Eczema and Mimics Dr Ranthilaka Ranawaka Consultant Dermatologist General Hospital Kalutara Sri Lanka

Commonest skin disease in our clinical practice Inflammation of the skin Diverse aetiologies Variable intensity of itching and soreness Dryness, erythema, excoriation, exudation, fissuring, hyperkeratosis, lichenification, papulation, scaling and vesiculation

Dermatitis and eczema ‘Dermatitis’ and ‘eczema’ are generally regarded as synonymous Some authors still use the term ‘dermatitis’ to include all types of cutaneous inflammation All eczema is dermatitis But not all dermatitis is eczema

Classification of eczematous dermatoses On aetiology –contact allergic or contact irritant dermatitis. On clinical features –pompholyx, discoid, acute, chronic Exogenous and endogenous Key strategy for exogenous eczema is to remove the cause Endogenous eczema more often requires pharmacological intervention

Exogenous eczemas Endogenous eczemas Irritant eczema Allergic contact eczema Photoallergic contact eczema Eczematous polymorphic light eruption Endogenous eczemas Atopic eczema Seborrhoeic eczema Asteatotic eczema Discoid eczema Eyelid eczema Pityriasis alba Hand eczema Venous eczema Metabolic eczema or eczema associated with systemic disease Eczematous drug eruptions

Management of eczema Antiprurutics (sedatives/ non-sedatives) Acute eczema- condys Topical steroids (mild/ moderate/ potent) Penetration of topical corticosteroids can be significantly increased by occlusion Antibiotics ± oral/ topical Aqueous cream and other bland emollients Identify additional aggravating factors (such as exposure to irritants, foods) Identify complicating factors (such as infections or allergies to medications)

Steroids Mild (hydrocotisone) – face, flexures, genital areas and in children Moderate (betamethasone) – body of adults Potent or very potent (clobetasol) – palms and sole, lichenified eczema

Side effects to topical steroids Acneform eruption Depigmentation Atrophy Striae Steroid acne

Emollients Aqueous cream Emulsifying ointment Vaseline Urea based (10-12% urea) Glycerin based

Acute eczema Mx - Pruritis- anti histamines Condys wash Antibiotics Topical steroids- creams ± Short course of oral steroids Advise to avoid exacerbating factors – foods, detergents etc

Discoid eczema Nummular eczema Anti pruritics Topical corticosteroids Antibiotics – if signs of infection Emollients

Chronic lchenified eczema Anti pruritics Topical corticosteroids – ointments with ± salicylic acids Emollients

Pompholyx Hands or feet should be soaked three or four times a day in condys Large bullae may be aspirated using a sterile syringe Topical steroids –potent, ointments

Asteatotic eczema Very dry skin Usually in the elderly Diuretics is an important contributory factor in elderly people May be a presenting sign of myxoedema Can also be due to zinc deficiency Mx- Avoid soaps and detergent cleansers Soap substitutes - emulsifying ointment, aqueous cream Emollients Weak topical corticosteroids

Pityriasis alba Often a manifestation of atopic dermatitis but it is not confined to atopic individuals Predominantly in children Last for year or more Mx- Emollients If itching or inflammation- mild topical steroid Reassurance

Recurrent focal palmar peeling No irritation Vesicles not seen Relatively asymptomatic MX Emollients Reassurance

Eyelid eczema Common feature of atopic dermatitis due to seborrhoeic dermatitis Contact allergy - eye makeup, nail varnish, fragrance, rubber, ophthalmic medicaments, nickel in spectacle frames Mx- Removal of the cause Treatment with hydrocortisone cream is often effective

Venous eczema (Gravitational eczema) Stasis eczema or varicose eczema Often associated with varicose veins but not always Usually middle-aged or elderly Mx- Underlying venous hypertension should be controlled. Obese patients - lose weight Well-fitted support stockings or firm bandages can be helpful if worn regularly The legs should be elevated as effectively as possible. Mild topical steroids to relieve irritation Potent steroids should be limited to short periods of a few days as they may cause cutaneous atrophy and increase the risk of ulceration.

Fingertip eczema Commonly due to allergy to Wathusudda flower in SL Occupational (in factory, market garden or house) may be either irritant (e.g. house wives handling detergents) or allergic (e.g. to colophony in polish, or to tulip bulbs or stems) Dominant hand- polish, gum Non- dominant hand - onions, garlic etc

Hair dye allergy Ammonia, PPD free hair dye (e.g. Eco Hair Color- Dremron) PPD- Para phenylenediamine

Contact dermatitis to underwear Examine fully exposed Allergy to either synthetic material or the fabric dye White, cotton underwear

Footwear Allergy

Cow milk Allergy

Commode dermatitis

Nickle allergy

Lip licking dermatitis Dryness of the lips Stick out tongue on the lips licking it to get away with the moisture-less lips Irritation due to frequent exposure to saliva

Post inflammatory depigmentation following contact dermatitis to footwear

Photodermatitis

Tinea infection – treated with topical steroids

Summary Eczema or dermatitis is very common Whatever the cause, treatment is same Antipruritics Topical steroids (depend on the site and age) ± condys ± antibiotics Identify the cause (if possible) and remove/ Rx the cause Avoid predisposing factors Avoid aggravating factors Lots of emollients to relieve dry skin