DERMATITIS Dr.

Tamari Darjania
Dermatovenereologist

Pg 775-785
DERMATITIS (ECZEMA) IS
superficial inflammation of the skin characterized by
redness
edema
oozing
crusting
scaling
sometimes vesicles
pruritus
ATOPIC DERMATITIS
Atopic dermatitis (AD) is an immune-mediated inflammation of the skin arising
from an interaction between genetic and environmental factors.
 Heritable epidermal barrier defect is a primary cause, and defects in the filaggrin
gene have been specifically implicated.
PATHOGENESIS
SYMPTOMS AND SIGNS
Red, weeping, crusted lesions appear on the face and spread to the neck, scalp,
extremities, and abdomen.
In the chronic phase , scratching and rubbing create skin lesions. Lesions typically
appear in antecubital and popliteal fossae and on the eyelids, neck, and wrists and
may occasionally become generalized.
Lesions slowly resolve to dry scaly macules (xerosis) that can fissure and facilitate
exposure to irritants and allergens.
In older children and adults, intense pruritus is the key feature.
DIAGNOSIS
Clinical evaluation
Sometimes testing for allergic triggers with skin prick testing or radioallergosorbent
testing levels
Allergen-specific IgE levels
TREATMENT
• Supportive care (eg, moisturizers, symptomatic treatment for pruritus)
• Antihistamines (hydroxyzine)
• Avoidance of precipitating factors
• Topical corticosteroids
• Tacrolimus and pimecrolimus
• Sometimes immune modulators (cyclosporine)
• Sometimes ultraviolet (UV) therapy
 STEROID ABSORPTION RATE

Plants- 0.14
Palms - 0.38
Cruris - 0.42
Arms - 1
Back - 1.7
Axilla - 3.6
Face - 13
Genitalia - 42

High Low
CONTACT DERMATITIS
Contact dermatitis (CD) is acute inflammation of the skin caused by irritants or
allergens. Skin changes range from erythema to blistering and ulceration, often
on or near the hands but occurring on any exposed skin surface.

Irritant contact dermatitis

Phototoxic dermatitis
Allergic contact dermatitis
IRRITANT CONTACT DERMATITIS
accounts for 80% of all cases of CD. It is a nonspecific inflammatory reaction to
substances contacting the skin; the immune system is not activated.
Irritants can be:
• Chemicals (eg, acids, alkalis, solvents, metal salts)
• Soaps (eg, abrasives, detergents)
• Plants (eg, poinsettias, peppers)
• Body fluids (eg, urine, saliva)

ICD is more common among patients with atopic disorders

IRRITANT CONTACT DERMATITIS
ICD is more painful than pruritic.

Signs range from mild erythema to

hemorrhage, crusting, erosion, pustules,
bullae, and edema.
IRRITANT CONTACT DERMATITIS
PHOTOTOXIC DERMATITIS
is a variant in which topical (eg, perfumes, coal tar) or ingested (eg, psoralens)
agents generate damaging free radicals and inflammatory mediators only after
absorption of ultraviolet light.
ALLERGIC CONTACT DERMATITIS
is a type IV cell-mediated hypersensitivity reaction that has 2 phases:

Sensitization Allergic
to an antigen response after
reexposure
PATHOGENESIS OF ACD
SYMPTOMS AND SIGNS
•Primary symptom is intense pruritus; pain is usually the result of excoriation or infection.
•Skin changes range from transient erythema through vesiculation to severe swelling with
bullae, ulceration, or both.
•Changes often occur in a pattern, distribution, or combination that suggests a specific
exposure, such as linear streaking on an arm or leg or circumferential erythema
•Any surface may be involved, but hands are the most common surface due to handling and
touching potential allergens. With airborne exposure (eg, perfume aerosols), areas not
covered by clothing are predominantly affected.
•The dermatitis is typically limited to the site of contact but may later spread due to scratching
and autoeczematization.
•In systemically induced ACD, skin changes may be distributed over the entire body.
ALLERGIC CONTACT DERMATITIS
DIAGNOSIS
• Clinical evaluation
• Sometimes patch testing
• The "use" test, in which a
suspected agent is applied far from
the original area of dermatitis,
usually on the flexor forearm, is
useful when perfumes, shampoos, or
other home agents are suspected.
PROGNOSIS
•Resolution may take up to 3 wk.
•Reactivity is usually lifelong.
•Patients with photoallergic CD can have flares for years when exposed to sun
(persistent light reaction).
TREATMENT
• Avoidance of offending agents
• Supportive care (eg, cool compresses, dressings, antihistamines)
• Corticosteroids (most often topical but sometimes oral)
• Systemic antihistamines (eg, hydroxyzine, diphenhydramine) help pruritus;
antihistamines with low anticholinergic potency, such as low-sedating H1blockers, are
not as effective.
EXFOLIATIVE DERMATITIS (ERYTHRODERMA)
Exfoliative dermatitis is a manifestation of rapid epidermal cell turnover.

Preexisting skin disorders

• atopic dermatitis, contact dermatitis, seborrheic dermatitis,
psoriasis, pityriasis rubra pilaris
Use of drugs
• penicillin, sulfonamides, isoniazid, phenytoin, barbiturates

Cancer
• mycosis fungoides, leukemia, and, rarely, adenocarcinomas
SIGNS AND SYMPTOMS
•Pruritus
•Malaise and chills.
•Diffuse erythema
•Extensive epidermal sloughing
•Abnormal thermoregulation
•Nutritional deficiencies because of
extensive protein losses,
•Increased metabolic rate with a
hypercatabolic state, and ypovolemia
due to transdermal fluid losses.
EXFOLIATIVE DERMATITIS
Diagnosis
•Clinical evaluation
•History and examination.
Treatment
Supportive care (eg, rehydration)
• Topical care (eg, emollients, colloidal oatmeal baths)
• Systemic corticosteroids for severe disease
The disease may be life threatening; hospitalization is often necessary. Any known
cause is treated.
HAND AND FOOT DERMATITIS
Patients often present with isolated dermatitis of the hands or feet. Causes include:

• Contact dermatitis
• Fungal infection
• Psoriasis
• Scabies
• Hand-foot-and-mouth disease
• Or certain chemotherapies (hand-foot syndrome).
• Some cases are idiopathic.
HAND AND FOOT DERMATITIS
•Dyshidrotic dermatitis
•Keratolysis exfoliative
•Hyperkeratotic eczema
•Id reaction
•Housewives' eczema
•Hand-foot syndrome
HAND AND FOOT DERMATITIS -
DYSHIDROTIC DERMATITIS
Pruritic vesicles or bullae on the palms, sides of the
fingers, or soles are characteristic of this disorder.
Scaling, redness, and oozing often follow
vesiculation.
Pompholyx is a severe form with bullae. The cause
is unknown, but fungal infection, contact dermatitis,
and id reactions to tinea pedis can cause a similar
clinical appearance and should be ruled out.
Treatment includes topical corticosteroids,
tacrolimus or pimecrolimus, oral antibiotics, and
ultraviolet light.
 HAND AND FOOT DERMATITIS - KERATOLYSIS
EXFOLIATIVA
Painless patchy peeling of the palms,
soles, or both is characteristic of this
disorder. The cause is unknown; treatment
is unnecessary because the condition is
self-resolving.
 HAND AND FOOT DERMATITIS -
HYPERKERATOTIC ECZEMA
Thick yellow-brown plaques on the palms
and sometimes soles are characteristic of
this disorder. The cause is unknown.
Treatment is with topical corticosteroids and
keratolytics, oral psoralen plus ultraviolet A
(PUVA), and retinoids.
 HAND AND FOOT DERMATITIS -
HOUSEWIVES' ECZEMA
This irritant contact dermatitis affects people
whose hands are frequently immersed in
water.
It is worsened by washing dishes, clothes,
and babies because repeated exposure to
even mild detergents and water or
prolonged sweating under rubber gloves
may irritate dermatitic skin or cause an
irritant contact dermatitis.
HAND AND FOOT DERMATITIS -HAND-
FOOT SYNDROME
This disorder (also called acral
erythema or palmar-plantar
erythrodysesthesia) represents
cutaneous toxicity caused by certain
systemic chemotherapies (eg,
capecitabine, cytarabine,
fluorouracil, idarubicin, doxorubicin,
taxanes, methotrexate, cisplatin,
tegafur). Manifestations include
pain, swelling, numbness, tingling,
redness, and sometimes flaking or
blistering of the palms or soles.
LICHEN SIMPLEX CHRONICUS
(NEURODERMATITIS)
Lichen simplex chronicus is thickening of the skin with variable scaling that arises secondary
to repetitive scratching or rubbing.
• Lichen simplex chronicus is not a primary process.
• Lichen simplex chronicus frequently occurs in people with anxiety disorders and nonspecific
emotional stress as well as in patients with any type of underlying chronic dermatitis.
• Skin that tends toward eczematous conditions (eg, atopic dermatitis) is more prone to
lichenification.
LICHEN SIMPLEX CHRONICUS
SYMPTOMS AND SIGNS
Lichen simplex chronicus is characterized by pruritic, dry, scaling,
hyperpigmented, lichenified plaques in irregular, oval, or angular
shapes. It involves easily reached sites, most commonly the legs, arms,
neck, and upper trunk.
LICHEN SIMPLEX CHRONICUS
Diagnosis
• Clinical evaluation
Diagnosis is by examination. A fully developed plaque has an outer zone of discrete, brownish
papules and a central zone of confluent papules covered with scales. Look-alike conditions
include tinea corporis, lichen planus, and psoriasis; lichen simplex chronicus can be distinguished
from these by potassium hydroxide wet mount and biopsy.

Treatment
• Education and behavioral techniques
• Corticosteroids (most often topical but sometimes intralesional)
• Antihistamines
NUMMULAR (DISCOID) DERMATITIS
Nummular dermatitis is inflammation of the skin characterized by coin-shaped or
discshaped lesions.

Nummular dermatitis is most common among middle-aged patients and is often associated
with dry skin, especially during the winter.
The cause is unknown.
SYMPTOMS AND SIGNS
Discoid lesions often start as patches of confluent
vesicles and papules that later ooze serum and form
crusts.
Lesions are eruptive, widespread, and pruritic.
They are often more prominent on the extensor
aspects of the extremities and on the buttocks but
also appear on the trunk.
Exacerbations and remissions may occur, and when
they do, new lesions tend to reappear at the sites of
healed lesions.
NUMMULAR (DISCOID) DERMATITIS
Diagnosis
Diagnosis is clinical based on the characteristic appearance and distribution of the
skin lesions.

Treatment
• Supportive care
• Antibiotics
• Corticosteroids (most often topical, but sometimes intralesional or oral)
• Ultraviolet light therapy
 SEBORRHEIC DERMATITIS
Seborrheic dermatitis (SD) is inflammation of skin that has a high density of sebaceous glands
(eg, face, scalp, upper trunk).
The cause is unknown, but Pityrosporum ovale, a normal skin organism, plays some role. SD occurs
with increased frequency in patients with HIV and in those with certain neurologic disorders. SD
causes occasional pruritus, dandruff, and yellow, greasy scaling along the hairline and on the
face.
SEBORRHEIC DERMATITIS
SEBORRHEIC DERMATITIS
Diagnosis is made by examination.

Treatment
is tar or other medicated shampoo and topical corticosteroids and antifungals.
STASIS DERMATITIS
Stasis dermatitis is inflammation of the skin of the lower legs caused by chronic venous
insufficiency.
Symptoms are itching, scaling, hyperpigmentation, and sometimes ulceration.
Diagnosis is clinical.
Treatment is directed at the chronic venous insufficiency and preventing occurrence or
progression of associated ulcers.