Dermatitis

Dr. Rodas Haile

M.D
OUTLINE

Atopic Dermatitis
•Contact Dermatitis
•Dyshidrotic Eczema
•Nummular Eczema
•Seborrheic Dermatitis
•Stasis Dermatitis
 INTRODUCTION

• Eczema- atopic dermatitis (atopic eczema). "Eczematous" also connotes some

scaling, crusting, or serous oozing as opposed to mere erythema.

• dermatitis" is typically used with qualifiers (eg, "contact dermatitis") to describe

several different skin disorders.
• approximately 10 to 30 % of dermatologic consultations
•
• Specific types are more common in some age groups
ATOPIC DERMATITIS
 Introduction
• chronic, pruritic, inflammatory skin disease that occurs most
frequently in children but also affects adults

• hallmarks of AD are dry skin, severe pruritus, and cutaneous

hyperreactivity to various environmental stimuli

• atopic stigmata, -keratosis pilaris , palmar hyperlinearity, pityriasis

alba, periorbital darkening, Dennie-Morgan infraorbital folds, and
nipple eczema.
Epidemiology
- Prevalence in children: 15-20%
in adults :1-3%
- F:M ≈ 1.3:1
- Affects all race
- Typically begins during infancy
* In 50% : in the 1st year of life
* in 30% : B/n age 1-5
* in 80% : before age 5
- 50-80% of AD pts develop allergic rhinitis or asthma
later in life.
Etiopathogenesis
- It has multifactorial causation

- Complex interaction between

- Genetic
- Environment &
- immune dysregulation.

- Socioeconomic status and family size.

( the hygiene hypothesis ) → controversial
 AD…development of skin
lesions
• Decreased barrier function (genetically defective stratum corneum)
↓
• ↑trans epidermal water loss
↓
• xerosis, fissuring of the skin
↓
• ↑entry of allergens, antigens, chemicals
↓
• Skin inflammation.
Clinical features

Pruritus : is the most prominent feature

- Worse at night
- often precedes the development of skin lesions
- Results in prurigo papules, lichenification,
eczematous skin lesions
- Distribution of lesions
• Infantile :
- 2month-2 years of age
- Symmetric lesions over cheeks, forehead,
scalp, trunk, and the extensor surfaces
• Childhood:

- 2-10 years of age.

- Symmetric lesions on wrists, ankles,
and flexor areas of the extremities.
Child hood AD
-Adolescent/ Adult:
- primarily involves the flexor areas of the arms,
legs, and neck.
Atopic dermatitis flexural dermatitis ( common in adults, adolescents, & older children
Flexural lichenification
In Adult with AD
Associated features..
• Xerosis ( dryness )
• Infraorbital fold (Dennie-Morgan
line)
• Pityriasis alba
• Palmar hyperlinearity …….etc.
Associated features…..Pityriasis alba
Lab investigation
- Not needed routinely.
- Serum IgE level ↑ed in 70-80% of
patients.
- Peripheral blood eosinophilia.
Complications
Infections are very common
complications
- viral
- fungal
- bacterial
Treatment.
- Goals of treatment :
▫ reduce itching
▫ reduce inflammation of the skin
▫ moisturize the skin
▫ prevent infection
- It incorporates
- cutaneous hydration
- pharmacologic
- identification & elimination of flare factors
1- Identification & elimination of triggering
factors
- Avoid contact with irritants.
- Do not use harsh soaps, detergents
- Short fingernails, as scratching may worsen
the inflammation (Itch-scratch cycle)
- Food allergens, aeroallergens- exacerbate AD
- Avoid extremes of temp.
- use cotton underwear.
- avoid frequent washing.
2-Cutaneous hydration

- It is the main stay of treatment.

- Aggressive treatment with emollients.
- Lukewarm soaking bath, application of an occlusive
emollients to retain moisture give symptomatic relief.
- Restores & preserves the stratum corneum barrier.
Cutaneous hydration
• Emolients !!!!!!!!!!!!!!!!!!!!!!!!!
• Emolients
• Emolients
• Emolients
• Emolients
• Emolients
• Emolents …….
3- pharmacologic: Topical steroids
- Mainstay of treatment for acute flare-ups.
- Low potency topical corticosteroids are used for face,
groin, axilla and for treatment of infants.
- Ointments are generally more potent than creams.
- Should be avoided in open, oozing or intertrigenous areas.
- Daily use is recommended.
- For up to 4 wks are safe & effective.
Side effects of Long term use of
steroids
○ Local
- Atrophy
- Striae
- Telangiectasia
- Worsening of acne
○ Systemic
- suppression of hypothalamic-pituitary-adrenal axis.
Topical calcineurin inhibitors (Tacrolimus &
pimecrolimus)
- Inhibit calcineurin in the skin
- Blocks early T cell activation & release of cytokines.
- Used as Second line treatment.
- Should not be used in those ‹2 years of age &
immunosuppressed.
Tar application
- Has antipruritic & ant inflammatory effect.
- May be used in reducing potency of topical steroids
required in chronic maintenance therapy.
- Not used on acutely inflamed skin (irritation.)
Other therapies
- Natural sunlight-might be beneficiary
- Phototherapy using UVB, UVA or PUVA
- For severe cases
UVB- immunosuppressive effect by blocking APCs/LC/ & altered
keratinocyte cytokine production.
UVA- targets epidermal LC& eosinophils
Systemic Rx
- For severe & resistant disease
- Systemic steroids - acute control, short term.
Clinical improvement is associated with severe
rebound flare up. (not recommended routinely)
- Other systemic therapies
- Cyclosporine
- Methotrexate
- Azathioprine
- Mycophenolate mofetil
Infections
- Antistaphylococcal Antibiotics
* Pencillinase resitant pencillins.
- Antiviral Rx for herpes infection
* acyclovir 400mg TID X 10 days or 200mg QID.
- Topical or systemic antifungals when fungal causes are
confirmed.
Prognosis
- natural history is not known
- tends to be severe & persistent in young children.
- Spontaneous resolution – after age 5 in 40-60% of pts
affected during infancy with mild AD.
- AD disappear in 20% of children followed from infancy
to adolescence but in 65% it becomes less severe.
Contact Dermatitis
Introduction
• Two main types of contact dermatitis:
• Irritant contact dermatitis

• Allergic contact dermatitis

Allergic Contact dermatitis
• is a form of dermatitis caused by an allergic reaction to an allergen, in
contact with the skin.
• more common in women than men
• young children are also allergic to nickel.
• topical antibiotics - >70 years
• especially common in metal workers hairdressers, beauticians, health
care workers cleaners painters and florists.
Pathophysiology
• type 4 or delayed hypersensitivity reaction
• occurs 48–72 hours after exposure to the allergen.
• involves CD4+ T-lymphocytes, which recognise an antigen on the skin
surface, releasing cytokines that activate the immune system and
cause the dermatitis.
• Patients with impaired barrier function of the skin are more prone to
allergic contact dermatitis,
Clinical features
Diagnosis
• Clinical
• Open application test
• Patch test
• Fungal scapings
• Dimethylgloxime test-nickel
Treatment
• Avoid allergen
• Emollient creams
• Topical steroids
• Topical or oral antibiotics for secondary infection
• Oral steroids, usually short courses, for severe cases
• Phototherapy or photochemotherapy.
• Azathioprine, ciclosporin or another immunosuppressive agent.
• Tacrolimus ointment and pimecrolimus cream are immune-modulating
calcineurin inhibitors and may prove helpful for allergic contact dermatitis.
 Irritant contact dermatitis

• exposure to substances that cause physical,

mechanical, or chemical irritation of the skin

• ICD of the hands is the most common type of

occupational dermatitis.
Pathophysiology
Clinical Features
Diagnosis
• Medical History
• Clinical Examination
• No tests for irritant eczema
Treatment
• Avoidance of all potential irritants
• Emollients
• Barrier creams
• Specific measures
• Specific treatments for some chemical irritants eg, calcium gluconate gel for hydrogen
fluoride burn
• Topical medications —
• Topical steriods
• calcineurin inhibitors
• Crisaborole
• Phototherapy
Asteatotic Eczema
AkA
Xerotic Eczema
Eczema Craquele
Structure(Description)
Pathogenesis
Risk Factors
Clinical features
 Diagnosis

• Appearance
• TSH, T3, T4
Nummular Eczema
Structure(Description)
Pathogenesis
Epidemiology
• occur at any age
• more common in older adult males (males tend to develop it more
often than females). .. After 50 years of age (men) and younger adult
females Before 30 years of age (women)
• In males there is an association with chronic alcoholism.
• Drug-induced discoid eczema can be due to medications that cause
skin dryness.
Clinical Features
Diagnosis
• Clinical
• Bacterial swabs
• Scrapings
• Patch testing
 Treatment
• Avoid allergens
• If patch testing has identified contact allergy, exposure to the allergen should be avoided.
• Anti-inflammatory treatments include:
• Topical steroids
Topical steroids are anti-inflammatory creams or ointments available on prescription to apply just to the patches once or twice daily for
2–4 weeks. Topical steroids reduce symptoms and clear the dermatitis.
• Antibiotics
Antibiotics (eg, erythromycin, flucloxacillin) are often prescribed if the dermatitis is blistered, sticky, or crusted. Sometimes discoid
eczema clears completely on oral antibiotics, only to recur when they are discontinued.
• Other treatments sometimes prescribed for severe discoid eczema include:
• Oral antihistamines
Antihistamine pills may reduce the itch in some patients with discoid eczema. They do not clear the rash.
• Ultraviolet radiation (UV) treatment
Phototherapy several times weekly for 6–12 weeks for generalised or widespread discoid eczema can reduce itch and improve the rash.
• Steroid injections
Intralesional steroids are sometimes injected into one or two particularly stubborn areas of discoid eczema. This treatment is
unsuitable for multiple lesions.
• Oral steroids
Systemic steroids are reserved for severe and extensive cases of discoid eczema. They are usually prescribed for a few weeks before
continuing topical steroids and emollients on residual dermatitis.
Self-Care
• Hydrate your skin:
• Avoid irritating your sensitive skin:
• Treat the spots and patches on your skin
• Get rid of infection
• Help you sleep
Seborrheic Dermatitis
Structure (Description)
• common noncontagious chronic relapsing mild form of dermatitis
• occurs in infants and in adults.
• Severity may vary from minimal, asymptomatic scaliness of the scalp
(dandruff) to more widespread
• “dandruff” (pityriasis capitis) -teenager’s or adult’s scalp,
• “Cradle cap” -baby’s.
• can also overlap with atopic dermatitis, especially in infants.
 Pathogenesis
• proliferation of commensal Malassezia metabolites (such
as the fatty acids oleic acid, malssezin, and indole-3-
carbaldehyde) may cause an inflammatory reaction
• An increased level of androgens (a hormone).
• An increased level of skin lipids.
• An inflammatory reaction.
• Family history (dermatitis runs in the family).
Risk Factors
• Factors that trigger or worsen seborrheic dermatitis include:
• Stress.
• Cold and dry climate.
• Oily skin.
• Using alcohol-based lotions.
• History of other skin disorders, including rosacea, psoriasis and acne.
• Immunosuppressions:
• Organ transplant recipients.
Neurological diseases:
• Adult Hodgkin’s Lymphoma.
Parkinson’s disease.
• Adult Non-Hodgkin’s Lymphoma.
Tardive Dyskinesia.
• HIV Epilepsy.
• Psychiatric disorders: Facial nerve palsy.
• Depression Spinal cord injury.
• Congenital disorders:
• Down Syndrome
• psychotropic medications:
• Lithium.
• Buspirone.
• Haloperidol decanoate.
• Chlorpromazine.
Clinical Features
 Treatment
• Frequent cleansing with soap
• Outdoor recreation
• Antifungal prepor 1 to 2 percentarations
• selenium sulfide 2.5 percent
• pyrithione zinc
• azole agents
• sodium sulfacetamide
• topical terbinafine 1%
• Anti-inflammatory agents -topical steroids
• Keratolytics -salicylic acid or coal tar preparations
• Variety of oils (peanut, olive or mineral)
 STASIS DERMATITIS

• common inflammatory dermatosis of the lower extremities occurring in patients with

chronic venous insufficiency

• erythematous, scaling, and eczematous patches or plaques on chronically edematous legs

• Acute forms may present with severely inflamed, weeping plaques, vesiculation, and
crusting, often with bacterial superinfection

• Allergic contact dermatitis (ACD) due to sensitization to topical preparations, dressings, and
topical antibiotics is a frequent complication
Clinical Features
Treatment
• Reduce swelling in the leg
• Don't stand for long periods.
• Take regular walks.
• Elevate your feet when sitting: if your legs are swollen they need to be
above your hips to drain effectively.
• Elevate the foot of your bed overnight.
• During the acute phase of eczema, bandaging is important to reduce
swelling
• Treatment for varicose veins
Treat the eczema

• Dry up oozing patches with Condy's solution (

potassium permanganate)
• Oral antibiotics -flucloxacillin for a secondary infection.
• topical steroid:
Prevention
• Venous eczema cannot be completely prevented but the number and
severity of flare-ups can be reduced by the following measures.
• Avoid prolonged standing or sitting with legs down.
• Wear compression socks or stockings.
• Avoid and treat leg swelling.
• Apply emollients frequently and regularly to dry skin.
• Avoid soap; use water alone or non-soap cleansers when bathing
 DYSHIDROTIC ECZEMA
• also called acute palmoplantar eczema,
pompholyx, or dyshidrosis

• an intensely pruritic, chronic and recurrent,

vesicular dermatitis of unknown etiology that
typically involves the palms and soles and lateral
aspects of the fingers

• most commonly in young adults of both sexes.

• the presence of multiple small, deep-seated

vesicles on the palmar or plantar skin, especially
along the lateral aspects of the fingers and toes