DERMATITIS EKSEMATOSA

Dr. Kristo A. Nababan, SpKK

Nummular eczema
Characteristic: Oval patches with crusted papulovesicles Localisation: Trunk Extremities

Dermatitis Numularis

Differential Diagnosis
Acute vesico papular dermatitis:
Contact dermatitis Infections: Dermatophyte, HS virus, Varicella Zoster, Bacteria

Chronic vesico papular dermatitis:

Chronic CD, psoriasis, drug eruption, fungal infect

Biopsy
- Intercellular edema widening intercellular spaces sponge like appearance epidermal (spongiosis) - Acute & severe : intra epidermal vesicular - Chronis: Epidermal hyperkeratotic
Thickened (acanthotic) Dermis: lymphocyte infiltration

Therapy
1. Corticosteroid: - topically - injectable intralesional - sistemic 2. Wide spread acute/ subacute eczematous: prednisone/ triamcinolone 40 mg/i. m wet dressing/bath: acute dermatitis 3. Chronic: baths containing oil moisturizers 4. Itching: hydroxyzine/ diphenhydramine

ATOPIC DERMATITIS
Chronic relapsing inflammatory skin disease. It is frequently associated with asthma, allergic rhinitis.

Debate
AD is primarily an allergen induced disease or Simply an inflammatory skin disorder found in association with respiratory allergy

Atopy
Familial hypersensitivity of skin and m. membrane against environmental substances

Atopy / Atopic Syndrome

Sindrome consist of : Bronchial asthma Allergic rhinitis Atopic Dermatitis

Epidemiology
Prevalence: AD Common health problem

10%> in children

Natural history
AD start early in life ( 60% of the patients develop the disease in infancy Majority improve < 5 years >> pats: resp. allergic disease: asthma & allergic rhinitis

Prognosis
- Depend of the severity - Start early in life more severe persist - recurrent of AD adolescent

Ethiology
Texture o/ t skin is abnormal with defective lipid barrier---> TEWL increase ( Transepidermal Water Loss) This is due to abnormal metabolism of fatty acid is not clear

Factors Contribute to the Development of A. D.

Genetics Environmental

A. D.
Immunological Pharmacologic

Genetics Factors
- Immunological abnormalities/ atopy - Hypersensitivity o/ t skin important development AD -genetic influence elevated Ig E product
T cell disregulation

Role of Allergen
Food: Milk, Egg infancy Aeroallergen late childhood (house dust mite) 80% (+) skin prick test

Food
-50% children AD clinical reactivity to food protein -Young children allergic to food: Milk Peanut soy wheat 75% (+) to food -Food direct contact provoke AD

Aero allergen
Older children, adultaero allergen (house dust mite, mould)

Food allergy less important

- Prick test and patch tes20-60% (+) to mite

Role of Infection
Pat AD develop viral, bacterial, fungal Skin infection

- Staphylococcus Aureus, Beta haemolytic strept common cutaneous pathogens - Staphy Aureus exotoxn, exoenzyme inflammatory skin lesion

Atopic Dermatitis
AD can be divided into three stages: 1. Infantile atopic dermatitis: 2 months-2 years of age 2.Childhood atopic dermatitis: 2 years-10 years 3. Adolescent and adult atopic dermatitis

Infantile Atopic Dermatitis

60 % In the first year of life Usually . 2 month of age Clinic: Itchy erythema of the cheeks Intraepidermal vesiclesrupture moist, crusted areas extend to other part of the body (scalp, neck, forehead, wrist, extensor extremities buttocks and diaper area spared

Chidhood Atopic Dermatitis

Childhood Clinic: less acute lesions Lesions less exudative, drier, >papular Locations: antecubital, popliteal fossae, flexor wrist, eyelids, face, around the neck lichenified, slightly scaly/ infiltrated plaques

Adolescents and adult AD

Older patients Clinic: Localized erythematous, scaly, papular/ vesicular plaques Pruritic, lichenified plaques Location: antecubital and popliteal fossae, front and sides of neck, forehead, area about the eyes Eruptions generalized more severe in flexures lichenified Plaques often erythematous/ hyperpigmented

Major Clinical features of AD (base on Hanifin and Rajka)

- Intense pruritus & excoriation - Typical morphology and distribution of skin lesions:-facial and extensor involvement in infant and early childhood -flexural lichenification in adult - Chronic or chronically relapsing dermatitis (>6 weeks) - Personal and family history of atopic disease

Minor features
-Dryness of the skin (xerosis) -Ichthyosis, keratosis pilaris, hyperlinear palms -Non specific hand/foot dermatitis -Scalp dermatitis e.g. cradle cap -Allergic shiners -Recurrent conjunctivitis and keratoconus - IgE reactivity -Dennie-Morgan infraorbital fold -Orbital darkening -Pityriasis alba -Food hypersensitivity

Intense pruritus
Itching, Scratching the day worse at night sleep disruption Pat AD threshold of itching decreased Humidity Excessive sweating Exposure to allergens, irritants (soap, detergent acrylic, wool) itch

Whats the etiology of pruritus in AD ?

- Not well understood - Local release of proinflammatory mediators & cytokines

Rukwied and Heyer (1999)

Pruritus: - Histamine - Cytokines - leukotrienes - neuropeptide - proteases

Morphological characteristic of AD
-Acute lesions are papules, vesicles on erythematous background with sign of erosion, bleeding and serous exudate -Sub acute lesions are erythematous and scaly papules on dry background -Chronic lesions are fibrotic papules on lichenified (thickened) back ground -Excoriation due to scratching in a all stage -Infection may alter the appearance with the presence of oozing or local abscess -Even uninvolved skin is often dry and scaly

Investigation
Total Ig E > not helpful diagnosis Skin prick test (SPT) Specific Ig E (RAST) more helpful

Diagnosis

3 or more major criteria 3 or more minor criteria

Atopic Dermatitis in Child

TREATMENT OF ATOPIC DERMATITIS

Basic Treatment Skin care Emollients Avoidance of irritants, sudden changes of temperature, humidity

Identification of specific Exacerbating factors Allergens Microbes Emotional factors

Anti inflammatory Treatment

Avoidance of trigger factors

1. Irritants detergents soap

2. Allergens: Food allergen Airborne allergens Child < 5 years : Usually allergy to 1 or > food cows milk, egg, wheat, bean 3. House dust mite: older children young adult 4. Emotional stress

TOPICAL EMOLLIENT
BASIS TOPICAL TREATMENT : 2 3 X / DAY WATER LOSS ITCHING

Topical treatment
CREAM / LOTION : EARLY PHASE OINTMENT : LICHENI FIED SKIN SEVERE CASE :
AFTER OINTMENT WETWRAP DRESSING EPIDERMAL WATER LOSS TOPICAL CROMOLYN IN WATER SOLUBLE EMOLLIENT VEHICLE ANTI INFLAMATORY EFFECT

ANTIBIOTIC
FUSIDIC ACID GRAM (+)

TETRA CYCLINE SKIN CLEANSER 10% POVIDONE IODINE GENERALIZED INFECTION : ANTI
MICROBIAL BATH (CHLORHEXIDIN 0,005%) SISTEMIC ANTIBIOTIC : FLUCLOCXACILLIN : MUPIROCIN

OTHER TREATMENT STRATEGIES

UVA PHOTOTERAPY CICLOSPORIN IF

Atopic Dermatitis in Child

Atopic Dermatitis in Infant and Child

Atopic Dermatitis in Child

CONTACT DERMATITIS An inflammatory reaction of the skin precipitated by an exogenous chemical

Contact Dermatitis
1. Irritant CD: produced by substance that has direct toxic effect on the skin 2. Allergic: trigger an immunologic reaction tissue inflammation

Pathogenesis
Irritant CD: nonspecific inflammatory reactions due toxic injury of the skin Allergic CD: Cell mediated immunity/ type IV A. Sensitization phase B. Elicitation Phase Sensitization: hapten + protein LCs Th1

type IV
antigens

inflammatory mediators

lymphokines

activated macrophage

Irritants
Subtances direct toxic effect of the skin Acids Alkalis Solvents Detergents

Allergens
Triggers immunologic reaction tissue inflammation

Metals Plants Rubber chemicals Medicines

Clinical appearance

Acute (vesicles) Chronic (lichenification)

Incidence: - Frequent problem - 50% occupational illness

History
First determine: ACD/ICD Strong irritant several hours skin damage Weaker irritants multiple application & days dermatitis Allergic Contact Dermatitis:
Requires 24-48 hours Often exposure Clinical disease Occasionally dermatitis (8-12 hours) up to 4-7 hours Detailed history of occupation, hygiene habits, hobbies

The most common Sensitizers

Poison Ivy Para phenylenediamine Nickel Rubber compounds Ethylenediamine Poison ivy: in the summer
Allergen: pentadecylcatechol (oleoresin of the plant)

PPD
Permanent coloring of hair Cross reaction : Azo, aniline dye, Benzocaine, procaine, Hydrochlorothiazine Sulfonamides When completely oxidized (fur coat), PPD not allergenic

Nickel
Most commonly in woman Ear piercing In all metals Hypoallergenic earring: one cannot be certain that they are free of nickel Stainless steel: nickel bound so tightly ACD (-)

Rubber compound
Shoes ACD on dorsa of the feet Allergen: Mercaptobenzothiazole Thiurams

Ethylenediamine
Preservative in Mycolog cream, ointment (-) Dyes, insecticides, Rubber accelerators, Synthetic waxes, In aminophyllin Sensitive individual generalized eczematous dermatitis

Physical Examination
Acute/chronic Depend upon the nature of the exposure patches/plaque, angular corner, geometric on lines, sharp margin Localization: Head& neck: cosmetics, hair dyes, permanent waves, shampoos Eyelid: eye cosmetic, nail polish Photo allergic: produce by a photoreaction between SUV & allergen, of the neck, arms

Physical Examination
The dorsum of the hands: industrial chemicals (irritants): petroleum, solvents The dorsum of the feet: shoes (rubber, leather tanning agents) Groins and buttocks in infants: Diaper dermatitis: moisture and feces

DD
Other eczematous eruptions Atopic dermatitis Seborrhoic dermatitis Stasis eczema Superficial fungus infections Bacterial cellulitis

Diagnosis
Patch test: The test material, in different vehicles (commonly white petrolatum) Is applied to the skin under a metal disc, called a Finn chamber A test battery of 20-24 allergens is used as standard allergens The sheet is placed on the upper back, scaled with adhesive tape The patch is removed after 48 hours read

Therapy
Prevention Avoidance of irritant/allergen change in life style & occupation Protective clothing Occupational: protective, barrier cream little benefit Substituted Topical steroid Antihistamine

Dermatitis Kontak Iritan

DKI pd tangan & ujung-ujung jari akibat asam

Dermatitis Kontak Alergi

DKA akibat kalung nikel

DKA akibat semen

Seborrheic Dermatitis/ Morbus Unna

Definition: a chronic, superficial, inflammatory process affecting the hairy regions of the body Etiology: unknown/ Pityrosporum ovale Dandruff is scaling of the scalp without inflammation Incidence: a common problem, 2-5% adult 18-40 years, baby (cradle cap), children 6-10 years, woman> man

Seborrheic Dermatitis
Predilection hairy region: scalp, eyebrow eyelid Nasolabial creases, ears, chest

History
The occurrence of Seborrheic Dermatitis parallels the increased sebaceous gland activity occurring in infant, after puberty, pruritus

Physical examination
Predilection for the hairy regions where there are numerous sebaceous gland: scalp, eyebrows, eyelids, nasolabial creases, ears, chest, intertriginous area: axilla, groin, buttocks, infra mammary folds Bilateral and symmetrically Most mild form, dandruff, fine whittis scaling without erythema. Patch/plaque: indistinct margin, erythema, yellowish, greasy scaling, uncommon hair loss

Physical examination S.D

Mild form: dandruff fine whitish scaling without erythema / Pityriasis sica Mild Moderate: erythema, yellowish greasy scaling

DD
1. A.D (infantile eczema) if infant Loc: diaper area & axilla diagnosis S.D If lesion: forearms, shins AD 2. Psoriasis: scalp, groin, other area papilosquamous patches & plaque 3. T. capitis: hair loss, urban black Biopsy : non diagnostic

Therapy S.D
Anti seborrheic shampoos (sulfur, salicylic acid, selenium sulfide, zinc pyrithione) Shampoos must be rubbed in to the scalp 5-10 minutes Inflam. Seborrrheic: topical steroid lot/gel in hairy area; hydrocortisone cream non hairy skin

Course & Complication

Infancy : to remit after 6-8 months Adult : chronic, unpredictable

STASIS DERMATITIS Defination:

An eczematous eruption of the lower leg secondary to peripheral venous disease

STASIS DERMATITIS
Venous incompetence hydrostatic pressure, capillary damage extravasation of red blood cell & serum inflammatory eczematous process

Incidence
Adults (middle age old age)
History: Chronic pruritic eruption precede by edema & swelling Patients with Stasis dermatitis have often had thrombophlebitis

Physical examination
Varicose vein are prominent 1. Edema 2. Brown pigmentation 3. Petechiae 4. Sub acute and chronic dermatitis 5. Thickened skin, scaling and /or weeping 6. Any portion of the leg prominent site is above the medial malleolus

DD
1. Contact Dermatitis 2. Peripheral Arterial Disease 3. Superficial Fungal Infection 4. Bacterial cellulitis Examination of peripheral pulses, history of topical agent, KOH, gram steins, bacterial culture should be done

Biopsy

Sub acute or chronic dermatitis with hemosiderin, fibrosis, and dilated capillaries in the dermis

Therapy
- Prevention of venous stasis and edema use of supportive hose - Standing should be restricted - Patients who are obese weight reduction - If this fails bed rest with elevation of legs - Topical steroid - Wet compresses if there is oozing or crusting

Course and Complications

Dusky erythema Ulceration total bed rest with leg elevation with antiseptic cleansing Systemic antibiotics not helpful Application of skin grafts Allergy to topical preparation 60% ( topical antibiotics)

LICHEN SIMPLEX CHRONICUS/Neurodermatitis

-Definition: A chronic eczematous eruption o/ t skin, that is result of scratching

Pruritus scratching lichenification & itching

LSC
Pruritus scratching and precipitated by frustration, depression and stress lichenification further itching, resulting itch-scratch-itch cycle

History

- Patient may have history of emotional or psychiatric problem

Physical Examinations
Patients: anxious Lichenified plaque, scratching (+)

Liken Simplek Kronikus/ Neurodermatitis

DD
1. Chronic dermatitis

2. Psychodermatoses (factitious dermatitis, delusion of parasitosis Factitious dermatitis: self inflicted injury o/ t skin bizarre eruption (often ulcerated), linear and geometric outlines Delusion of parasitosis: in disturbed/ anxious eccentric individual Begins intractable pruritus crawling sensation, that they are harboring parasites & bring specimens Active lesions: excoriated, crusted papule secondary to picking

DD
3. Neurotic excoriations Linear :dug out lesions: Upper mid back (Where scratching fingers cannot reach. Neurotic woman

Therapy

Difficult Tranquilizer and anti depressants Topical steroid and intralesional steroid

Tabel ECZEMATOUS ERUPTIONS

Incidence* Nonspeciffic eczematous dermatitis 11.4 History Pruritus Physical Acute-vesicles, weeping, crusted patches Subacute-juicy papules Chronic-lichenified, scaling plaques Differential Diagnosis Contact dermatitis Atopic dermatitis Seborrheic dermatitis Fungal infection Psoriasis Drug rash Eczematous dermatitis Fungal infection Cellulites Lab. -

Contact dermatitis

2.8

Irritant-contact precedes rash by hours to days Allergic-contact precedes rash by 1-4 days Allergic rhinitis Asthma

Vesicles, juicy papules, lichenified plaques Sharp margins Geometric or linear configuration Conforms to area of contact Vesicles, juicy papules-infants Lichenified plaques-adults and older children Head, neck, antecubital and popliteal fossa Scaling papules and patches Scalp, eyebrows, nasal, sternum

Patch test

Atopic dermatitis

2.6

Contact dermatitis Scabies

IgE

Seborrheic dermatitis

3.7

Dandruff

Atopic dermatitis Psoriasis Fungal infection Histiocytosis X Lupus erythematosus Cellulitis Contact dermatitis Arterial disease Fungal infection Psoriasis

Stasis dermatitis

0.4

Varicose veins Leg swelling Thrombophlebitis Rash subsequent to pruritus

Juicy papules Lichenified plaques Brown pigmentation Lower legs Lichenified plaque Within reach of fingers

Lichen simplex chronicus

0.8

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