ECZEMA
The term Eczema and Dermatitis are used interchangeably
It is one most common skin disorders
DEFINITION :
It may be defined as polymorphic inflammatory reaction pattern involving the epidermis and dermis caused by exogenous and endogenous factors
CLASSIFICATION / TYPES
1. Exogenous eczema (contact dermatitis)
i Environmental and occupational factors are important triggers
± Irritant contact dermatitis ( ICD )
± Allergic contact dermatitis
2. Endogenous eczema
± Atopic dermatitis ± Seborrheic dermatitis ± Discoid/ Nummular eczema ± Stasis dermatitis ± Lichen simplex chronicus ( LSC ) (Neurodermatitis)
± Prurigo nodularis ± Asteatotic eczema
i Genetic, emotional and environmental factors are important triggers
hCLINICAL PRESENTATION
PHASES :
¤ Acute Þ Erythema, edema papules , vesicles and bulla (occasional)
¤ Sub-acute
¤ Chronic Þ may show all the features of above but less vesiculation. Lichenified,
scaly erythematous or pigmented patch/plaque, occasional fissures and excoriation
DIFFERENCE BETWEEN AND ICD AND ACD
POINTS ICD ACD
(1) Case involvement 80% 20%
(2) Type of reaction Nonimmunological Immunological
(Type IV sensitivity
(3) Dose/concentration Dose dependent Small dose
Any person only sensitized
may be involved person, 2nd exposure necessary
(4) Time, course Immediate to late Sensitization takes
few hours after place after 2 weeks
exposure
(5) Diagnostic tests None Patch test
EXAMPLES OF ICD :
þ Dettol, Savlon; þ Soaps, detergents;
þ Excessive water exposure; þ Chemicals;
þ Herbal extract(KabiraJ),þ Gacozema oint,
þ Fish feeds, þ fertilizer direct contact
EXAMPLES OF ACD :
§ Cement ( C can – Chromate, Cobalt, Arsenic, Nickel
§ Hair dye allergy
§ Eye shadow, Eye liner, Mushkara, Lip stick
§ Ornaments
§ Spectacles
§ Welding rods
§ Textile dermatitis (Phenylene diamine) – Clothing dyes
§ Glue (Phenol )
§ Shoe dermatitis
§ Cosmetics
§ Neomycin, Clotrmazole, Betamethasone Cream
REMEMBER THE NOTES :
FIrritating compounds can be allergic and allergen compounds can be irritating as well
FAllergic CD and psoriasis è TH1 cells responsible
(Interferon g. IL2
F Atopic dermatitis – TH2 Cell are responsible (IL4 , IL5 , IL6 , IL10 )
Q. Which part of hand most commonly involved – palmer or dorsal surface? (ACD)
Dorsal surface of hand because palmer surfaces have more resistance to allergic substances.
Q. How will you confirm ACD ?
By patch test
LABORATORY DIAGNOSIS
Skin biopsy for histo-pathological examination (Dermato-pathology)
Inflammation with intraepidermal, intercellular edema (spongiosis) and monocyte and histocytes infiltration in the dermis suggests ACD , while more superficial vesicles containing polymorphonuclear leukocytes suggest a primary ICD
2. Patch test : For ACD
3. Leukocyte Transformation Test
4.Macrophage Migration Inhibition Test
MANAGEMENT :
ÓGeneral measures :Identify and avoid the causative agents / factors
Ó Topical measures (Specific)
ª Tacrolimus oint (.03%) (Tacrol) or
ª Pimecrolinus oint cream (0.1%) (Eldel) or
ª Steroid (mild to moderate) Hydrocortisone twice daily
Clobetasone butyrate (Non-exudative, Nonbullous lesion)
Ó Systemic measures :
ª Specific ® systemic steroid (severe case)
Tab Prednisolone – 1 mg / kg / day
or Inj T.A. (reduced over 1 – 2 weeks)
ª Supportive : Antihistamine- Chlorpheniramine or Mebhydrolin
RX of complication if any
Infection Ü Antibiotics Ü Azithromycin ( 500 mg ) 1 tab daily for 5 days
ATOPIC DERMATITIS
½ Atopy means – ‘out of place’ or strange
½ The concept of Ad – the itch that rashes
½ Pruritus is the hallmark of the disease
HEREDITARY TENDENCY
* If mother is atopic (asthma, allergic rhinitis, hay fever), the child may develop Ad by the age of 3 months (1/4 off-spring)
* If if one of the parents are atopic – 1/2 of the child may be involved by the age of 2 years
* Mother ® Father (Risk)
* Atopic dermatitis patients frequently have high levels of IgE
½ Atopics are the highest risk for ACD
AD STAGES
AD is usually divided into three stages
¶ Infantile AD – 2 months to two years (face and trunk common)
· Childhood AD – 2 years to 10 years. ( Flexural distribution as the child grows older)
¸ Adolescent or Adult AD – 10 years onwards ( Neck, cubital fossa. Popleteal fossa)
DIAGNOSTIC CRITERIA OF AD :
Major criteria – 3 must be present
=Pruritus
=Personal or family H/O Atopic Diseases
= Chronic or chronically relapsing dermatitis
=Typical Morphology and Distribution
Ö Flexural Lichenification Ù in adult
Ö Facial and extensor involvement Ù in infancy
MINOR CRITERIA
i Serum IgE
i Pityriasis alba
i Facial pallor or erythema Periorbital darkening
i Icthyosis Dennie
i Keratosis pillaris Morgan
i Hyperlinear palm Intra -orbital folds
i Xerosis Recurrent conjunctivitis
i Perifollicular accentuation
i Food hypersensitivity
i Itch when sweating
i Intolerance to wool
i Nipple eczema
i White dermatographism
i Induced by environment
i Cheilitis
i Hand-foot dermatitis ( Non-specific)
MANAGEMENT
* General Measures :
FReassurance and patient’s education
F Avoidance of excessive bathing (over bathing), vigorous rubbing or itching.
FAvoidance of soap, detergents and chemicals
FAvoidance of extreme of cold, humidity and temperature
FAvoid allergic foods , tight clothing etc
FAvoid emotional stress (anxiety, tension etc)
FUse of emollients ( Olive oil , Neutrogena/Dove Soap for clearing.
Topical Measures :
Ê Tacrolimus (.03%) or Pimecrolimus (.1%)- Apply twice daily
Ë Steroids (Hydrocortisone / Clobetasone Oint.)
Ì 10% Urea cream Ù for exfoliative skin (keratolysis)
Í Antibiotic (if infection associated)
Fusidic acid
Î I/L therapy : By steroid
Ï Phototherapy: PUVA, UVA, UVB
SYSTEMIC MEASURES
o Specific :
4 Tab Prednisolone
4 Since frequently associated with infection Antibiotics (Flucloxacillin / Cephradin )
o Others : (Nonsteroid therapy)
4Cyclosporin (severe cases) 5 mg/kg /day
4Evening prime rose or fish oil
4IFN -g (immumodulation)
4Chinese herbs
o Supportive :
v Antihistamine
v Mast cell stabilizer
v Leucotrine inhibitors
v Anxiolytic- Amitryptiline
v Vitamins Vit B, Vit E, Zinc, Iron
