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1. Clinical Overview of Eczema/ Dermatitis Rich Callahan MSPA, PA-C
ICM I Summer 2009
2. Eczema/Dermatitis Eczema and dermatitis are two different words which essentially have the same meaning: Inflammation of the epidermis and dermis.
This group of diseases includes Atopic Dermatitis, commonly known as eczema or winter dry skin.
All diseases in this group share the primary characteristics of pruritis, inflammation and disruption of the skin barrier.
Skin barrier has been disruptedSkin barrier has been disrupted
3. Eczematous Dermatitis is a family of diseases including: Non-allergic, or irritant Contact Dermatitis (ICD)
Allergic Contact Dermatitis (ACD)
Atopic Dermatitis, or Eczema
Lichen Simplex Chronicus (LSC)
Seborrheic Dermatitis (Dandruff)
All primarily characterized by pruritis, inflammation and scratching.
4. Other Diseases in the Group Nummular Eczema: A variant of Atopic Dermatitis
Dyshidrosis: A vesicular form of hand dermatitis which often affects patients with a history of atopic dermatitis. Can be precipitated by stress.
Asteatotic Eczema and Stasis Dermatitis: Both are pruritic, eczematous eruptions primarily affecting the lower legs of elderly patients.
Contact Urticaria: Hives brought on by contact with a substance.
We will focus on the more common diseases for this lecture.
5. Dermatitis presents in many different ways Moderate to Severe Well-defined, erythematous and edematous plaques with superimposed vesicles, weeping erosions and crusts.
Mild to moderate Less defined, mildly erythematous to pink plaques with dry adherent scale, superficial desquamation (skin looks peeled off). Sometimes also has pink to erythematous papules mixed in.
Chronic Pink to purple, thickened, lichenified papules and plaques. Lesions can be quite hyperpigmented in darker-skinned individuals. Constant scratching is the main driving force with these lesions.
6. Urticaria (hives) Urticaria means an outbreak of wheals (hives) which are caused by contact with an irritant (non-allergic) or an immunologic antigen (allergic.)
Wheals are essentially areas of localized edema in the deep dermis which show at the skin surface as relatively featureless bumps. As you would expect, there are no epidermal changes apparent.
Urticaria can be caused by both external contact with a substance, or internal ingestion.
7. ICD(Non-allergic or Irritant Contact Dermatitis) Comes from exposure to any irritating substance, and can happen to anyone. Mediated by the substances direct toxicity to skin cells.
Can occur immediately after a patients first exposure to the substance, or can take months to develop over the course of repeated exposures.
Patients who do a lot of wet work either at home or on the job are especially predisposed to contact hand dermatitis as frequent wetting/drying of the hands leads to breakdown of the skin barrier and better penetration of irritating substances.
8. ICD: Clinical Presentation Large variance in clinical presentation:
Mild/Early: Pink to mildly erythematous patches, or slightly raised papules and plaques. Lesions may/may not be scaly or vesicular. Can be distributed randomly or present in a symmetrical pattern (I.e., if a patient develops ICD from the dye in a new pair of sandals, you could see ICD lesions develop in the pattern the straps make across the top of the foot.)
Severe/Late: Eroded, crusted, fissured patches and plaques which frequently bleed and become secondarily infected.
9. Just about any substance can cause contact dermatitis in the right individual, but heres a short list of frequent culprits: Croton oil, kerosene, gasoline, detergents of all kinds, cinnamic, sorbic and benzoic acids, insect stings, moths, nickel, polyethylene glycol, animal keratin (hairs.) Also includes many ingredients in common household and industrial products. Always suspect sizing chemicals in unwashed new clothing. This is but any tiny sample of the potential list. Clinical Pearl: Topical antibiotics are common contact irritants! Approx. 1/10 of my patients have some sensitivity to neosporin and 1/20 to Bacitracin and Polysporin almost never. Confusing this with bacterial infection can lead to unnecessary antibiotic prescriptions. Switch to straight vaseline when this happens.
10. These cases of ICD often require some detective work to figure out Clinical Case Example: Referred by PCP, 52 y/o male city municipal employee presents with recurrent, chronic bilateral hand dermatitis characterized by patches of dry, fissured, desquamated (peeling) skin which were prone to bleeding and secondary infection.
On physical exam lesions were discrete and affected both palms in an asymmetric pattern which suggests chronic contact with a specific object.
The patient mostly operates the same truck, which is a snowplow in the winter. His truck dumps a lot of salt.
I had him show me how he habitually holds the steering wheel, and the areas of dermatitis directly corresponded to where his hands would touch it.
11. Hand Dermatitis The Plot Thickens! Through further questioning we found that this problem started when the city switched to a new road salt, which he called magnesium chloride.
In the winter, his hands were in constant contact with this substance while at work, and he had never cleaned the steering wheel of the truck. Steering wheel described by patient as totally dirty with caked-on grime.
Treatment included cleaning the steering wheel, always wearing gloves when in contact with road salt, a course of topical steroids.
The Problem resolved approx. 1 months later.
12. ACD Clinical Presentation Poison Ivy is the classic example: Gradual, random development of intensely pruritc papules, vesicular plaques and outright groups of vesicles (blisters) which quickly erode into weepy, crusted lesions.
Tends to be randomly distributed in cases of contact with plants, liquids/powders, etc.
Tends to be arranged in a symmetric pattern when secondary to chronic contact with offending substances in clothing or footwear.
13. Allergic Contact Dermatitis Poison Ivy is the classic example a type of delayed type IV hypersensitivity in which a strong sensitizer (like the urushiol resin in poison ivy) is recognized and taken up by Langerhans cells in the epidermis, which then process the urushiol and present it as an antigen to specialized T-cells. The activated T-cells then multiply and spread throughout the entire body, sensitizing all skin surfaces to the offending contactant.
This is why p. ivy can give the illusion of spreading over a period of several weeks, leading patients to think they are getting new exposures.
14. Poison Ivy dermatitis does not spread from one part of the body to another. The main property of urushiol that makes it such an effective contactant is that the molecule has qualities that allow it to penetrate the skin easily to a depth of about 1mm, and then adhere to surrounding cells.
People often dont recognize they were in poison ivy until way too late, and the oily resin spreads around so well from one object (animate or inanimate,) to another that diverse and scattered areas of the body can become involved.
The hypersensitivity reaction proceeds in a gradual progression around the body, seeming to focus on one area, and then move on to previously unaffected areas.
This is why it can start on the face, move to the chest 3 days later and then to the legs 7 days later.
15. Atopic Dermatitis aka Eczema An inherited disorder usually accompanied by personal/family history of allergic rhinitis, asthma and hay fever.
Characterized by chronically dry, itchy skin which gets scratched/rubbed, breaking down the skin barrier and increasing susceptibility to contact allergens, bacteria and fungi.
Usually first presents before the age of 12, but can rarely start in adulthood also.
Often chronic over periods of months to years. More inherited than acquiredMore inherited than acquired
16. Atopic Dermatitis Clinical Presentation When it comes on acutely: Widespread erythematous patches, papules and plaques which are often excoriated and weeping/crusting. Lesions are often scaly.
When its chronic: Affected areas become thickened and lichenified (skin markings are accentuated.) Over a period of time, hypopigmentation, fissuring and cracking can develop.
In any case, its always itchy. Pruritis is the hallmark of this disease, and because theyre human, patients are inevitably lead to scratch and exacerbate their condition.
17. Atopic Dermatitis Clinical Presentation Usually involved areas are ears, face, eyelids, occipital scalp/posterior neck, ventral upper extremity (especially in antecubital regions,) lower legs, popliteal fossae and dorsal feet.
Can be a child with a new diagnosis, or an adult already experienced with the disease.
Usual flare precipitants include stress and onset of cold weather (heat turns on, inside humidity drops, TEWL (transepidermal water loss) increases, skin dries out and becomes itchy, patient starts scratching.)
18. Clinical Pearl: Tinea Incognito Fungus masquerading as something else If it scales, scrape it: If you are questioning the diagnosis in a new patient and the lesions have scale, it is always a good idea to scrape it and prepare a KOH slide. Occasionally you will find fungus either masquerading as atopic dermatitis or exacerbating an already existing case.
Also suspect bacterial colonization in all severe cases that respond poorly to treatment or show symptoms and signs suggestive of infection. Topical and oral antibiotics may be necessary.
19. Clinical Presentation Lichen Simplex Chronicus Often secondary to chronic Atopic Dermatitis.
Lesions present as lichenified, thickened, well-defined plaques, occasionally scaly, and violaceous to pink color.
Lesions often brown or black in darker-skinned patients.
Driving force formation of LSC is repeated scratching lesions of crusted and excoriated from recent picking.
Lichenified lesions become hypersensitive over time lesions itch at the slightest provocation and patients will admit taking great pleasure in itching them.
Male = Female. Any age.
20. Clinical Presentation Asteatotic Dermatitis Usually presents in elderly patients, especially those in nursing homes, on arms, legs, hands and occasionally on trunk.
Used to be called eczema craquele or marred with cracks because skin acquires a cracked-china appearance.
Primary precipitating factors are low indoor relative humidity and over bathing/over washing of the skin.
Lesions are erythematous-to-pink, dry, scaly patches and plaques with crazy pavement skin markings. Lesions usually excoriated. Extreme pruritis.
Asteatotic without oilAsteatotic without oil
21. Clinical Presentation - Dyshidrosis Dyshidrosis is a vesicular form of hand (and occasionally foot) dermatitis. Patients often have prior history of AD.
Tends to occur in acute episodes lasting 2-3 weeks each. Often chronic over months to years.
Presents as crops of tiny translucent papules and vesicles on all hand surfaces, which develop over several weeks, rise to the surface and rupture. Secondary cracking, peeling and fissuring are the rule.
Lesions tend to have a classic tapioca pearl appearance. Patients often describe burning, itching and tingling.
Usually seen in adults. Men = Women.
22. Clinical Presentation of Seborrheic Dermatitis Pruritic, scaling dermatitis occurring in areas of skin rich in sebaceous glands: Face, scalp, ears and sternum.
Usually chronic and recurrent over long periods of time.
Men = Women. First episodes in childhood/teenage yrs.
Lesions present as erythematous papules and plaques with loosely adherent yellowish, greasy scale. Scale can be gently peeled back to reveal raw, erythematous skin.
Etiology not entirely understood, but thought to be related to over activity of the yeast Malassezia furfur accompanied by excessive inflammatory response to its presence.
23. Diagnosis of Eczema/Dermatitis Almost always a clinical diagnosis based on patient history and PE.
Rarely biopsy is needed to diagnose cases with atypical presentation.
Patients with Atopic Dermatitis are usually easy to sort out because they often already have a chronic history of the disease and other features that go along with it like hay fever, allergic rhinitis and history of asthma.
If it scales, scrape it.
24. Diagnosis of Eczema/Dermatitis In cases of chronic ICD and ACD where poison ivy is not the obvious culprit, allergy patch testing may be necessary to find out whats causing it.
In these cases it is critical to take a good, thorough history focusing on all skin contactants: Soaps, detergents, fabric softeners, moisturizers, new household/workshop chemicals, shaving cream/aftershave, perfumes, bug sprays, chemicals at work, etc. Also watch for history of recently trying on/wearing new clothes that have never been washed (sizing chemicals,) and heavily colored/dyed clothing warn next to skin on hot day.