dermatitis and eczema: itching for answers

1. DERMATITIS AND ECZEMA:ITCHING FOR ANSWERS Anthony A. Gaspari, MD Shapiro Professor and Chair Department of Dermatology University of Maryland School of Medicine

3. FUNCTIONS OF SKIN Protect against infections, chemical toxins and physical agents (UV, ionizing radiation) Prevent insensible water loss Control body temperature (thermoregulation) Sensation, communication (psychosocial, sexual, endocrine functions) Self-regeneration and healing

4. TERMINOLOGY Dermatitis = Dermat + itis refers to skin means �inflamed� (thus, inflamed skin) Other examples: arthritis, colitis, encephalitis, etc.

5. TERMINOLOGY

6. CARDINAL FEATURES OF INFLAMMATION Calor (warmth) - increased blood flow Rubor (redness) -dilated blood vessels Dolor (pain)- irritation of nerves in inflamed tissues

7. TYPES OF DERMATITIS Allergic contact dermatitis Irritant contact dermatitis Atopic dermatitis Other types

8. IMPACT OF CONTACT DERMATITIS T-lymphocyte-mediated type IV allergic reaction Commonest specific skin disorder encountered Second commonest dermatosis encountered in Dermatologist office 30% of all occupational disease USA annual cost $250 million/year

10. COMMON ALLERGENS Nickel Jewelry, foods Benzocaine anesthetics Fragrance perfumes, personal care products Mercaptomix rubber gloves Black rubber mix rubber gloves PPD black hair dye Potassium dichromate leather, spackling, detergents Cinammic aldehyde fragrance,toothpaste Quaternium 15 preservative personal care products

11. TREATMENT OF ACD Avoidance! Avoidance! Avoidance! Other

12. TREATMENT OF ACD Topical glucocorticoids Oral antihistamines Compresses Topical Emollients Oral antibiotics Oral glucocorticoids

13. IRRITANT CONTACT DEMATITIS Non-immunologic inflammatory reaction of the skin due to an external agent Varied morphology Clinical types Chemical burns Irritant reactions Acute irritant contact dermatitis Chronic irritant contact dermatitis

14. COMMON IRRITANTS Water Skin cleansers Industrial cleaning agents Acids and alkalis Oils and organic solvents Oxidizing and reducing agents Plants Animal products Miscellaneous

15. CLINICAL EFFECTS OF IRRITANTS Dermatitis Ulcerations Acneiform rashes Miliaria Disorders of pigmentation Alopecia Urticaria Granulomas

16. TREATMENT OF ICD Define/remove exposures Moisturizers Barrier creams Topical glucocorticoids Oral antihistamines

17. ATOPIC DERMATITIS Common immune-mediated inflammatory skin disorder Prevalence in general population in Western industrialized countries: 10-20% Multi-factorial etiology Interactions of genes and environment Family history of disease usually positive for affected blood relatives AD genes localized to certain chromosomes-known genes in these areas control immune response and inflammation

18. EPIDEMIOLOGY OF ALLERGIC DISEASES Tenfold regional differences in the prevalence of asthma and atopic diseases Allergic diseases more common in westernized environments Asthma and allergy less common in children of animal farmers Asthma and atopy less common in younger siblings Asthma and atopy less common in households with dogs as pets

19. CLINICAL CHARACTERISTICS:AGE AT DIAGNOSIS

20. ATOPIC TRIAD

21. ATOPIC DERMATITIS:SIGNS AND SYMPTOMS Pruritus (itching) Dry, scaly skin Crusted rashes on face, scalp, hands, arms feet or legs Small bumps that open and weep when scratched Redness and swelling of the skin Thickening of the skin (with chronic dermatitis)

22. ATOPIC DERMATITIS:SIGNS AND SYMPTOMS Location of Dermatitis Back of knees and bend of elbows Face Outer part of ankle Neck

23. CHILDHOOD ECZEMA

25. ATOPIC DERMATITIS:EXACERBATING FACTORS(TRIGGERS) Anxiety/stress Climatic factors Temperature Humidity Irritants Detergents/solvents Wool or other rough material Perspiration Allergens (contact, inhalant & food) Infections (staph and strep)

26. FLARE FACTORS IN ATOPIC DERMATITIS

27. TREATMENT OF ATOPIC DERMATITIS Identify and control �flare factors� Topical treatments Glucocorticosteroids Newer �non-steroidal� TIMs Emollients Moisturizers Baths with added lubricants Systemic treatments Oral antihistamine (a cornerstone of treatment) Oral antibiotics Systemic steroids Immunosuppression (phototherapy, cytotoxic drugs)

28. LIMITATIONS TO TOPICAL STEROID THERAPY Efficacy (do they work as they should?) Skin side effects Atrophy Telangiectasia Striae Perioral dermatitis Risk of cataracts and glaucoma Cushing syndrome and growth retardation HPA-axis suppression

29. TOPICAL STEROID PHOBIA In patients with AD: 73% worried about corticosteroid usage 24% admit non-compliance due to worry Key concerns: Skin thinning (35%) Non-specific long-term effect (24%) Absorption/effect on growth (10%) Br J Dermatol 2000;142:931

30. TOPICAL GLUCOCORTICOIDS

31. TOPICAL IMMUNE MODULATORS Two new agents: Tacrolimus (Protopic) 0.1% ointment Pimecrolimus (Elidel) 1.0% cream Derived from fungal polypeptides and Inhibit T-lymphocyte activation; Potent immunosuppressive if given systemically Demonstrated to be effective in childhood and adult AD Don�t cause atrophy of the skin or other steroid side effects Slow acting anti-inflammatory Causes stinging and burn at initiation of therapy; slight increase in skin infections ? Long-term safety not known

32. SUMMARY