Nummular Dermatitis Primary lesions discrete, coin-shaped, erythematous, edematous, vesicular and crusted patches, 20-40 mm in diameter APPEARANCE: Begins on lower legs, dorsa of the hands, or extensor surfaces of the arms DISTRIBUTION: As new lesions appear, old lesions expand by tiny papulovesucular (satellite lesions) appearing at the periphery and fusing with the main plaque. Severe cases: palm-sized or larger patches EVOLUTION: May form after trauma (Koebner’s phenomenon) Pruritus is usually severe and of the same paroxysmal, compulsive quality, and nocturnal timing seen in circumscribed neurodermatitis OTHERS: Reference:Andrew’s Diseases of the Skin: Clinical Dermatology

Nummular Dermatitis

NUMMULAR DERMATITIS Patient, 9 y.o. Primary lesions discrete, coin-shaped, erythematous, edematous, vesicular and crusted patches 20-40 mm in diameter papules and plaques Begins on lower legs, dorsa of the hands, or extensor surfaces of the arms Mainly over the antecubital and popliteal fossae Infancy, lesions on the cheeks and scalp As new lesions appear, old lesions expand by tiny papulovesucular (satellite lesions) appearing at the periphery and fusing with the main plaque. Severe cases: palm-sized or larger patches May form after trauma (Koebner’s phenomenon) Pruritus is usually severe and of the same paroxysmal, compulsive quality, and nocturnal timing seen in circumscribed neurodermatitis Itchy temporarily relieved by application of hydrocortisone cream Recurrent, 7 years duration

Stasis Eczema Eczematous eruption of the lower legs secondary to peripheral venous disease Venous incompetence  increased hydrostatic pressure and capillary damage with extravasation of red blood cells and serum Incidence: a disease of adults, predominantly of middle and old age May cause inflammatory eczematous process Reference: Lookingbill’s and Marks’ Principles of Dermatology, 4th ed.

Stasis Eczema Eczematous eruption of the lower legs secondary to peripheral venous disease History: Subacute or chronic, pruritic eruption of lower legs preceded by edema and swelling Have often had thrombophlebitis May cause inflammatory eczematous process Reference: Lookingbill’s and Marks’ Principles of Dermatology, 4th ed.

Stasis Eczema: Physical Examination Prominent varicose veins and pitting edema Peripheral pulses in tact Involved skin has brownish hyperpigmentation, dull erythema, petechiae, thickened skin, scaling, or weeping, Any portion of the lower leg; predominant site is above the middle malleolus Reference: Lookingbill’s and Marks’ Principles of Dermatology, 4th ed.

Stasis Eczema: Treatment Therapy: the cornerstone of stasis dermatitis management is the prevention of venous stasis and edema. Supportive hose (Jobst) while the patient is ambulatory. Standing should be restricted, and patients who are obese should be placed on a weight reduction program. If this approach fails, bed rest with elevation of the legs is required. The dermatitic skin is treated witth topical steroids and wet compresses if oozing or crusting is present Course and Complications: Chronic and slowly progressive disease unless treated Dusky erythema in areas of stasis dermatitis is the harbinger of leg ulceration Allergy to topical preparations may occur in 60% of patients with stasis dermatitis. The compromised epidermal barrier from stasis allows sensitization to occur more easily than in normal skin. Contact dermatitis can easily be misdiagnosed as a flare-up of stasis dermatitis. Topical antibiotics are particularly prone to cause allergic contact dermatitis. Reference: Lookingbill’s and Marks’ Principles of Dermatology, 4th ed.

KEY POINTS Eczematous patches or plaques overlying lower leg edema STASIS ECZEMA Patient Disease of adults, predominantly middle and old age Infancy to childhood (9 years old) Subacute and chronic dermatitis, brownish hyperpigmentation, edema, petechiae Papules and plaques Lower leg, predominanty above the medial malleolus Mainly over the antecubital and popliteal fossae Infancy, lesions on the cheeks and scalp Pruritic Treatment: reduction of leg edema, compression stockings, leg elevation, with steroids for crusting and oozing Itchy Temporarily relieved by application of hydrocortisone cream Recurrent, 7 years duration KEY POINTS Eczematous patches or plaques overlying lower leg edema Chronic and itchy Treat venous hypertension with compression stockings