Eczema Atopic Dermatitis Contact Dermatitis Fahad Al Sudairy , M.D.

ECZEMA An inflammatory skin reaction to a variety of agents characterized histologically by spongiosis and clinically by a variety of features, notably vesiculation

Endogenous Eczema Exogenous Eczema CLASSIFICATION Endogenous Eczema Exogenous Eczema

Endogenous Eczema Atopic Eczema Seborrhoeic Eczema Discoid Eczema Pityriasis Alba Pompholyx Gravitational Eczema Asteatotic Eczema

Exogenous Eczema Irritant Contact Dermatitis Allergic Contact Dermatitis Photo Allergic Contact Dermatitis Infective Dermatitis

Stages of Eczema Acute Eczema Subacute Eczema Chronic Eczema

Clinical Staging Acute Weeping, papules, vesicles & bullae Chronic Dryness, redness, lichenification, scaling & fissuring

Acute Eczema

ACUTE ECZEMA Spongiosis Intercellular edema of keratinocytes in the epidermis

ACUTE ECZEMA

ACUTE ECZEMA

Chronic Eczema

Chronic Eczema Thickening of the epidermis Hyperkeratosis (thickening of the stratum corneum) Parakeratosis (retention of nuclei in the stratum corneum). Hypergranulosis (thickening of the stratum granulosum) Acanthosis (thickening of the stratum spinosum)

Chronic Eczema

Atopic Eczema Atopy – genetically determined increased liability to form IgE Aetiology – unknown inherently itchy & dry skin psychological climatic allergic factors

DIAGNOSTIC GUIDELINES FOR ATOPIC DERMATITIS Must have: An itchy skin condition (or parental report of scratching or rubbing in a child) plus Three or more of the following: History of involvement of the skin creases such as folds of elbows, behind the knees, fronts of ankles or around the neck (including cheeks in children under 10 years of age) A personal history of asthma or hay fever (or history of atopic disease in a first-degree relative in children under 4 years of age)

Cont’d A history of general dry skin in the last year Visible flexural eczema (or eczema involving the cheek/forehead and outer limbs in children under 4 years of age) Onset under 2 years of age (not used if child is under 4 years of age)

DIAGNOSTIC FEATURES OF ATOPIC DERMATITIS Major features (3 of 4 present) Pruritus Typical morphology and distribution of skin lesions Chronic or chronically relapsing dermatitis Personal or family history of atopy Minor features (3 of 23 present) Xerosis Ichthyosis / palmar hyperlinearity / keratosis pilaris Immediate (type I) skin test reactivity Elevated serum IgE

Cont’d Early age of onset Tendency toward cutaneous infections / impaired cell-mediated immunity Tendency toward non-specific hand or foot dermatitis Nipple eczema Cheilitis Recurrent conjunctivitis Dannie-Morgan infraorbital fold Keratoconus Anterior subcapsular cataract Orbital darkening

Cont’d Facial pallor / erythema Pityriasis alba Anterior neck folds Pruritus when sweating Intolerance to wool and lipid solvents Perifollicular accentuation Food intolerance Course influenced by environmental / emotional factors White dermographism / delayed blanch

PHASES OF ATOPIC DERMATITIS infantile phase – 2-6 months cheeks, forehead, scalp child restless, sleepless crawling – extensor aspect of knees

ATOPIC ECZEMA

CONT’D childhood phase - 18-24 months elbows & knee flexures sides of neck wrists & ankles reticulate pigmentation on neck

CONT’D adult phase lichenification of hands & flexures photosensitivity allergic hand eczema

ATOPIC ECZEMA

RETICULAR PIGMENTATION IN Atopic Eczema

TREATMENT General measures wear cotton clothes avoid overheating rooms avoid irritant soaps reassurance foods

CONT’D Local Systemic emollients topical steroids tacrolimus ointment antihistamines oral corticosteroids low dose cyclosporin azathioprine

SEBORRHOEIC ECZEMA occurs in sebaceous gland rich areas Etiology - unknown, malassezia furfur erythema, greasy yellowish scales

CONT’D infants cradle cap face flexures

CRADLE CAP

Cradle Cap

SD

CONT’D adults Scalp - dandruff Retro-auricular area Face, blephritis, conjunctivitis Trunk Severe recalcitrant to treatment – in HIV

Treatment CONT’D no permanent cure keratolytics mild topical steroids antifungals

DISCOID ECZEMA rounded plaques of eczema clearly demarcated edge sites - limbs atopy, dry skin, allergic contact emotional factors

Discoid (Numular) Eczema

POMPHOLYX eczema of palms & soles characterized by vesicles & bullae hyperhidrosis, drugs, food allergies, emotional stress spontaneous remission – 2-7 weeks

PITYRIASIS ALBA ill-defined erythematous scaly patches – leave hypopigmentation 3-16 years, atopic eczema face, neck, arms Treatment - emollients, tar, 1% hydrocortisone

STASIS ECZEMA eczema secondary to venous hypertension often obese lower legs edema, varicosities, purpura, ulceration, infection

CONTACT ECZEMA

IRRITANT CONTACT DERMATITIS Irritant substance physical or chemical which produces cell damage if applied for sufficient length of time and in adequate concentration

CONT’D strong irritant – response immediate weak irritant – repeated exposure

IRRITANT CONTACT DERMATITIS First exposure gives response Everyone exposed can develop Strictly limited to area of contact

IRRITANT CONTACT DERMATITIS Subjective irritant response Immediate type stinging e.g. ethanol, chloroform Delayed type stinging e.g. 5% lactic acid, phenol Immediate non-immune contact e.g. arthropods, caterpillar, capsaicin Chronic irritant dermatitis e.g. hair dressers Toxic burn e.g. strong acids

Caustic burn wet cement

Dermatitis eyelid volatile irritant

Irritant dermatitis in barber

Irritant finger web eczema

Dry irritant contact

Dry fingertip dermatitis

PHOTODERMATITIS

PHOTODERMATITIS

PHOTODERMATITIS

ALLERGIC CONTACT DERMATITIS occurs in only those allergic to a contactant mediated by lymphocytes (delayed hypersensitivity) not dose related

MOST COMMON ALLERGENS Rubber Perfumes Some Plants Metals - nickel Dyes Cosmetics Medicaments

Irritant Contact Dermatitis Allergic Contact Dermatitis Accounts for approximately 80% of all contact dermatitis Accounts for the remaining 20% of all contact dermatitis Result from a local toxic effect It is a delayed-type hypersensitivity reaction of Th1 response Affect every one ,no sensitization is required Prior sensitization is required Reaction soon after contact -minutes to hours Reaction delayed for hours to days Repeated or prolonged exposure is required, a dose-response relationship Small amount of allergen is enough to elicit the reaction No cross-reaction Cross-reaction can occur Burning prominent Burning not prominent Lesions are restricted to the area where the irritant damaged the tissue Localized, but may be more diffuse Negative patch test Positive patch test

CD TO RUBBER

CD TO RUBBER

CD TO PERFUME

CD TO PLANTS

CD TO PLANTS

COSMETICS - NAIL POLISH

COSMETICS - LANOLINE

HAIR DYE - PPD

SHOE CONTACT DERMATITIS

CONTACT SHOE DERM

CD TO NICKLE

Nickel Contact Eczema

Nickel Contact Eczema

CD TO NICKLE

CD TO MEDICAMENTS

CD TO MEDICAMENTS

OCCUPATIONAL CD - ACRYLATE

NAPKIN DERMATITIS

DIAGNOSIS History Examination Patch testing

MANAGEMENT Remove the causative agents Treat the dryness (Emollients) Choose the correct steroid for the site and activity of disease Antihistamines (Itching)

TOPICAL STEROIDS CLASSIFICATION USES COMPLICATIONS

TOPICAL STEROIDS POTENCY RANKING Class 1 (Superpotent) Clobetasol propionate OINTMENT AND CREAM 0.05% (dermovate , temovate) Betamethasone dipropionate OINTMENT (optimized vehicle) 0.05% (diprolene) Class 2 (High Potency) Betamethasone diproprionate CREAM 0.05% (diprolene) Betamethasone diproprionate OINTMENT 0.05% (diprosone) Betamethasone diproprionate CREAM 0.05% (diprosone) Mometasone furoate ointment 0.1% (elocom)

Class 4 (Medium Potency) Cont’d Class 3 (High Potency) Fluticasone proprionate OINTMENT 0.05% (cutivate) Class 4 (Medium Potency) Hydrocortisone valerate OINTMENT 0.2% (Westcort) Mometasone furoate CREAM 0.1% (elocom) Triamcinolone acetonide OINTMENT 0.1% (Kenalog) Hydrocortisone butyrate OINTMENT 0.1% (Locoid)

Cont’d Class 5 (Medium Potency) Class 6 (Low Potency) Fluticasone proprionate CREAM 0.05% ( cutivate ) Hydrocortisone valerate CREAM 0.2% (Westcort) Hydrocortisone butyrate CREAM 0.1% (Locoid) Triamcinolone acetonide CREAM 0.1% (Kenalog) Class 6 (Low Potency) Alclometasone diproprionate OINTMENT 0.05% ( perderm ) Alclometasone diproprionate CREAM 0.05% ( perderm ) Class 7 (Low Potency) Topicals with hydrocortisone acetate 1 %

Important about topical steroids What skin conditions are topical corticosteroids used for? Potency of topical corticosteroids How safe are topical steroids? Does the formulation of steroid make any difference? Misuse of topical steroids How long should topical steroids be used for? How often should topical steroids be applied? How much should be applied? How much should be prescribed? Can topical corticosteroids be used safely on infected skin? Using topical steroids in children and geriatric group Tachyphylaxix

SUGESSTED AMOUNT FOR TOPICAL THERAPY AREA TREATED SINGLE APPLICATION (G) BID FOR I WEEK FACE 1 15 SCALP 2 30 ONE HAND ONE ARM 3 45 ANTERIOR TRUNK 4 60 POSTERIOR TRUNK ONE LEG INCLUDING FOOT 5 70 ANOGENITAL AREA WHOLE BODY 30-40 450-500

Topical Steroids in Adults Area of skin to be treated (adults) Size is roughly: FTUs each dose (adults) A hand and fingers (front and back) About 2 adult hands 1 FTU A foot (all over) About 4 adult hands 2 FTUs Front of chest and abdomen About 14 adult hands 7 FTUs Back and buttocks Face and neck About 5 adult hands 2.5 FTUs An entire arm and hand About 8 adult hands 4 FTUs An entire leg and foot About 16 adult hands 8 FTUs

Regional differences in penetration 1. mucous membranes 2. scrotum 3. eyelids 4. face 5. chest and back 6. upper arms and legs 7.lower arms and legs 8. dorsa of hands and feet 9.palmar and plantar skin 10. nails

Skin absorption of topical steroids Steroids are absorbed at different rates from different parts of the body. A steroid that works on the face may not work on the palm. But a potent steroid may cause side effects on the face. Forearm absorbs 1% Armpit absorbs 4% Face absorbs 7% Eyelids and genitals absorb 30% Palm absorbs 0.1% Sole absorbs 0.05%

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