dermatitis dr. ruth westra dr. ruth westra june 4, 2008

DERMATITISDERMATITIS

Dr. Ruth WestraDr. Ruth Westra

June 4, 2008June 4, 2008

TYPES OF DERMATITISTYPES OF DERMATITIS

Atopic Dermatitis (Eczema)Atopic Dermatitis (Eczema) Contact DermatitisContact Dermatitis Seborrheic DermatitisSeborrheic Dermatitis Stasis DermatitisStasis Dermatitis PhotodermatitisPhotodermatitis MultifactorialMultifactorial

ATOPIC DERMATITISATOPIC DERMATITIS

Chronic, pruritic eczematous Chronic, pruritic eczematous condition of the skin that is condition of the skin that is associated with a personal or family associated with a personal or family history of atopic disease (asthma, history of atopic disease (asthma, allergic rhinitis)allergic rhinitis)

Etiology unknownEtiology unknown

INCIDENCE OF ATOPIC INCIDENCE OF ATOPIC DERMATITISDERMATITIS

Disease of childhood – 10% of Disease of childhood – 10% of children affected in U.S.children affected in U.S.

Uncommon for adults to develop Uncommon for adults to develop atopic dermatitis without a history of atopic dermatitis without a history of eczema in childhoodeczema in childhood

EPIDEMIOLOGY OF ATOPIC EPIDEMIOLOGY OF ATOPIC DERMATITISDERMATITIS

Increased prevalence may be due to Increased prevalence may be due to exposure to pollutants, indoor exposure to pollutants, indoor allergens, and decline in breast allergens, and decline in breast feedingfeeding

?Autosomal dominant gene?Autosomal dominant gene

ALLERGENS FOR A.D.ALLERGENS FOR A.D.

Food allergensFood allergens AeroallergensAeroallergens MicrobesMicrobes

CLINICAL FEATURES OF CLINICAL FEATURES OF ATOPIC DERMATITISATOPIC DERMATITIS

PruritisPruritis Facial and Extensor Papulovesicles in Facial and Extensor Papulovesicles in

InfancyInfancy Flexural Lichenification in Adults and Flexural Lichenification in Adults and

Older ChildrenOlder Children Chronic-relapsing CourseChronic-relapsing Course Personal or Family History of Atopic DxPersonal or Family History of Atopic Dx

TABLE 1 Diagnostic Features of Atopic Dermatitis*

Major features Pruritus Chronic or relapsing dermatitis Personal or family history of atopic disease Typical distribution and morphology of atopic dermatitis rash:

Facial and extensor surfaces in infants and young children Flexure lichenification in older children and adults

Minor features Eyes

Cataracts (anterior subcapsular) Keratoconus Infraorbital folds affected

Facial pallor Palmar hyperlinearity Xerosis Pityriasis alba White dermatographism Ichthyosis Keratosis pilaris Nonspecific dermatitis of the hands and feet Nipple eczema Positive type I hypersensitivity skin tests Propensity for cutaneous infections Elevated serum IgE level Food intolerance Impaired cell-mediated immunity Erythroderma Early age of onset *--The diagnosis of atopic dermatitis should be suspected if three major criteria and three minor criteria are present.

DIFFERENTIAL DIAGNOIS OF DIFFERENTIAL DIAGNOIS OF A.D.A.D.

Congenital DisordersCongenital Disorders Chronic DermatosesChronic Dermatoses Infections and InfestationsInfections and Infestations Malignancies Malignancies ImmunodeficienciesImmunodeficiencies Metabolic DisordersMetabolic Disorders Immunologic DisordersImmunologic Disorders

TREATMENT FOR A.D.TREATMENT FOR A.D.

Cutaneous hydrationCutaneous hydration Topical Glucocorticoid RxTopical Glucocorticoid Rx Identify and Eliminate Flare FactorsIdentify and Eliminate Flare Factors

NEW RXNEW RX

Protopic (tacrolimus),topical Protopic (tacrolimus),topical immunomodulator, inhibits T-cell immunomodulator, inhibits T-cell activation by preventing transcription activation by preventing transcription of early cytokines (CREAM)of early cytokines (CREAM)

Elidel (pimecrolimus), a calcineurin Elidel (pimecrolimus), a calcineurin inhibitorinhibitor

Both for short-term and intermittent Both for short-term and intermittent long-term therapy without occlusive long-term therapy without occlusive dressingsdressings

TREATMENT OF PRURITISTREATMENT OF PRURITIS

AntihistaminesAntihistamines Tar PreparationsTar Preparations

ELIMINATE AGGRAVATING ELIMINATE AGGRAVATING FACTORSFACTORS

Specific allergensSpecific allergens Emotional StressorsEmotional Stressors Infectious AgentsInfectious Agents

POORLY CONTROLLED A.D.POORLY CONTROLLED A.D.

Wet Dressings and OcclusionWet Dressings and Occlusion Systemic GlucocorticoidsSystemic Glucocorticoids Ultraviolet Light (PUVA)Ultraviolet Light (PUVA) Leukotriene InhibitorsLeukotriene Inhibitors Immunosuppressants and Immunosuppressants and

AnitneoplasticsAnitneoplastics HospitalizationHospitalization

COMPLICATIONS OF ATOPIC COMPLICATIONS OF ATOPIC DERMATITISDERMATITIS

EyeEye InfectionsInfections Hand DermatitisHand Dermatitis Exfoliative DermatitisExfoliative Dermatitis

PROGNOSISPROGNOSIS

Spontaneous resolution after age 5 in 40%Spontaneous resolution after age 5 in 40% 84% of children “outgrow” by adolescents84% of children “outgrow” by adolescents Predictive factors of Poor Prognosis Predictive factors of Poor Prognosis

Wide spread AD in childhood Wide spread AD in childhood Associated allergic rhinitis or asthma Associated allergic rhinitis or asthma Early age at onset of AD and female sex Early age at onset of AD and female sex Family history of AD in parents or siblings Family history of AD in parents or siblings

CONTACT DERMATITISCONTACT DERMATITIS

Inflammatory reaction of the skin Inflammatory reaction of the skin precipitated by an exogenous chemicalprecipitated by an exogenous chemical

Two types of contact dermatitis Two types of contact dermatitis Irritant - direct toxic effect on the Irritant - direct toxic effect on the skin Allergic - immunologic reaction skin Allergic - immunologic reaction that causes tissue inflammation (Type that causes tissue inflammation (Type IV Hypersensitivity)IV Hypersensitivity)

INCIDENCE OF CONTACT INCIDENCE OF CONTACT DERMATITISDERMATITIS

Environmental AllergensEnvironmental Allergens Occupationally related illnessOccupationally related illness

SENSITIZERS OF CONTACT SENSITIZERS OF CONTACT DERMATITISDERMATITIS

Poison IvyPoison Ivy ParaphenylenediamineParaphenylenediamine NickelNickel Rubber CompoundsRubber Compounds EthylenediamineEthylenediamine

CLINICAL FEATURES OF CLINICAL FEATURES OF CONTACT DERMATITISCONTACT DERMATITIS

Acute – linear streaks of vesiclesAcute – linear streaks of vesicles Chronic - lichenification, eczematous Chronic - lichenification, eczematous

reactionreaction

LOCATION OF CONTACT LOCATION OF CONTACT DERMATITISDERMATITIS

Head and neck-cosmeticsHead and neck-cosmetics Scalp-hair dyes, permanents and Scalp-hair dyes, permanents and

shampoosshampoos Eyelids-eye cosmetics and nail polishEyelids-eye cosmetics and nail polish Dorsum of hands-industrial chemicalsDorsum of hands-industrial chemicals Dorsum of feet-shoes, rubber, leatherDorsum of feet-shoes, rubber, leather

DIFFERENTIAL DIAGNOSIS DIFFERENTIAL DIAGNOSIS OF CONTACT DERMATITISOF CONTACT DERMATITIS

Atopic DermatitsAtopic Dermatits Seborrheic DermatitisSeborrheic Dermatitis Stasis DermatitisStasis Dermatitis Fungal InfectionsFungal Infections Bacterial CellulitisBacterial Cellulitis

LABORATORYLABORATORY

No testing for Irritant Contact No testing for Irritant Contact DermatitisDermatitis

Patch Testing for Allergic Contact Patch Testing for Allergic Contact Dermatitis - North American Contact Dermatitis - North American Contact Dermatitis Group Standard Patch Dermatitis Group Standard Patch Test SeriesTest Series

MOST FREQUENT MOST FREQUENT ALLERGENSALLERGENS

Nickel sulfateNickel sulfate Quaternium-15Quaternium-15 Fragrance mixFragrance mix BacitracinBacitracin Neomycin sulfateNeomycin sulfate CobaltCobalt Balsam of PeruBalsam of Peru Para-Para-

phenylenediaminephenylenediamine ThimerosolThimerosol Thiuram mixThiuram mix FormaldehydeFormaldehyde Carba mixCarba mix

TREATMENT FOR CONTACT TREATMENT FOR CONTACT DERMATITISDERMATITIS

Prevention-Allergen AvoidancePrevention-Allergen Avoidance Symptomatic TherapySymptomatic Therapy Physicochemical BarriersPhysicochemical Barriers Tolerance InductionTolerance Induction

SEBORRHIEC DERMATITISSEBORRHIEC DERMATITIS

Chronic, superficial inflammatory process Chronic, superficial inflammatory process affecting the hairy regions of the body affecting the hairy regions of the body (scalp, eyebrows and face especially)(scalp, eyebrows and face especially)

Affects infants and adultsAffects infants and adults Wide range from mild to severeWide range from mild to severe One of most common skin manifestations One of most common skin manifestations

in patients with HIV infectionin patients with HIV infection

INCIDENCE OF SEBORRHEIC INCIDENCE OF SEBORRHEIC DERMATITISDERMATITIS

Two peaks - Infancy in the first 3 Two peaks - Infancy in the first 3 months Adult in the fourth to months Adult in the fourth to seventh decadeseventh decade

In adults more common than psoriasis In adults more common than psoriasis 2-5% of the population 2-5% of the population

Men affected more than womenMen affected more than women 85% incidence in HIV infection 85% incidence in HIV infection

patientspatients

ETIOLOGY OF SEBORRHEIC ETIOLOGY OF SEBORRHEIC DERMATITISDERMATITIS

UnknownUnknown Associated with oily-looking skin but Associated with oily-looking skin but

not a disease of the sebaceous glandnot a disease of the sebaceous gland Associated with Parkinson’s DiseaseAssociated with Parkinson’s Disease

CLINICAL FEATURES OF CLINICAL FEATURES OF SEBORRHEIC DERMATITISSEBORRHEIC DERMATITIS

Bilateral and SymmetricalBilateral and Symmetrical Predilection for Hairy Regions Predilection for Hairy Regions Patches and Plaques with indistinct Patches and Plaques with indistinct

marginsmargins Uncommon to have hair loss Uncommon to have hair loss

CLINICAL FEATURES OF S.D.CLINICAL FEATURES OF S.D.

Infantile Infantile Scalp (cradle cap) Scalp (cradle cap) Trunk (including flexures Trunk (including flexures and diaper area) Leiner’s disease and diaper area) Leiner’s disease (non-familial and Familial (non-familial and Familial Complement 5 dysfunction)Complement 5 dysfunction)

CLINICAL FEATURES OF S.D.CLINICAL FEATURES OF S.D.

Adult Adult Scalp Scalp Face Face Trunk - Trunk - Petaloid, Pityriasiform, Flexural, Petaloid, Pityriasiform, Flexural, Eczematous plaques, Follicular Eczematous plaques, Follicular Generalized Generalized

FIGURE 7. Typical symmetrical distribution of seborrheic dermatitis on the head (top), and on the body (bottom).

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISSEBORRHEIC DERMATITISSEBORRHEIC DERMATITIS

Atopic DermatitisAtopic Dermatitis PsoriasisPsoriasis Tinea CapitisTinea Capitis SLESLE RosaceaRosacea Histiocytosis XHistiocytosis X

DRUGS CAUSING S.D. RASHDRUGS CAUSING S.D. RASH

Produce Seborrheic Dermatitis like Produce Seborrheic Dermatitis like lesions Arsenic lesions Arsenic Gold Gold Methyldopa Methyldopa Cimetidine Cimetidine NeurolepticsNeuroleptics

NEUROLOGIC NEUROLOGIC ABNORMALITIES AND S.D.ABNORMALITIES AND S.D.

Variety of Neurologic Abnormalities Variety of Neurologic Abnormalities associated with seborrheic dermatitis associated with seborrheic dermatitis Parkinson’s Disease Parkinson’s Disease Facial Paralysis Facial Paralysis Poliomyelitis Poliomyelitis Quadriplegia Quadriplegia

EpilepsyEpilepsy

PHYSICAL FACTORSPHYSICAL FACTORS

Seasonal variationSeasonal variation Relation to PUVARelation to PUVA

IMMUNODEFICIENCY AND IMMUNODEFICIENCY AND S.D.S.D.

Clue to the presence of HIV Clue to the presence of HIV Distribution is extensive, severity Distribution is extensive, severity remarkable and treatment often remarkable and treatment often difficultdifficult

TREATMENT GOALS OF S.D.TREATMENT GOALS OF S.D.

Loosening and removal of scales and Loosening and removal of scales and crustscrusts

Inhibition of yeast colonizationInhibition of yeast colonization Control of secondary infectionControl of secondary infection Reduction of erythema and itchingReduction of erythema and itching Control rather than cureControl rather than cure

TREATMENT FOR INFANTSTREATMENT FOR INFANTS

Scalp Scalp Removal of crusts with 3-5% Removal of crusts with 3-5% salicylic acid in olive oil or water salicylic acid in olive oil or water soluble base Warm olive oil soluble base Warm olive oil compresses compresses Application of low potency Application of low potency glucocorticoids Mild baby shampoosglucocorticoids Mild baby shampoos

TREATMENT FOR INFANTSTREATMENT FOR INFANTS

Intertriginous areas Intertriginous areas Drying lotions (0.2-0.5% Drying lotions (0.2-0.5% clioquinol in zinc lotion or zinc oil) clioquinol in zinc lotion or zinc oil) Candidiasis- Candidiasis- Nystatin Cream Nystatin Cream

Gentian Violet 0.1-0.25% if oozing Gentian Violet 0.1-0.25% if oozing

TREATMENT OF ADULTSTREATMENT OF ADULTS

Chronic Condition Chronic Condition

Anti-inflammatory Anti-inflammatory Anti- Anti-fungal fungal KerolyticsKerolytics

TREATMENT OF ADULTSTREATMENT OF ADULTS

Scalp - Daily Shampoo containing 1-2.5% Scalp - Daily Shampoo containing 1-2.5% selenium sulfide, antifungals, zinc, selenium sulfide, antifungals, zinc, benzoyl peroxide, salicylic acid, coal or benzoyl peroxide, salicylic acid, coal or juniper tarjuniper tar

Crusts - can be removed by overnight Crusts - can be removed by overnight application of topical glucocorticoids or application of topical glucocorticoids or salicylic acid in water soluble basesalicylic acid in water soluble base

Tinctures and alcoholic solutions in hair Tinctures and alcoholic solutions in hair tonics aggravatetonics aggravate

TREATMENT OF ADULTSTREATMENT OF ADULTS

Face and trunk - low potency Face and trunk - low potency glucocorticoids (1% hydrocortisone) glucocorticoids (1% hydrocortisone)

Avoid greasy ointments Avoid greasy ointments Lotion – Cream – Ointment Lotion – Cream – Ointment

(strongest)(strongest)

TREATMENT OF ADULTSTREATMENT OF ADULTS

Anti-fungals - Imidazoles Anti-fungals - Imidazoles 95% improvement with 95% improvement with ketaconazole inhibition of cell ketaconazole inhibition of cell wall synthesis no proof of wall synthesis no proof of fungal etiologyfungal etiology

Metronidazole - topical 0.75% gel Metronidazole - topical 0.75% gel (Metrogel) some improvement(Metrogel) some improvement