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The word eczema means 'to boil over.

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Lection 3 Eczema

Etiology and pathogenesis of eczema. It is necessary to comprehend that eczema is a polyetiological disease with complex pathogenesis, where the main role is played by allergic factors, affecting the organisms with changed reactivity of the central and vegetative nervous systems. The autoallergic phenomenon is of certain significance, which is due to the presence of focal infection, visceral and endocrinopathy, immune conditions. Eczema starts with the formation of monovalent sensitization (increased sensitivity towards a certain allergen) which afterwards may transfer into polyvalent sensitization.
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Pathogenic types of eczema


True eczema Microbial eczema Nummular eczema Varicose eczema Posttraumatic eczema Seborrheic eczema Infantile eczema

Classification of dermatitis
Simple dermatitis Physical Mechanical Chemical Biological Allergic dermatitis

Terminology

ECZEMA: Use as a clinical descriptive term, it describe a process that is clearly superficial in form and that, early, is erythematous, papulovesicular, oozing and crusting and, later, red-purple, scaly, lichenified and possibly pigmented. Epithelial disruption and non-sharp margination are its characteristics.
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True eczema

True eczema the main role in pathogenesis is played by a polyvalent sensitization and pronounced neurogenic disturbances. Clinical features: disseminated, symmetric and blunt borders of the lesions, intense itching; primary lesion is a punctulated microvesicle (serous wells), crusts with small foci, fine-laminar desquamation.
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First appears erythema (eczema erythematosum), against the background of which microvesicles (the size up to of a pinhead), papules (mostly exudative), and pustules are formed (eczema vesiculosum, papulovesiculosum, papulosum, and pustulosum). The microvesicles in the centre of the focus rupture, the serous exudate seeps onto the skin surface and produces oozing areas with a macerated and scaling horny layer (eczema madidans). Careful examination of the focus will reveal numerous 'point' erosions from which small drops of serous exudate emerge (serous wells).
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Stage Morphology of Lesions Symptoms


Acute

vesicles, blisters, intense red intense itch, stinging, burning.


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Stage Morphology of Lesions Symptoms

Subacute red, scale, fissuring, parched appearance, scalded appearance slight to moderate itch, stinging, burning

Stage Morphology of Lesions Symptoms

Chronic thickened skin, lichenified excoriation, fissuring moderate to intense itch 9

Dyshidrotic eczema

Dyshidrotic eczema is a deep vesicular skin reaction involving the fingers, the interdigital spaces and the feet. The vesicles have a characteristic morphological appearance as that of sago grains. The condition is rare in young age groups and more common in adults. Pruritus is common, sometimes lesions can be painful or it may be asymptomatic. Scratching of vesicles leads to weeping and crusting. 10

Microbial eczema
Microorganisms or their products that clear when the organisms are eradicated may cause microbial eczema. This should be distinguished from infected eczema, in which eczema is complicated by secondary bacterial or viral invasion of the broken skin. The skin becomes sensitized to bacterial products or chemicals present in the exudates. Infectious eczematoid dermatitis is considered as an example of autosensitisation. The mechanism by which microorganisms can cause eczema is not understood. Bacterial antigens can promote a cytotoxic reaction in the skin. 11

Microbial eczema. Clinical features.


The distinction between infective and infected eczema is difficult. Infected eczema shows erythema with exudation and crusting. The exudation may be profuse with crusting, or slight, with the accumulation of layers of somewhat greasy moist scale, below the surface is raw and red. The margin is characteristically sharply defined. There may be small pustules and fissures in the advancing edge . Infective eczema usually presents as an area of advancing erythema, sometimes with micro vesicles. It is seen predominantly around discharging wounds or ulcers, or moist skin lesions of other types. Infective dermatitis is relatively common in patients with venous leg ulcers, but care must be taken to distinguish it 12 from contact dermatitis due to topical preparations .

Microbial eczema. Varicose form.


Acute inflammation is characterized by a red, superficial, itchy plaque with weeping and crusting on the lower limbs especially the medial side of lower legs, ankles and calves. This is due to a combination of eczematous changes and cellulitis. A vesicular eruption (id reaction) on the palms, trunk, extremities sometimes accompanies this acute inflammation. In subacute and chronic stages, an increased hydrostatic pressure lead to extravasation of red blood cells from the leg veins. Disintegration of these red blood cells lead to haemosiderin deposition. The skin looks dry, scaly, hyperpigmented and accompanied with white atrophic changes ('atophie blanche'). Ulceration is common in the late stage and is a serious consequence.
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Microbial eczema Nummular form


Nummular dermatitis is a chronic eczematous lesion that is caused by different known and unknown factors. The condition may be preceded by atopic dermatitis. The lesion may appear as a separate entity as annular, coin-like or discoid lesions on the extensor surface of the extremities, trunk and the buttocksNummular eczema (discoid eczema) is characterized by circular or oval plaques of eczema with a clearly demarcated margin. The typical lesions are coinshaped, 1 to 5 cm in diameter itchy plaques. There are commonly distributed on the extremities and can become generalized. Acute lesions may be vesicular; chronic lesions may become scaly, cracked and confluent.

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Seborrhoeic dermatitis

Seborrhoeic dermatitis is characterized by a distinctive morphology (red, sharply marginated lesions covered with greasy looking scales) and a distinctive distribution (scalp, face and upper trunk) which are areas rich in sebaceous glands. 15

Seborrhoeic dermatitis. Face.


Face Medial sides of the eyebrows, glabella, nasolabial fold, are predilected sites . Blepharitis is a feature.

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Seborrhoeic dermatitis. Scalp.


Scalp Dandruff is usually the earliest manifestation. In chronic cases, there may be hair loss which is reversible when the inflammation is controlled. Ears are a common site of involvement.

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Seborrhoeic dermatitis. Trunk.

Trunk Petaloid form is commoner than the pityriasiform. Follicular papules with greasy scale that may become confluent, and commonly found over the sternum and interscapular region.
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Seborrhoeic dermatitis. Infantile.


The eruptions in infants frequently first appear between the third and eighth weeks of life. It may start in the napkin area, the face and scalp, and occasionally on the trunk outside the napkin area. The rash comprises welldefined areas of erythema and scaling with tiny vesicles. Papular and lichenified lesions are not seen. Typically the infant is well and not irritable (c/w atopic dermatitis). The prognosis is usually good. Most uncomplicated cases clear in 3 to 4 weeks. 19

"Every rose has its thorns. Robert Herrick

IRRITANT DERMATITIS
Irritant dermatitis can affect virtually anyone depending on the person's skin barrier function and the potency and duration of the irritant stimulus. Irritant dermatitis ranges from mild erythema to hemorrhagic bullae and necrosis. After several episodes of irritation, a person is often at risk for allergic sensitization. Mechanical irritation accounts for the majority of unpleasant reactions due to plant exposure.
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IRRITANT DERMATITIS. Diagnostic features


The affected sites characteristically conform to history of specific contact to a susceptible contactants. Some non-exposed areas are also susceptible to irritant contact dermatitis, e.g., body folds and flexural areas, due to a combination of friction and direct contact with sweat or urine. Once exposure to the irritant ceases, improvement start to occur.
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IRRITANT DERMATITIS. Clinical presentation.


Strong irritant contact dermatitis can occur after a single brief exposure. The latent period is short. Examples are acid and alkaline burns, thermal burns and frost bites. The offending irritant is usually obvious. Weak irritant contact dermatitis develops after multiple exposures, latent period is long.
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IRRITANT DERMATITIS. Management.


The offending irritant should be identified and removed. Soap and detergents should appropriately be minimized. Cool water is less detrimental than hot water. Advice on the use of protective barriers whilst at work, e.g., gloves, protective clothes etc. should be strictly followed by the patient. Restoration of the lipid layer can be accomplished by frequent application of emollients. In case of maceration, wet clothing should be changed frequently, non-porous clothing to be avoided. Inflammatory element can be controlled with topical steroid.
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Allergic dermatitis
The characteristic distribution of the lesions can often gives a clue to a particular allergen. Removal of the suspected allergen leads to resolution of the dermatitis. A positive patch test to a suspected offending contactant support the clinical diagnosis 24

Allergic dermatitis
Both allergic contact dermatitis and irritant contact dermatitis bear similar clinical signs. In acute cases weeping and crusting will be present, while in chronic cases scaling and fissuring are the dominant findings. Sometimes, allergic contact dermatitis differs from irritant contact dermatitis in that erythema and edema may be more prominent and pruritus more troublesome in the former.
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Allergic dermatitis
Acute ACD is characterized by pruritic papules and vesicles on an erythematous base. Lichenified pruritic plaques may manifest chronic ACD. Occasionally, ACD may affect the entire integument (ie, erythroderma, exfoliative dermatitis). The initial site of dermatitis often provides the best clue regarding the potential cause of ACD.
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Differential signs Sensitization Time of development of inflammation under the effect of irritant Localization

Simple dermatitis Allergic dermatitis Eczema Absent Monovalent Polyvalent Immediate From a few hours to Few days and 1-2 days more

Character of focus

On the place of the On the place of effect of irritant effect of irritant and outside its boundary Diffused Diffused with secondary elements

Polymorphism Itching Progress Relapses

Not expressed Absent (usually burning , pain) Not long Absent

Weakly expressed Moderate Longer Rare

On different places of the skin Combination of diffused and distributed elements Expressed Intense Long Frequent

Allergic dermatitis. Management.


The first step is the identification and removal of the contactant. A detailed history and a careful examination is usually sufficient. Patch testing is indicated for cases in which inflammation persists despite avoidance and appropriate topical therapy. For acute inflammation with blisters and intense erythema, cold wet compresses e.g. KMnO4 are highly effective. They should be used for 15 to 30 minutes several times a days until blistering and severe itching is controlled. Prednisolone, in dosage of around 30-40 mg a day in divided doses is used for extensive inflammation. Topical steroids for reduction of local inflammation.
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Neurodermatitis. Definition.

Lichenification denotes a cutaneous response to repeated rubbing or scratching. It is characterized clinically by a thickened appearance of the skin, with accentuation of the surface markings so that the affected skin surface resembles tree bark. Lichen simplex is a circumscribed area of lichenification resulting from repeated rubbing and scratching occurring on some predilected sites. This term is used when there is no known 29 predisposing skin disorder.

Neurodermatitis. Clinical features.

Women are more common affected than men. Pruritus is the predominant symptom and is often out of proportion to the extent of the objective changes. During the early stages the skin is reddened and slightly oedematous, and the normal markings are exaggerated. The redness and oedema subsided and the central area becomes scaly and thickened and sometimes pigmented. Almost any sites are affected, but the commonest sites are those that are conveniently reached. The usual sites are the nape of the neck, the lower legs and ankles,. the sides of the necks, the scalp, the upper thighs, the vulva, pubis or scrotum and the extensor forearms.
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Neurodermatitis. Management.
A search for a causation should be made before the lichenification is considered to be primary, then a careful psychological history should be taken and the patient given some assistance in reducing her tensions. Topical steroid is the treatment of choice, sometimes with occlusion to enhance absorption and prevent further scratching. Intralesional triamcinolone is useful for circumscribed chronic lesions. Topical antibiotic may be prescribed if secondary infection is present.

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AD
The aetiology is unknown and the pathogenetic mechanisms are speculative. However, a number of clinical, pathological and immunological abnormalities are frequently observed in these patients. Elevated IgE occur in about 80 percent of AD patients and are directed against a wide variety of antigen like pollens, molds, foods, house dust mites and bacterial antigens etc. A high IgE level is not a unique feature of AD but appears to correlate with the clinical severity and falls with remission. 32

Atopic dermatitis. Clinical features


Pruritus Dry Skin (Xerosis) Eczematous Lesions Prurigo Lichenification Dennie Morgan Fold Hand and Feet Involvement

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Atopic dermatitis. Four Phases of AD


Infantile Phase Lesions first appear on the cheeks, forehead, and scalp, but may occur on the trunk, neck, hands and feet. Eczema with oozing and crusts are more typical. Nocturnal restless, irritability and crying are prominent. When the child begins to crawl, the exposed areas especially the extensor aspects of knees are affected 34

Atopic dermatitis. Four Phases of AD


Childhood Phase At about 18 months, the eczematous lesions tend to be replaced by lichenification. Prurigo papules occur and are very itchy. Elbow and knee flexures, wrists and ankles and neck are commonly involved. The neck may show striking reticulate repigmentation (dirty neck). Hands may be dry and lichenified; sole involvement may mimic juvenile plantar dermatosis. The face is less frequently affected. Problems with schooling may occur.
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AD. Four Phases of AD

Adolescent/Young Adult Phase Predominant features are pruritus, lichenification, prurigo papules, scratch marks, and crusting. Lesions occur mostly on the face, neck, flexures, and upper trunk. Localized patches of eczema around the nipple or vermillion of the lips can occur. Psychological difficulties occur in some.
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Atopic dermatitis. Four Phases of AD


Adult Phase AD resolves spontaneously in most patients after age of 20. Majorities of the patients, however, still have sensitive, unstable skin and a higher tendency to develop dermatitis. Full blown AD occurs in only a small percentage of patients throughout adulthood.
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