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

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

3. Endogenous Eczema Exogenous Eczema
CLASSIFICATION
Endogenous Eczema
Exogenous Eczema

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

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

6. Stages of Eczema
Acute Eczema
Subacute Eczema
Chronic Eczema

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

8. Acute Eczema

9. ACUTE ECZEMA Spongiosis
Intercellular edema of keratinocytes in the epidermis

10. ACUTE ECZEMA

11. ACUTE ECZEMA

12. Chronic Eczema

13. 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)

14. Chronic Eczema

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

17. 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)

18. 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)

19. 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

20. 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

21. 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

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

25. ATOPIC ECZEMA

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

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

28. ATOPIC ECZEMA

30. RETICULAR PIGMENTATION IN Atopic Eczema

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

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

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

38. CONT’D
infants
cradle cap
face
flexures

39. CRADLE CAP

40. Cradle Cap

41. SD

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

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

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

54. Discoid (Numular) Eczema

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

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

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

65. CONTACT ECZEMA

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

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

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

69. 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

70. Caustic burn wet cement

71. Dermatitis eyelid volatile irritant

72. Irritant dermatitis in barber

73. Irritant finger web eczema

74. Dry irritant contact

75. Dry fingertip dermatitis

76. PHOTODERMATITIS

77. PHOTODERMATITIS

78. PHOTODERMATITIS

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

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

81. 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

82. CD TO RUBBER

83. CD TO RUBBER

84. CD TO PERFUME

85. CD TO PLANTS

86. CD TO PLANTS

87. COSMETICS - NAIL POLISH

88. COSMETICS - LANOLINE

89. HAIR DYE - PPD

90. SHOE CONTACT DERMATITIS

92. CONTACT SHOE DERM

93. CD TO NICKLE

94. Nickel Contact Eczema

95. Nickel Contact Eczema

96. CD TO NICKLE

97. CD TO MEDICAMENTS

98. CD TO MEDICAMENTS

99. OCCUPATIONAL CD - ACRYLATE

100. NAPKIN DERMATITIS

101. DIAGNOSIS
History
Examination
Patch testing

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

103. TOPICAL STEROIDS
CLASSIFICATION
USES
COMPLICATIONS

104. 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)

105. 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)

106. 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 %

107. 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

108. 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

109. 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

110. 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

111. 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%

113. Thank You