Eczema & Psoriasis Dr. Jerald E. Hurdle Kennebec Medical Consultants Waterville, ME 04901

Learning Objectives  To familiarize you with the many presentations of eczema & psoriasis,  To understand how to get the most out of topical therapies, and  To recognize newer therapies now becoming available.  To familiarize you with the many presentations of eczema & psoriasis,  To understand how to get the most out of topical therapies, and  To recognize newer therapies now becoming available.

Eczema  From the Greek “to boil over”  Eczema = Dermatitis  Wastebasket term for many undiagnosed rashes  Histology shows edema or spongiosis  From the Greek “to boil over”  Eczema = Dermatitis  Wastebasket term for many undiagnosed rashes  Histology shows edema or spongiosis

Eczema is itchy!  Acute: Vesicles  Sub acute: Juicy Papules  Chronic: Lichenification  Lesions tend to have indistinct borders  Acute: Vesicles  Sub acute: Juicy Papules  Chronic: Lichenification  Lesions tend to have indistinct borders

Eczema is itchy!  Acute: Vesicles  Sub-acute: Juicy Papules  Chronic: Lichenification  Lesions tend to have indistinct borders  Acute: Vesicles  Sub-acute: Juicy Papules  Chronic: Lichenification  Lesions tend to have indistinct borders

Eczema is itchy!  Acute: Vesicles  Sub acute: Juicy Papules  Chronic: Lichenification  Lesions tend to have indistinct borders  Acute: Vesicles  Sub acute: Juicy Papules  Chronic: Lichenification  Lesions tend to have indistinct borders

New patients presenting to a dermatology clinic Types of Dermatitis  Essential:11.4%  Contact:2.8%  Atopic:2.6%  Seborrheic:3.7%  Stasis:0.4%  Lichen Simplex Chronicus (LSC):0.8% Types of Dermatitis  Essential:11.4%  Contact:2.8%  Atopic:2.6%  Seborrheic:3.7%  Stasis:0.4%  Lichen Simplex Chronicus (LSC):0.8% Source: Hershey Medical Center Dermatology Clinic

Essential Dermatitis  Pruritus  Eczematous lesions not conforming to other patterns of dermatitis  Pruritus  Eczematous lesions not conforming to other patterns of dermatitis Essential Contact Atopic Seborrheic Stasis Lichen Simplex Chronicus

Essential Dermatitis  Dyshidrotic  Autosensitization  Xerotic  Nummular  Dyshidrotic  Autosensitization  Xerotic  Nummular “tapioca” on lateral borders of fingers Essential Contact Atopic Seborrheic Stasis Lichen Simplex Chronicus

Essential Dermatitis  Dyshidrotic  Autosensitization  Xerotic  Nummular  Dyshidrotic  Autosensitization  Xerotic  Nummular Hypersensitivity to a substance produced by local dermatitis Essential Contact Atopic Seborrheic Stasis Lichen Simplex Chronicus

Essential Dermatitis  Dyshidrotic  Autosensitization  Xerotic  Nummular  Dyshidrotic  Autosensitization  Xerotic  Nummular “crazy paving" appearance: affects elderly particularly in winter Essential Contact Atopic Seborrheic Stasis Lichen Simplex Chronicus

Essential Dermatitis  Dyshidrotic  Autosensitization  Xerotic  Nummular  Dyshidrotic  Autosensitization  Xerotic  Nummular Coin-shaped lesions Essential Contact Atopic Seborrheic Stasis Lichen Simplex Chronicus

Contact Dermatitis  Irritant vs. Allergic  Only affects area of contact  Rx : avoid contactant  Irritant vs. Allergic  Only affects area of contact  Rx : avoid contactant Essential Contact Atopic Seborrheic Stasis Lichen Simplex Chronicus

Contact Dermatitis Cosmetics Essential Contact Atopic Seborrheic Stasis Lichen Simplex Chronicus

Contact Dermatitis Nickel Essential Contact Atopic Seborrheic Stasis Lichen Simplex Chronicus

Contact Dermatitis Poison Oak or Poison Ivy Essential Contact Atopic Seborrheic Stasis Lichen Simplex Chronicus

Contact Dermatitis Irritant Essential Contact Atopic Seborrheic Stasis Lichen Simplex Chronicus

Atopic Dermatitis  Triad of atopic disease  Pruritus  Waxing/waning course  Hands/face/neck common in adults  Triad of atopic disease  Pruritus  Waxing/waning course  Hands/face/neck common in adults Essential Contact Atopic Seborrheic Stasis Lichen Simplex Chronicus

Seborrheic Dermatitis  Dandruff on the body  Hypersensitivity to yeast  Rx: Anti yeast & steroids  Dandruff on the body  Hypersensitivity to yeast  Rx: Anti yeast & steroids Essential Contact Atopic Seborrheic Stasis Lichen Simplex Chronicus

Stasis Dermatitis  Eczema overlying edematous legs  Chronic  : Compression  Beware of Ulcers  Eczema overlying edematous legs  Chronic  : Compression  Beware of Ulcers Essential Contact Atopic Seborrheic Stasis Lichen Simplex Chronicus

Lichen Simplex Chronicus  Localized chronic dermatitis  Occluded steroids may help  Localized chronic dermatitis  Occluded steroids may help Essential Contact Atopic Seborrheic Stasis Lichen Simplex Chronicus Scratch ItchScratch Itch

Treatment Of Eczema  Gentle skin care  ↓ Frequency of washing  Cooler Water  Avoid Soap  Gentle skin care  ↓ Frequency of washing  Cooler Water  Avoid Soap

Treatment Of Eczema  Use cream based emollients as soap  Encourage greasiest  Copious quantities  Use cream based emollients as soap  Encourage greasiest  Copious quantities increasing greasiness

Treatment Of Eczema Topical Steroids  Ointments > Cream  Use lowest effective potency  BID Topical Steroids  Ointments > Cream  Use lowest effective potency  BID clobetasol fluocinonide triamcinolone aclomethasone hydrocortisone Potency

Psoriasis

 2-5% Caucasians  Onset at any age  2 peaks in 20s & 50s  May be pruritic  2-5% Caucasians  Onset at any age  2 peaks in 20s & 50s  May be pruritic

Psoriasis: precipitants  Genetics  Stress  Infections -- i.e. Strep  Trauma (Koebner)  Medications: Lithium, β Blockers  Obesity (insulin resistance)  Alcohol  Genetics  Stress  Infections -- i.e. Strep  Trauma (Koebner)  Medications: Lithium, β Blockers  Obesity (insulin resistance)  Alcohol

Chronic Plaque  Commonest  Extensor surfaces  Stable disease  Commonest  Extensor surfaces  Stable disease

Guttate  Explosive onset  May be preceded by Strep infection  Consider other Dx: Pityriasis Rosea & syphilis  Explosive onset  May be preceded by Strep infection  Consider other Dx: Pityriasis Rosea & syphilis

Palmar Plantar Pustulosis  Commoner in smokers  Tends to be difficult to treat  Groups of sterile pustules  Commoner in smokers  Tends to be difficult to treat  Groups of sterile pustules

Erythrodermic Pustular  Rare  Skin often painful  Pustules tiny (look close)  Later get lakes of pus  Need to admit patient to stabilize  Rare  Skin often painful  Pustules tiny (look close)  Later get lakes of pus  Need to admit patient to stabilize

Nail Psoriasis  Commoner in pts with Ps arthritis  Pitting  Oil spots  Onycholysis  Difficult to Rx

Treatments  Remember Koebner  Point to a scar  Emollients  Topical Agents  UV light  Systemics  Biologics  Emollients  Topical Agents  UV light  Systemics  Biologics

Treatments  Corticosteroids (potent & super potent)  Vit D Analogue (Dovonex)  Tars (LCD)  Anthralin (Dithrocream)  Emollients  Topical Agents  UV light  Systemics  Biologics  Emollients  Topical Agents  UV light  Systemics  Biologics

Treatments  Immunosuppressant  UVB (Narrow band vs. broadband  PUVA: Psoralen + UVA  Treatment course 3x weekly for 6 weeks  Beware of skin cancer!  Emollients  Topical Agents  UV light  Systemics  Biologics  Emollients  Topical Agents  UV light  Systemics  Biologics

Treatments  Retinoids: Acitretin monitor LFTs & Lipids (avoid in ♀ of childbearing potential)  Methotrexate (once weekly) monitor LFTs & CBC  Cyclosporine : monitor BP & Renal function : great rescue drug but need exit strategy!  Emollients  Topical Agents  UV light  Systemics  Biologics  Emollients  Topical Agents  UV light  Systemics  Biologics

Treatments  Anti-TNF: Etanercept, infliximab & adalumimab  IL 12/23 blockers  Watch out for TB/infections  No long term safety data  $$$$  Not Better than CyA or MTX  Emollients  Topical Agents  UV light  Systemics  Biologics  Emollients  Topical Agents  UV light  Systemics  Biologics

Treatments  Avoid systemic corticosteroids!!!

Snowbird

Eczema: Key Points  Appearance varies from blisters to scaling plaques  Itching is prominent  Distribution can be localized or generalized  Appearance varies from blisters to scaling plaques  Itching is prominent  Distribution can be localized or generalized

Psoriasis: Key Points  Well demarcated erythematous, silvery, scaling plaques  Elbows, knees & scalp are typically involved  Inflammation and epidermal proliferation  Well demarcated erythematous, silvery, scaling plaques  Elbows, knees & scalp are typically involved  Inflammation and epidermal proliferation

Learning Objectives  To familiarize you with the many presentations of eczema & psoriasis,  To understand how to get the most out of topical therapies, and  To recognize newer therapies now becoming available.  To familiarize you with the many presentations of eczema & psoriasis,  To understand how to get the most out of topical therapies, and  To recognize newer therapies now becoming available.

And Remember… For scaling rashes of uncertain etiology… “if it scales, scrape it!”