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

2. 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

3. 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

4. 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

5. 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

6. 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)

7. 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

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

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

10. 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

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

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

13. 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

14. 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

15. 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

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

17. 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

18. 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.

19. 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

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

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

22. Footwear Allergy

23. Cow milk Allergy

24. Commode dermatitis

25. Nickle allergy

26. 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

27. Post inflammatory depigmentation following contact dermatitis to footwear

28. Photodermatitis

29. Tinea infection – treated with topical steroids

30. 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