ECZEMA

1. ECZEMA

2. Definition • Eczema is an inflammatory condition of the skin that is characterized by erythema, papulo-vesicles, oozing & crusting in the acute stages & lichenification in the chronic stages. • 'Ekze', in Greek means “to boil over”. • All eczema is dermatitis, but not all dermatitis are eczemas.

3. The “Itch / Scratch” Cycle The sensation of itch and subsequent scratching is hallmark of most eczemas scratch itch scratch itch

4. Classification • Irritant dermatitis • Allergic contact dermatitis • Photodermatitis • Dermatophytid • Hand eczema Exogenous eczemas Endogenous eczemas • Atopic dermatitis • Pityriasis alba • Seborrhoeic dermatitis • Discoid eczema • Hand eczema • Asteatotic eczema • Gravitational eczema • Lichen simplex chronicus • Prurigonodularis

5. Classification • Exogenous eczemas Those related to clearly defined external trigger factors; inherited tendencies may play a part. • Endogenous eczemas Those mediated by internal factors; that is, processes originating within the body. • Some types of eczema are precipitated by both external and internal factors.

6. Clinical stages • The inflammatory changes of eczema evolve through three stages: • Acute eczematous inflammation • Subacute eczematous inflammation • Chronic eczematous inflammation • The skin changes vary in different stages.

7. Acute eczematous inflammation Classical clinical features • Intense itching • Intense erythema • Oedema • Papulovesicles • Oozing Examples: Contact dermatitis, Id eruption, Pompholyx

8. Subacute eczematous inflammation Classical clinical features • Erythema (lesser than in acute stage) • Crusting and scaling • Fissuring • Slight to moderate itching • Stinging and burning sensation Examples: Asteatotic eczema, Atopic dermatitis, Eczematizedtinea

9. Chronic eczematous inflammation Classical clinical features • Dryness of skin • Excoriation • Fissuring • Lichenification Examples: Lichen Simplex Chronicus, Atopic dermatitis, Nummular eczema

10. Secondary dissemination Auto-eczematization • Eczema has a characteristic tendency to spread far from its point of origin, known as secondary dissemination or autoeczematization. • Secondary eczema lesions :small, oedematous papules and plaques, grouped papulovesicles. • It subsides, if the primary lesion settles; but it often recurs, if the primary lesion relapses.

11. Secondary dissemination Mechanisms • Contact with an external allergen • Ingestion or injection of an allergen • Conditioned hyperirritability • Bacterial hypersensitivity

12. Exogenous Eczemas Contact dermatitis

13. Irritant dermatitis • Non-immunologic inflammatory reaction of the skin due to an external agent • Varied morphology • Clinical types • Symptomatic (subjective) irritant responses • Chemical burns • Acute irritant contact dermatitis • Chronic irritant contact dermatitis

14. Chronic irritant dermatitis: common irritants Common irritants • Water and wet work; sweating under occlusion • Household agents: detergents; soaps; shampoos; disinfectants • Industrial cleaning agents: solvents; abrasives • Alkalis, including cement; acids • Cutting oils; organic solvents • Oxidizing agents, including sodium hypochlorite Contd….

15. Chronic irritant dermatitis: common irritants • Reducing agents, including phenols; aldehydes • Certain plants • Pesticides • Raw food; animal enzymes and secretions • Dessicant powders; dust; soil • Miscellaneous chemicals

16. Chronic irritant dermatitis: Personsatrisk • Mothers; due to repeated changing of child’s diapers • Housewives • Persons with atopic diathesis • Persons in occupations of : • Hairdressing • Medical, dental, veterinary • Food preparation, catering, fishing • Printing and painting, metal work • Construction

17. Allergic contact dermatitis • Delayed-type hypersensitivity reaction that occurs upon contact of the skin with an allergen • Inflammatory reaction following absorption of antigen applied to the skin with prior sensitization • Develops within 12 to 48 hours of antigen exposure and persists for 3 to 4 weeks

18. Allergic contact dermatitis Clinical features • Acute inflammation • Well demarcated patches of erythema, edema, vesicles or bullae. • Linear, erosive and crusted lesions • Chronic inflammation • Lichenification; scaling; or fissures • Clinical features depend on location; duration of contact with allergen • Intensity of the inflammation depends on the degree of sensitivity, concentration of antigen

19. Allergic contact dermatitis

20. Allergic contact dermatitis: Patch testing • It is the miniature reproduction of eczema by application of allergens on the intact skin of patients of allergic contact dermatitis. • It should be undertaken for patients in whom the inflammation persists even after the avoidance of the offending agent and the appropriate topical therapy.

21. Patch test reading and interpretation

22. Photodermatitis • An eczematous response of skin to sunlight • Distribution typically on the light exposed areas of the skin • Types of reactions to sunlight : • Photo-toxic • Photo-allergic • Eczematous polymorphic light eruptions

23. Photodermatitis • Systemic/ topical drugs, chemicals, contactants in combination with UVA spectrum induce phototoxic and photoallergic reactions.

24. Phototoxicreactions: Inducing agents Topical • Perfumes • Dyes • Psoralens • Tars • Plants (lime, celery) Systemic • Psoralen • Tetracycline • Phenothiazine

25. Photoallergicreactions: Inducing agents Topical • Perfumes (soaps, aftershave) • Sunscreens (PABA) • Neomycin • Halogenated compounds • Parthenium (congress grass) Systemic • NSAIDS • Phenothiazine • Thiazides

26. Photoallergicreactions Parthenium induced photoallergic dermatitis • A type of hypersensitivity reaction aggravated by sunlight • Commonly seen in people coming in contact with the pollen grains and other parts of the plant Partheniumhysterophorus • Often occurs in farmers and people living in the vicinity of these plants

27. Polymorphic light eruption (PMLE) • Clinically characterized by an intermittent, delayed, and transient abnormal cutaneous reaction to UVR exposure • The reaction consists of nonscarring, pruritic, erythematous papules, vesicles, or plaques on the light-exposed areas of the skin

28. Dermatophytid • Eczematous reaction that occurs as an allergic response to a dermatophyte infection elsewhere on the skin Diagnostic criteria • A proven focus of dermatophyte infection. • A positive skin test to a group-specific trichophytin antigen. • Absence of fungi in the dermatophytid lesion. • Clearing of the dermatophytid after the eradication of the primary fungal infection.

29. Hand eczema • Commonly seen in dermatology practice; can be exogenous, endogenous or of combined aetiology. • Causes discomfort, embarrassment, interferes with normal daily activities. • Common in industrial occupation and threatens job security if infection is not controlled.

30. Hand eczemaMorphological types • Irritant eczema • Allergic eczema • Recurrent focal palmar peeling • Hyperkeratoticpalmar eczema • Fingertip eczema • Pompholyx (dyshidrotic eczema) • Id reaction

31. Recurrent focal palmar peeling • A chronic, idiopathic, asymptomatic, non-inflammatory peeling of palms. • Common during summer; often associated with sweaty palms and soles. Occasionally, may involve feet. • Begins with occurrence of round, scaling lesions (2 or 3 mm) on the palms or soles; followed by peeling. • Lesions resolve in 1 to 3 weeks and require no therapy other than lubrication.

32. Fingertipeczema • Chronic eczema of the palmar surface of the fingertips, which may involve one or all fingertips. • The skin is dry, cracked, scaly and may break down into painful and tender fissures. • Resistant to treatment. • Advise patient to avoid irritants; use topical steroids and maintain lubrication of hands.

33. Pompholyx (Dyshidroticeczema) • Involves palmar surface of the fingers, palms and soles in which fluid accumulates to form visible vesicles or bullae. • Deep-seated, symmetrical, pruritic, sago grain-like vesicles, preceded by moderate to severe itching. • Vesicles resolve gradually in 3 to 4 weeks, and may be followed by chronic eczematous changes • Cause not known; not associated with any abnormality of the sweat glands.

34. Hand eczema General instructions to patients • Wash hands infrequently. • Avoid use of soap and wash hands in lukewarm water. • Avoid direct contact with cleansers and detergents. • Avoid direct contact with and/or handling anything that causes burning or itching. E.g. wool; wet nappies; peeling potatoes; handling fresh fruits, vegetables, raw meat. • Preferably wear gloves while doing housework or work that involves contacting irritants. • Ensure frequent use of moisturizers and emollients.

35. Endogenous eczema

36. Hand eczema General instructions to patients • Wash hands infrequently. • Avoid use of soap and wash hands in lukewarm water. • Avoid direct contact with cleansers and detergents. • Avoid direct contact with and/or handling anything that causes burning or itching. E.g. wool; wet nappies; peeling potatoes; handling fresh fruits, vegetables, raw meat. • Preferably wear gloves while doing housework or work that involves contacting irritants. • Ensure frequent use of moisturizers and emollients.

37. Atopicdermatitis • A chronic, immune-mediated, pruritic, inflammatory skin condition. • Marked by alternating periods of remission and flare-ups. • A result of complex interplay between environmental, immunologic, genetic and pharmacologic factors. • Frequently associated with elevated serum IgE levels; personal or family history of atopic dermatitis, allergic rhinitis and/or asthma. • Aggravated by infection, psychological stress, seasonal changes, irritants, and allergens.

38. AtopicTriad Atopic Dermatitis Allergic Rhinitis Asthma

39. Atopicdermatitis Diagnosis • It cannot be precisely defined as it does not have specific skin changes, histologic features or diagnostic laboratory test • The diagnosis is usually arrived on the basis of clinical findings, comprising three or more major criteria and three or more minor criteria

40. Atopicdermatitis Diagnostic criteria: Major features • Pruritus • Typical morphology and distribution • Facial and extensor involvement in infants and children • Flexural lichenification in adults • Chronic or relapsing dermatitis • Personal or family history of atopy (atopic dermatitis; asthma; allergic rhinitis)

41. Atopicdermatitis Diagnostic criteria: Minor features • Xerosis • Cutaneous infections • Non-specific dermatitis of the hands or feet • Ichthyosis; palmarhyperlinearity; keratosispilaris • Pityriasis alba • Nipple eczema • White dermographism and delayed blanch response • Anterior subcapsular cataracts, keratoconus Contd…

42. Atopicdermatitis Diagnostic criteria: Minor features • Elevated serum IgE levels • Positive immediate (Type I) skin test reactivity • Early age of onset • Dennie-Morgan infraorbital folds, periorbital darkening • Facial erythema or pallor • Perifollicular accentuation • Course influenced by environmental and/or emotional factors

43. Atopicdermatitis Clinical features • Age of onset typically during infancy (2 to 6 months); but may start at any age. • Clinical features vary at different phases of life; and comprise: • Itching • Macular erythema, papules or papulo-vesicles • Eczematous areas with crusting • Lichenification and excoriation • Dryness of the skin • Cutaneous reactivity • Secondary infection

44. Atopicdermatitis Infantile phase (2 months to 2 years) • Sites: cheeks, perioral area and scalp; extensors of feet and elbows • Oozing lesions. • Teething, respiratory infections, emotional upsets and seasonal changes influence the disease course. • The disease often subsides by 18 months of age; but may progress to the childhood phase.

45. Atopicdermatitis Childhood phase (2 to 12 years) • Characteristically involves elbow and knee flexures, sides of the neck, wrists and ankles. • Scratching and chronicity lead to lichenification. • Hands may often be involved with exudative lesions, sometimes with nail changes. • Secondary bacterial or viral infection may give rise to acute generalized or localized vesiculation.

46. Atopicdermatitis Adult phase (12 years onwards) • Commonly involves flexural areas. • The disease may be diffuse or patchy. • May manifest only as chronic hand eczema. • Dermatitis of the upper eyelids and blepharitis.

47. Atopicdermatitis Triggering factors • Anxiety; emotional stress • Temperature change and sweating • Decreased humidity • Excessive washing • Contact with irritants • Allergens • Foods • Microbial agents

48. Atopicdermatitis Management • First-line treatment • Second-line treatment • Third-line treatment • Counselling; occupational advice

49. Management of Atopicdermatitis First-line treatment • Identify and control ‘flare factors’ • Topical treatments • Bathing; Emollients; Humectants • Corticosteroids • Calcineurin inhibitors: Pimecrolimus; tacrolimus • Icthamol and tar

50. Management of Atopicdermatitis First-line treatment • Oral treatment • Antihistamines • Sedative antihistamines preferred • Promethazine; trimeperazine; hydroxyzine • Antibiotics • Systemic steriods (in severe cases)