Dermatitis

1. Dermatitis Yeddi

2. Hx • Seven key questions are useful in obtaining the history of a skin lesion: 1.         When did it start? 2.         Does it itch, burn, or hurt? 3.         Where on the body did it start? 4.         How has it spread? 5.         How have individual lesions changed? 6.         Are there any provocative factors? 7.         Has the patient tried any previous treatment?

3. OE • On physical examination, four cardinal features should be noted about skin lesions [5]: • 1. Type of lesion, based on description. • 2.Shape of individual lesions. • 3.Arrangement of multiple lesions: isolated, grouped, or disseminated • 4. Distribution of lesions: extent, general pattern, characteristic location • Other physical exam findings that will be helpful in the differential diagnosis will be the color, consistency, depth, and margins of the lesion.

4. Terminology

5. Flat, circumscribed skin discoloration that lacks surface elevation or depression Vitiligo 2ry syphillis macule

6. Flat, circumscribed skin discoloration, a very large macule Vitiligo Patch

7. Elevated, solid lesion <0.5 cm in diameter B.C.C Intradermal Nevi Papule

8. Elevated, solid”confluence of papule”>0.5 cm in diameter that lacks a deep component Psoriasis Plaque

9. Elevated, solid lesion>0.5 cm in diameter, a larger-deeper papule Lipoma Rheumatoid nudule Nodule

10. Plaque that contains clear fluid ,a blister Herpes simplex Herpes zoster Contact dermatitis Vesicle

11. Localized fluid collection>0.5 cm in diameter, a large vesicle Pemphigus vulgaris Bullous pemphigoid Bullous impetigo Bulla

12. vesicle that contains purulent material Folliculitis Impetigo Acne Pustular psoriasis Pustule

13. Firm,edematous,plaque that is evanescent and pruritic, a hive Urticaria Urticaria pigmentosa Wheal (Hive)

14. A collection of cellular debris ,dried serum,and blood A scab antecedent primary lesion is usually a vesicle,bulla or pustule Impetigo Capitis Tinea Crust

15. An elevated channel in the superficial epidermis produced by parasite such as mite sarcoptes scabiei Scabies Burrow

16. Focal area of thickened skin produced by chronic scratching or rubbing Atopic Dermatitis Lichenification

17. Dermatitis in General • Dermatitis or eczema is a pattern of cutaneous inflammation that presents with erythema, vesiculation, and pruritus in its acute phase. • The chronic phase is characterized by dryness, scaling, lichenification, fissuring, and pruritus . • There are multiple types of dermatitis: • Atopic, dyshidrotic, nummular, seborrheic and contact.

18. Atopic Dermatitis: The Basics • Atopic dermatitis (AD) is a chronic, pruritic, inflammatory skin disease with a wide range of severity • AD is one of the most common skin disorders in developed countries, affecting up to 20% of children & 1-3 % of adults • In most patients, AD develops before the age of 5 and typically clears by adolescence • Primary symptom is pruritus (itch) • AD is often called “the itch that rashes” • Scratching to relieve AD-associated itch gives rise to the ‘itch-scratch’ cycle and can exacerbate the disease (scratching the itch leads to the rash) • Patients experience periods of remission and exacerbation

19. Question What is a common site at which to find atopic dermatitis in an adult? • a) The gluteal fold • b) The olecranon • c) The popliteal fossa • d) The patella • e) The toe web spaces

20. Answer c) The popliteal fossa Children typically have eczema on the scalp, cheeks, or forehead and can have eczema on either flexural or extensor surfaces. Adults with atopic dermatitis typically have flexural involvement, as well as head and neck dermatitis in more severe forms. Psoriasis plaques are often seen on extensor surfaces (e.g. overlying olecranon or patella) or in the gluteal fold. Tineapedis can be found in toe web spaces.

21. AD: Clinical Findings • Lesions typically begin as erythematous papules, which then coalesce to form erythematous plaques that may display weeping, crusting, or scale • Distribution of involvement varies by age: • Infants and toddlers: eczematous plaques appear on the cheeks forehead, scalp and extensor surfaces • Adults: lichenification in flexural regions and involvement of the hands (Dyshidroticeczema), wrists, ankles, feet, and face (particularly the forehead and around the eyes) • Xerosis is a common characteristic of all stages

22. Atopic Dermatitis: Treatment • Combination of short-term treatment to manage flares and longer-term strategies to help control symptoms between flares • Recommend gentle skin care • Tepid baths(preferred over shower) without washcloths or brushes • Mild synthetic detergents (cleansers) instead of soaps • Emollients: petrolatum and moisturizers • Use ointments or thick creams (no watery lotions) • Apply once to twice daily to whole body (and immediately after bathing for optimal hydration, so-called “soak and seal”) • If topical steroid is needed, put it on first and then the moisturizing lotion • Identification and avoidance of triggers and irritants (such as wool and acrylic fabrics)

23. Atopic Dermatitis: Treatment 4 Major Components Anti-inflammatory Anti-pruritic Antibacterial Moisturizer

24. AD Treatment: Moisturizers • Wide range of moisturization options, from cheap to outrageously expensive • Greasier ointments are better in general, however, greasier preparations can be unpleasant for some patients, and adherence may suffer

25. Question Which of the following statements about topical treatments for dermatologic conditions is true? • a) Sprays should not be used on dermatitis that is oozing. • b) Petrolatum-based ointments are easy to wash off. • c) Medicated creams should be put on the skin lightly, so that they are still visible after application. • d) Ointments tend to dry the skin out. • e) Topical steroids generally lose potency going from ointment to cream.

26. Answer e) Topical steroids generally lose potency going from ointment to cream. (ointments are more potent than creams and lotions) Ointments moisturize the skin and are more potent than creams. Sprays are often advantageous on lesions that are oozing, so that the hands do not have to come in contact with the oozing material and risk causing an infection.

27. AD Treatment: Anti-inflammatory • Treat acute inflammation with topical corticosteroids. The potency depends on the area of the body. • Ointments are preferred vehicles over creams • Low potency for the face • Body and extremities often require medium potency • Using stronger steroid for short periods and milder steroid for maintenance helps reduce risk of steroid atrophy and other side effects • Potential local side effects associated with topical corticosteroid therapy use include striae, telangiectasias, atrophy, and acne

28. AD Treatment: Anti-inflammatory • Topical calcineurin inhibitors: 2nd-line therapy • Use when the continued use of topical steroids is ineffective or inadvisable • Not great during a severe flare • Have been studied and shown to be effective at preventing flares when used twice weekly to trouble spots once the disease is controlled (proactive treatment)

29. AD Treatment: Anti-pruritus • Limited options for itch • Antihistamines • Although it is a pruritic condition, there is debate as to how much histamine is involved. • No role in lichenifcation (T-cell reaction) • Topical anti-pruritics (e.g., camphor/menthol or pramoxine) • Minimally effective, short-term relief only; can be allergic sensitizers as well

30. AD Treatment: Antibacterial • Treat co-existing skin infection with systemic antibiotics • Staphylococcus is most common infection by far; methicillin resistance is rising and must be considered • Topical antibacerial agents such as mupirocin can also be used to treat localized infections such as impetiginized areas

31. The bride-to-be with the neck rash has recently tried over-the-counter hydrocortisone cream on the rash but with no effect. You prescribe a medium potency topical steroid, but after two weeks of putting on the steroid cream, triamcinolone 0.1%, she sees no improvement in the spot in her neck.  She has not been wearing any jewelry around her neck. She asks you what treatments are available, since she is near frantic to clear up the rash for her wedding in one week. Which one of the following would NOT be a good choice as a potential treatment for the lesion pictured above? • a) Tacrolimus (FK506) • b) Pimecrolimus • c) Prednisone • d) Betamethasone valerate 0.1% ointment • e) Lanolin

32. Answer The emollient lanolin should be avoided because it can lead to a contact dermatitis.

33. Contact dermatitis • Contact dermatitis is a skin condition created by a reaction to an externally applied substance . There are two types of contact dermatitis: • Irritant Contact Dermatitis (ICD) • Allergic Contact Dermatitis (ACD)

34. Question Your patient who went hiking outdoors in shorts comes to you with an itchy rash (next slide). Which of the following is UNLIKELY to be an effective topical treatment in relieving the itch associated with the rash? • a) Topical diphenhydramine • b) Calamine lotion • c) Burow's solution • d) Colloidal oatmeal bath • e) Topical triamcinolone ointment

36. Answer a) Topical diphenhydramine Histamine may not be involved in the allergic reaction of plant dermatitis, so may not have an effect on the associated symptoms. If anti-histamines are used for pruritus, their effectiveness may be more because of associated sedation, not from blocking histamine receptors. In that case, an oral anti-histamine would be needed, not a topical anti-histamine. Topical antihistamines and anesthetics should be avoided in a plant dermatitis rash, since their ingredients may be sensitizing and eventually cause a rash of their own. The only topical anti-histaminic agent that has shown some success in clinical trials in relieving itch is doxepin. 

37. Allergic Contact Dermatitis • ACD occurs when contact with a particular substance elicits a delayed hypersensitivity reaction . • The sensitization process requires 10-14 days • Upon re-exposure, dermatitis appears within 12-48 hrs. The most common cause is Rhus dermatitis, from poison ivy, poison oak, or poison sumac (all contain the resin – urushiol) • Other common causes include: • • Fragrances • Formaldehyde • Preservatives • • Topical antibiotics • Benzocaine • Vitamin E • Rubber compounds • Nickel

38. ACD: Clinical Findings • The main symptom of ACD is pruritus (itching) Presents as erythematous, scaly edematous plaques with vesiculation distributed in areas of exposure  ACD is bilateral if the exposure is bilateral (e.g., shoes, gloves, ingredients in creams, etc.)

39. ACD Treatment • Avoid exposure to the offending substance • In mild to moderate cases, topical steroids of medium to strong potency for a limited course is successful • A course of systemic steroids may be required for acute or severe flares • Oatmeal baths or soothing lotions can provide further relief in mild cases • Wet dressings are helpful when there is extensive oozing and crusting . • Chronic cases or patients with dermatitis involving over 10% of the BSA should be referred to a dermatologist

40. Irritant Contact Dermatitis • ICD is an inflammatory reaction in the skin resulting from exposure to a substance that can cause an eruption in most people who come in contact with it • No previous exposure is necessary • May occur from a single application with severely toxic substances, however, most commonly results from repeated application from mildly irritating substances (e.g., soaps, detergents)

41. Pathogenesis • Most important exogenous factor for ICD is the inherent toxicity of the chemical for human skin • There are site differences in barrier function, making the face, neck, scrotum, and dorsal hands more susceptible • Atopic dermatitis is a major risk factor for irritant hand dermatitis because of impaired barrier function and lower threshold for skin irritation

42. ICD: Clinical Findings • Mild irritants produce erythema, chapped skin, dryness and fissuring after repeated exposures over time • Can range from mild (erythema, pruritus) to extreme (erosions, exudate, bullae)

43. ICD Evaluation and Treatment • Identification and avoidance of the potential irritant is the mainstay of treatment • Topical therapy with steroids to reduce inflammation and emollients to improve barrier repair are usually recommended • Referral to a dermatologist should be made for patients who are not improving with removal of the irritant or in severe cases • Patch testing should be performed in occupational cases with suspected chronic irritant dermatitis to exclude an allergic contact dermatitis

44. ICD Prevention • Once an irritant has been identified as the causal factor, patients should be educated about irritant avoidance, including everyday practices that may cause or contribute to the ICD • Use personal protective equipment (e.g., protective gloves should be worn for any wet work) • Instead of soap, use less irritating substances, such as emollients and soap substitutes when washing