Dermatitis 101: Diagnosis and Treatment of Eczema Adrian Guevara MD

Dermatitis 101 Atopic Atopic Seborrheic Seborrheic Contact Contact Allergic Allergic Irritant Irritant Nummular Nummular Asteatotic Asteatotic Stasis Stasis Neurodermatitis/Lichen Simplex Chronicus Neurodermatitis/Lichen Simplex Chronicus

Dermatitis 101 Dermatitis=“Eczema”=Spongiosis

Acute Dermatitis Acute Dermatitis Dermatitis 101

Subacute Dermatitis Subacute Dermatitis Commonly misdiagnosed as tinea

Dermatitis 101 Chronic Dermatitis Chronic Dermatitis Commonly misdiagnosed as psoriasis

24 y/o male 2 year h/o red, scaly feet 24 y/o male 2 year h/o red, scaly feet

Allergic Contact Dermatitis Type 4 Hypersensitivity Response Type 4 Hypersensitivity Response Classically well demarcated/patterned Classically well demarcated/patterned Exposure can be infrequent (once a month) Exposure can be infrequent (once a month) Patch testing is gold standard for diagnosis Patch testing is gold standard for diagnosis Severe reactions need systemic steroids Severe reactions need systemic steroids Forget the dose pack

Allergic Contact Dermatitis Poison Ivy/Oak/Sumac Poison Ivy/Oak/Sumac linearity

Allergic Contact Dermatitis Potassium Dichromate Potassium Dichromate in Leather in Leather

Allergic Contact Dermatitis Latex Latex Cleaning products Cleaning products Cosmetics Cosmetics Occupational Occupational exposures exposures Check the feet and nails!!!

Allergic Contact Dermatitis

40 y/o female homemaker with dry, itchy hands

Irritant Contact Dermatitis Most contact dermatitis is irritant in nature Most contact dermatitis is irritant in nature Occupational morbity Occupational morbity Irritant vs allergic Irritant vs allergic Prevention is key! Prevention is key!

Look at the cuticles

Lip licker dermatitis Blunting of vermillion Accentuation of angles

4 y/o boy with chronic, itchy, bleeding plaques

Atopic Dermatitis 10-20% of population 10-20% of population Primary symptom: itch Primary symptom: itch Location, location, location Location, location, location Associated with atopic background Associated with atopic background Periorbital pallor

Look for keratosis pilaris

52 y/o male with erythematous, scaly patches of face and scalp

Seborrheic Dermatitis Distribution Distribution Face, scalp, axillae, upper chest Face, scalp, axillae, upper chest Chronic condition Chronic condition Nonsteroidal adjuvants Nonsteroidal adjuvants Disease associations Disease associations

45 y/o female with intermittent “fungus all over”

Nummular Dermatitis Coin shaped patches and plaques Coin shaped patches and plaques Secondary to xerosis cutis Secondary to xerosis cutis Primary symptom itch Primary symptom itch Notice the surrounding xerosis

Asteatotic Dermatitis Extreme case of xerosis Extreme case of xerosis Riverbed type cracking Riverbed type cracking

52 y/o male with painful, itchy rash on right leg

Stasis Dermatitis Venous hypertension Venous hypertension Full spectrum of timing Full spectrum of timing Id reaction common Id reaction common Complicated by ulceration Complicated by ulceration

Pseudokaposi’s (acroangiodermatitis) Venous ulceration Dispigmentation (chronic) Lipodermatosclerosis

Id reaction Superimposed allegic contact Do: 1) dry weeping lesions 2) cover for infection Don’t: 1) apply neosporin 2) just hope steroids will fix it

Elephantiasis Verrucosa Nostras

14 y/o anxious female who can’t stop itching

Neurodermatitis/Lichen Simplex Chronicus Paroxysmal pruritus Paroxysmal pruritus Habitual excoriating or rubbing Habitual excoriating or rubbing Skin thickens to defend Skin thickens to defend Consider underlying disease Consider underlying disease Increased skin markings

Lichen simplex chronicus Prurigo simplex No fungus on the scrotum!

Butterfly sign Prurigo Nodularis Consider screening

Prevention Remove the offending agent Remove the offending agent Edema, allergen, irritant, yeast, long fingernails Edema, allergen, irritant, yeast, long fingernails Daily cleansing and MOISTURIZING Daily cleansing and MOISTURIZING Dove, Oil of Olay, Neutrogena Dove, Oil of Olay, Neutrogena Mild temperatures Mild temperatures Cream/Ointment based emollients Cream/Ointment based emollients Neosporin, antifungals ≠ moisturizers

Treatment Topical Steroids Topical Steroids Clobetasol I Clobetasol I TriamcinoloneIV TriamcinoloneIV DesonideVI DesonideVI HydrocortisoneVII HydrocortisoneVII

Treatment TIM TIM Protopic 0.1% oint Protopic 0.1% oint Elidel cr Elidel cr Light Light nbUVB nbUVB Systemic immunosuppressives Systemic immunosuppressives Prednisone Prednisone Cyclosporine Cyclosporine Azathioprine Azathioprine IVIG IVIG Only on thin skin !!!

Treatment Antihistamines Antihistamines Mechanism of action: soporific Mechanism of action: soporific Indications for Dermatitis ≠ Urticaria

7 m/o infant with itchy skin

75 y/o nursing home patient with intolerable itchy skin

Common Pitfalls Misdiagnosis Misdiagnosis Scabies (intensely pruritic, burrows/vesicles, others itch) Scabies (intensely pruritic, burrows/vesicles, others itch) Psoriasis (elbows/knees/inflammatory arthritis/nail changes) Psoriasis (elbows/knees/inflammatory arthritis/nail changes) Fungus (central sparing, well marginated, scaly border) Fungus (central sparing, well marginated, scaly border) Lose the Lindane!

25 y/o male tx’d for eczema in antecubital fossa with “some cream”

Common Pitfalls Mistreatment Lose the Lotrisone! 1) Commit to a diagnosis 2) Shotgunners: “Don’t be a wimp” Quadriderm: betamethasone, gentamycin, clotrimazole Animax

The End