial but loosely thought to be synonymous with the term ‘dermatitis’. Strictly speaking dermatitis is inflammation of the skin (any cause).

Classification Endogenous –Atopic –Seborrheic –Discoid (nummular) –Pompholyx –Gravitational (venous stasis) –Asteatotic –Neurodermatitis

Classification Mainly exogenous –Irritant dermatitis –Allergic contact dermatitis –Photodermatitis

Atopic dermatitis- key features Chronic relapsing dermatitis associated with intense pruritus Can occur at any age but 70-95% of cases arise before the age of 5 years Typically infantile, childhood and adulthood; periods of acquiescence can occur between stages Aetiology and pathogenesis is still not fully elucidated Often associated with atopy Genetic basis with variable expression influenced by environmental factors

Immuno-aberration is evidenced by the common occurrence of serum IgE elevation and eosinophilia; the Th2 predominance in acute lesions evolves into a predominance of IFN gamma producing T-cells in chronic lesions. There is enhanced reactivity to irritants, self-proteins, allergens and infectious antigens and superantigens

CLINICAL APPEARANCE Acute eczema- weeping and crusting blistering redness, papules and swelling- with an ill defined border scaling

Chronic eczema- May show all the above but Less vesicular and exudative More scaly, pigmented and thickened More likely to show lichenification More likely to fissure

ALL FORMS OF ECZEMA ARE ASSOCIATED WITH INTENSE PRURITUS IF IT DOES NOT ITCH IT’S PROBABLY NOT ECZEMA!!

DIFFERENTIAL DIAGNOSIS SCABIES FUNGAL INFECTION

INVESTIGATIONS USUALLY CLINICAL DIAGNOSIS PATCH TESTING- if ACD suspected SERUM TOTAL AND SPECIFIC IgE SWABS FOR STAPH AND CANDIDA MICROSCOPIC EXAMINATION OF SCALES AND FUNGAL CULTURE TO RULE OUT OTHER DIAGNOSES.

Infantile eczema

TREATMENT Acute weeping eczema- –Soaks with potassium permanganate. –Wet wrap dressings and/ or bandages such as icthopaste, viscopaste –Topical steroids and emollients –Tacrolimus/ pimecrolimus

Chronic eczema- –Steroids in an ointment base –Emollients –Systemic or topical antibiotics –Ichthammol and zinc pastes –Anti-histamines and other anti-itch preparations

SYSTEMIC TREATMENTS Prednisolone Cyclosporine Azathiaprine Tacrolimus/sirolimus Mycophenolate mofetil

Pompholyx eczema

Palmar/ plantar eczema

Varicose eczema

Treatment Elevate legs when sitting or standing Emollients such as hydrommol oint Mild topical steroids such as Betnovate RD ointment or Eumovate ointment Check ABPIs If suitable then compression stockings, above knee during daytime

Discoid eczema

Juvenile plantar dermatosis

Occurs in pre-pubertal children from age 3 onwards, rare in adults Worse in winter, boys more than girls Associated with sports shoes with plastic or rubber soles The humid environment leads to maceration of the keratin layer, which is then rubbed off with friction leading to a glazed and thinned appearance of the skin.

The balls of the feet are tender and dry with a shiny appearance, at times scaly May develop cracks and fissures Chronic but self-limiting Avoid wearing impermeable socks and shoes Emollients and keratolytics may be helpful

Seborrheic dermatitis

Treatment Daktacort/ Canesten HC ointments Tacrolimus/ pimecrolimus