ECZEMA

CH MANASWI

ECZEMA

▪ Greek term “To boil over”

▪ Usually refers to severely inflamed dermatitis, and the signs and symptoms associated with such an acute process (itching, sting, burning of the skin with drainage from lesions)

Cause

▪ The cause of eczema is unknown but is presumed to be a combination of genetic and environmental factors.

▪ The failure of the body to metabolize linoleic acid into y-linoleic acid (GLA) may be a cause of eczema, and administration of GLAs has been demonstrated to alleviate symptoms. Eczema may be in some cases caused by an inherited abnormality of essential fatty acid metabolism.

Distribution

▪ In infants, the face is often affected first, then the hands and feet; dry red patches may appear all over the body.

▪ In older children, the skin folds are most often affected, especially the elbow creases and behind the knees.

▪ In adults, the face and hands are more likely to be involved.

Distribution

Pathophysiology

▪ There are two phases

Acute phase

Chronic phase

▪ In acute stage, fluid escapes from dialated dermal blood vessels to produce edema in epidermis

▪ This collects into tiny vesicles or blisters, particularly where the skin is thick, as on the palms and soles. These vesicles coleasce into larger blisters.

▪ Where the skin is thinner they lead to rupture onto the skin surface, causing exudation, and crusting.

▪ The chronic stage shows less edema and vesiculation and more thickening of the epidermis and horny layers, produced by prolonged rubbing and scratching by the sufferer.

▪ Both stages are accompanied by a heavy inflammatory cell infilteration of dermis and epidermis

Acute eczema

▪ It is cherecterized by progression through number of diseases

¥ Red, hot, swollen and itchy skin

¥ Papules and tiny blisters

¥ Exudation and crusting

¥ scaling

blistering

Chronic eczema

▪ In addition to features listed in acute eczema, chronic eczema may show

¥ Drier skin, becoming more scaly

¥ Lichenification

¥ Painful fissures

Main Types Of Dermatitis:Atopic dermatitis

▪ Atopic dermatitis (AD) is a chronic, highly pruritic, eczematous skin disease that follows patients from early childhood into puberty and sometimes adulthood.

▪ This allergic disease is believed to have a hereditary component and often runs in families whose members also have asthma or hay fever.

▪ Itchy rash is particularly noticeable on head and scalp, neck, inside of elbows, behind knees, and buttocks. It is very common in developed countries, and rising.

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)

Exacerbating factors

▪ Anxiety/stress

▪ Climatic factors▪ Temperature▪ Humidity

▪ Irritants▪ Detergents/solvents▪ Wool or other rough material▪ Perspiration

▪ Allergens (contact, inhalant & food)

▪ Infections (staph and strep)

CONTACT DERMATITIS

▪ Two types of CD exist

¥ In the first the rash is caused by an allergen to an external substance( cell mediated immune or type IV reaction)

¥ In the second, the cause is caused by wear and tear and irritation.

¥ It accounts for 30% of all occupational disease

ALLERGIC CONTACT DERMATITIS

COMMON ALLERGENS

▪ Nickel Jewelry

▪ 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 in personal care products

IRRITANT CONTACT DEMATITIS

▪ Non-immunologic inflammatory reaction of the skin due to an external agent

▪ It is commonly seen in housewifes, nurses, hairdressers, caterers, and those who work with oil and grease in industries

COMMON IRRITANTS

¥ Water

¥ Skin cleansers

¥ Industrial cleaning agents

¥ Acids and alkalis

¥ Oils and organic solvents

¥ Oxidizing and reducing agents

¥ Plants

¥ Animal products

Xerotic eczema

▪ Also known as asteatotic eczema

▪ This means ‘lacking in oil ‘ and is typically found in elderly, in whom skin becomes over dry, perhaps aggravated by the use of soap.

SEBORRHOEIC ECZEMA

▪  It is a condition sometimes classified as a form of eczema that is closely related to dandruff.

▪ It causes dry or greasy peeling of the scalp, eyebrows, and face, and sometimes trunk.

▪ The condition is harmless except in severe cases of cradle cap.

▪ In newborns it causes a thick, yellow crusty scalp rash called cradle cap, which seems related to lack of biotin and is often curable.

Vesicular palmoplantar dermatitis

▪ Also known as dyshidrosis,  only occurs on palms, soles, and sides of fingers and toes.

▪ Tiny opaque bumps called vesicles, thickening, and cracks are accompanied by itching, which gets worse at night.

▪ A common type of hand eczema, it worsens in warm weather

Discoid eczema

▪ Discoid eczema is characterized by round spots of oozing or dry rash, with clear boundaries, often on lower legs. It is usually worse in winter. Cause is unknown, and the condition tends to come and go

Venous eczema

▪ Venous eczema occurs in people with impaired circulation, varicose veins and edema, and is particularly common in the ankle area of people over 50.

▪ There is redness, scaling, darkening of the skin and itching.

▪ The disorder predisposes to leg ulcers.

TREATMENT: Pharmacological

ⱥ Moisturizing

ⱥ Itch relief

ⱥ Corticosteroids

ⱥ Immuno-modulators

ⱥ Antibiotics

ⱥ Anti-Fungal agents

ⱥ Immunosuppressants

ⱥ Oral Retinoid

Non pharmacological

ⱥ Light therapy

ⱥ Diet

ⱥ Traditional remedies

ⱥ Managing mental and emotional state

Moisturizers

▪ Moisturizers or emollients including bath oils, soap substitutes can be applied to the dermatitis as frequently as required to relieve itching, scaling and dryness.

▪ Emollients should also be used on the unaffected skin to reduce dryness.

▪ Emollient therapy helps to restore one of the skin's most important functions, which is to form a barrier to prevent bacteria and viruses getting into the body and therefore help to prevent a rash becoming infected.

▪ Moisture Trapping effectiveness ▪ Best: Oils (e.g. Petroleum Jelly) ▪ Moderate: Creams ▪ Least: Lotions

▪ Apply emollients after bathing and times when the skin is unusually dry (e.g. winter months).

Topical Immunomodulators(calcineurin ihibitors)

▪ Topical immunomodulators (TIMs) are a new type of non-steroidal anti-inflammatory drug for the treatment of eczema.

▪ Mild burning sensations have been reported when applying TIMs. 

▪ Apply a thin layer of tacrolimus ointment to affected skin areas twice daily rub in gently and completely. Treatment should be continued for one week after clearing sign and symptoms. Should not be used with occlusive dressing.

▪ e.g. Tacrolimus ointment ( 0.03% & 0.1%). & Pimecrolimus cream ( 1%)

 Corticosteroids

▪ According to their duration of action are classified into:

▪ Short to medium acting: e.g.Hydrocortisone butyrate 0.1% cream apply thinly 1-2 times daily.

▪ Intermediate acting: e.g. Triamcinolone 0.1% ointment apply thinly 1-2 times daily.

▪ Long acting : e.g. Betamethasone (as valerate) 0.1% cream apply thinly 1-2 times daily.

▪ Severe cases may be treated with oral corticosteroids.

▪ Adverse effects

▪ an increase in appetite, weight gain, insomnia, fluid retention mood changes, such as feeling irritable, or anxious, osteoporosis, hypertension (high blood pressure), diabetes, weight gain, increased vulnerability to infection, cataracts and glaucoma (eye disorders), thinning of the skin, bruising easily muscle weakness.

Antibiotics

▪ Damaged skin is susceptible to bacterial infection. People living with eczema tend to develop more skin infections than others. Antibiotics, topical or oral, may be required to treat eczema.

▪ Clindamycin dosage and application: Clindamycin Topical solution(50ml) Each ml contains : 10 mg of clindamycin Squeeze few drops of the solution on a small piece of cotton or face pad and apply to affected area twice daily after cleaning the skin with soap and rinsing well with water.

▪ Gentamicin Sulfate Cream Each gram contains: 3mg of gentamicin supplied in 30 gram tubes, a small amount of gentamicin sulfate cream should be applied gently to the lesions three or four times daily . If necessary this may be covered with a dressing.

Antifungal agents

▪ Antifungal agents - Indicated for suspected candidiasis or proven candidal infection by a medical practitioner.

▪ Commonly used topical antifungal agents are nystatin cream or ointment and econazole nitrate cream .

▪ Dosage and Administeration: Nystatin cream-ointment. Each gram contain: 100,000 units Nystatin. Supply in atube of 15 gm Apply 2-4 times daily .

Antihistamines

▪ Antihistamines are occasionally prescribed to control itching and help the eczema sufferer sleep.

▪ Their effectiveness as anti-itch medication is limited, however, as histamines are not important components of eczema-associated itching.

▪ Sedating antihistamines such as promethazine (Phenergan) diphenhydramine (Benadry) are more effective at relieving itch than the newer, nonsedating antihistamines.

▪ Dosage and Administration: Diphenhydramine 25-50 mg Two times daily or at night.

Immunosuppressants

▪ When eczema is severe and does not respond to other forms of treatment, immunosuppressant drugs are sometimes prescribed.

▪ These dampen the immune system and can result in dramatic improvements to the patient's eczema.

▪ E.g. cyclosporin , azathioprine and methotrexate 

▪  Dosage and Administration: Methotrexate 2.5mg tablet. Should be taken 1 hr before or 1-2 hrs after meal. Generally 7.5-16 mg in a week not exceed 20 mg. If not effective after 8 weeks with the maximum dose should discontinued.

▪ ADR: Bone marrow depression Hepatotoxic Hair loss Skin rash Mouth sore

Coal tar

▪ Coal tar- has been used to treat the itching and inflammation caused by skin conditions for hundreds of years.

▪ The tar contains chemicals that soothe the skin. Coal tar is very sticky and messy.

▪ Tar creams and ointments are usually used to treat discoid eczema which is often resistant to topical steroids

▪ ADR: photosensitivity, acneform eruptions, etc

Phototherapy

▪ It involves the use of light to treat a medical condition. Ultraviolet light therapy improves eczema symptoms in some people.

▪ Phototherapy may only use ultraviolet light, or may combine the use of ultraviolet light with psoralen , a rug that increases light sensitivity.

▪ PUVA or UVB

▪ ADR: erythema, blisreing, nausea, lethargy, pruritus

▪ Chinese herbal medicine

Some Chinese herbal preparations contain prescription medications, including prednisone, and have been associated with cardiac and liver problems.

▪ Bleach baths-A randomized, investigator-blinded, placebo-controlled trial including 31 patients showed that intranasal mupirocin ointment and diluted bleach (sodium hypochlorite) baths improved atopic dermatitis symptoms in patients with clinical signs of secondary bacterial infection.

Dermatologists recommend the following for soap use:

• Avoid harsh detergents or drying soaps • Choose a soap that has an oil or fat base; a "super fatted" soap is best• Use an unscented soap • Patch test your soap choice, by using it only on a chosen area until you are sure of its results • Use a non-soap based cleanser • Bathe in warm water — not hot • Use soap sparingly • Avoid using washcloths, sponges, or loofahs • Use soap only on areas where it is necessary • Soap up only at the very end of the bath • Use a fragrance free barrier type moisturizer such as vaseline or aquaphor before drying off • Never use any kind of lotion, soap, or fragrance unless doctor recommended or allergen free • Don’t rub skin, it removes the natural oils and moisture