Eczema

Li Xiao-hong
Dept. of Dermatology
The first affiliated hospital of
zhengzhou university
Definition(1)
 The terms 'dermatitis' and 'eczema'
are nowadays generally regarded as
synonymous.
 Some authors still use the term
'dermatitis' to include all types of
cutaneous inflammation
 All eczema is dermatitis, but not all
dermatitis is eczema.
Definition(3)
 The clinical features of eczema may
include clustered papulo-vesicles,
redness, scaling and itching ；
 Eczema is an inflammatory skin reaction
characterized histologically by
 spongiosis with varying degrees of acanthosis,
 a superficial perivascular lympho-histiocytic
infiltrate.
Definition(2)

 Spongiosis refers to intercellular edema of the epidermis.

 Acanthosis refers to increased thickness of the epidermis.
 superficial perivascular lympho-histiocytic infiltrate.
 The condition may be induced by a wide
Etiology

range of external and internal factors acting
singly or in combination.
 Endogenous factors
 genetic factor (hereditary background)
 infection focus (bacteria or virus)
 neuropsychic factor (anxious, stress, depressed)
 ▪▪▪ ▪▪▪
 Exogenous factors
 some irritant food (pepper, white wine ▪▪▪)
 physic factor (sunlight, coldness▪▪▪)
 chemical factor (cosmetics, soap ▪▪▪)
 ▪▪▪ ▪▪▪
Pathogenesis
 Some cases of eczema may be related to
type Ⅳ hypersensitivity.
 However, the pathogenesis of some
cases is unknown.
 Eczema accounts for a large proportion of
skin diseases.
Classification(1)
 The classification of the many clinical
forms is difficult, because in many cases
the precise cause is unknown, and
because two or more forms of eczema
may be present in the same patient
simultaneously or consecutively.
 The classification divides eczema into
two groups
 exogenous eczema
 endogenous eczema.
Classification(2)
 Exogenous eczemas are related to
clearly defined external trigger factors in
which inherited tendencies play a minor
role
 Exogenous eczemas include irritant
dermatitis, allergic dermatitis, infective
dermatitis, et al.
Classification(3)
 endogenous eczema implies that the
eczematous condition is not due to
exogenous or external environmental
factors, but is mediated by processes
originating within the body.
 Endogenous eczemas include atopic
eczema, hand eczema, nummular
eczema, asteatotic eczema, stasis
eczema, et al.
Three stages of eczema

 Acute eczema

 Subacute eczema

 Chronic eczema
Clinical Manifestation
 Acute eczema
 The onset is acute;
 Erythema, papule, papulovesicle, erosion,
exudation are common.

Erythema, grouped papules and Erosion, exudation on the

papulovesicles on the left arm. anterior area of the right ear.
Clinical Manifestation
 Subacute eczema
 Subacute eczema is
from the relief of
acute eczema or the
aggravation of
chronic eczema;
 The lesions are little
xerotic erythema with
small patch of
exudation and The erythema with small patch of
scattered crusting. exudation and scattered crusting
on the periumblical area.
Clinical Manifestation
 Chronic eczema
 The chronic eczema is often
from the prolongation of the
acute or subacte eczema,
occasionaly beginning as
the chronic feature;
 The lesions of chronic
eczema include
lichenification,
pigmentation, scaling and
excoriation.
Notable lichenification with excoriation,
scaling on the ankle.
Diagnosis
 Regardless
of any form, eczema shows
some common clinical features as
follows:
 Chronic and recurrent;
 Symmetrical distribution and ill-defined;
 The lesions include erythema, papule, papulo-
vesicles, scaling, lichenification, which tend to
exudation;
 Intense and severe pruritus.
Some important eczemas
 infective eczema

 atopic eczema
 hand eczema
 nummular eczema
 asteatotic eczema
 stasis eczema
 ▪▪▪ ▪▪▪
Infective eczema(1)
 Infective eczema is eczema which is
caused by microorganisms or their
products, and which clears when the
organisms are eradicated.
 This should be distinguished from
infected eczema in which eczema due to
some other cause is complicated by
secondary bacterial or viral invasion of
the broken skin.
Infective eczema(2)

 Infective eczema in a man.

 Well-demarcated erythema, with some papulo-
vesicles, on the lumbosacral area.
 Histology of this localized rash showed eczema, and
Staphylococcus aureus was repeatedly isolated. There
was no response to topical steroid therapy, but the
condition cleared rapidly with oral flucloxacillin.
Atopic eczema --definition
 Atopic eczema or dermatitis (AD) is a
pruritic disease of unknown origin that
starts in early infancy and is typified by
pruritus, eczematous lichenified lesions,
and xerosis of the skin.
 AD is associated with other atopic
diseases (asthma, allergic rhinitis,
urticaria) and increased immunoglobulin
E (IgE) production.
Atopic eczema -- etiology
 Hereditary background
 A family history is obtained in about 70% of all cases.
 Immunological abnormalities
 The main immunological abnormalities are excessive
formation of IgE.
 Bacteriology
 The skin of patients with atopic dermatitis tends to carry more
staphylococci, even without clinical evidence of infection.
 ▪▪▪ ▪▪▪
Atopic eczema -- three stages

 Atopic eczema or dermatitis can be divided

into three stages:
 Infantile atopic eczema, occurring from 2
month to 2 years of age;
 Childhood atopic eczema, from 2 to 10 years;
 The adolescent and adult stage of atopic
eczema.
Atopic eczema
-- Infantile atopic eczema(1)
 The disease runs a chronic, fluctuating course,
varying with such factors as teething, respiratory
infections, et al.
 The lesions most frequently start on the face. The
exposed surfaces, especially the extensor aspect of
the knees, are most involved.
 The lesions consist of erythema and discrete or
confluent edematous papules, and may become
exudative and crusted as a result of rubbing.
 The lesions are intensely itchy.
Atopic eczema -- Infantile atopic
eczema(2)

the erythema and minute erosion

on the face
Atopic eczema -- Childhood
atopic eczema(1)
 The lesions are often lichenified, slightly
scaly, or infiltrated plaques which are apt
to less exudative, drier, and more popular
than those of infantile atopic eczema.
 The classic locations are the antecubital
( 肘 ) and popliteal( 腘 ) fossae, the flexor
wrist, eyelids, and face, and around the
neck.
Atopic eczema -- Childhood
atopic eczema(2)

Marked lichenification on Flexural atopic dermatitis

the cubital fossa of the wrist in a child
Atopic eczema -- Childhood
atopic eczema(3)

erythema, papules, excoriations, Nail involvement in atopic

crusting ， but little lichenification. dermatitis in childhood.
Atopic eczema -- the adolescent
and adult stage of atopic eczema(1)

 The picture in this stage is essentially

similar to that in later childhood, with
lichenification, especially of the flexures
and hands.
 In addition, dryness is prominent.

 A brown ring around the neck is typical but

not always present.
Atopic eczema -- the adolescent
and adult stage of atopic eczema(2)

Dirty neck sign in chronic

Adult flexural dermatitis
atopic dermatitis
Atopic eczema --diagnostic
criteria(1)
 the UK diagnostic criteria, the child must have
 An itchy skin condition (or parental report of scratching or
rubbing in a child)
 Plus three or more of the following
 1 Onset below age 2 years (not used if child is under 4 years)
 2 History of skin crease involvement (including cheeks in children
under 10 years)
 3 History of a generally dry skin
 4 Personal history of other atopic disease (or history of any
atopic disease in a first degree relative in children under 4 years)
 5 Visible flexural dermatitis (or dermatitis of cheeks/forehead and
outer limbs in children under 4 years)
Hand eczema(1)
 Hand eczema is a common, often recurrent
condition which varies from being acute and
vesicular to chronic, hyperkeratotic and
fissured.
 Hand eczema results from a variety of
causes, such as atopic eczema, allergic
causes, fungal infection and occupational
factors, and often several factors are
involved.
Hand eczema(2)
 Hand eczema often Hyperkeratotic, fissured
eruptions on the palms and fingers
present as a chronic
eczema( scaling,
hyperkeratotic and
fissured ), but may
appear as a vesicular
eruption because of
pompholyx, atopic
eczema or contact
dermatitis.
Hand eczema(3)
 Hand eczema---pompholyx(1)
 Pompholyx is a form of eczema of the palms
and soles.
 Pompholyx may occur at any age, but it is
more common before the age of 40 years.
Onset before 10 years is unusual.
 It often occurs in warm weather, and is often
recurrent.
Hand eczema(4)
 Hand eczema---pompholyx(2)
 In a typical case the vesicles develop
symmetrically on the palms and/or soles. In
80% of patients only the hands are involved.
 The primary lesions are macroscopic, deep-
seated vesicles on the sides of the fingers,
palms and soles.
 The eruption is symmetrical and pruritic,
with pruritus often preceding the eruption.
Hand eczema(5)

 Pompholyx, showing macroscopic, deep-seated vesicles

on the palm
Nummular eczema(1)
 Nummular (discoid) eczema is an eczema of
unknown etiology characterized by coin-
shaped lesions on the limbs, which typically
affects middle-aged women.
 The diagnostic lesion of discoid eczema is a
coin-shaped plaque of closely set, thin-walled
vesicles on an erythematous base. This
arises, quite rapidly, from the confluence of
tiny papules and papulovesicles.
 Pruritus is usually severe.
Nummular eczema(2)

coin-shaped plaque on coin-shaped plaque on

the dorsum of hand the lower leg
Asteatotic eczema(1)
 Asteatotic eczema is also known as
xerotic eczema or winter itch.
 Asteatotic eczema is a dry eczema with
fissuring and cracking of the skin, often
affecting limbs in the elderly.
 Overwashing of patients in institutions, a
dry winter climate, hypothyroidism and
use of diuretics can contribute to eczema
in elderly atrophic skin.
Asteatotic eczema(2)

 This condition occurs particularly on the legs,

arms and hands.
 The primary lesion is a round, small patch
covered with a skin-colored to red adherent
scale.
 The lesions resemble crackled porcelain
Asteatotic eczema(3)

The asteatotic skin is dry and slightly scaly. The lesions resemble
crackled porcelain
Stasis eczema (dermatitis)(1)
 Stasis eczema is associated with underlying venous
disease ， usually in the lower leg. Incompetence of
the deep perforating veins increases the hydrostatic
pressure in the dermal capillaries.
 The eczema is usually accompanied by other
manifestations of venous hypertension, including
dilatation or varicosity of the superficial veins,
edema, purpura, haemosiderosis, ulceration, or
small patches of atrophy .
 Leashes of dilated venules around the dorsum of
the foot or the ankle are particularly common.
Stasis eczema(2)

 Stasis eczema: pigmentation, edema, ulceration of

the lower legs
Treatment(1)
 General advice (therapy)

 Topical therapy

 Systemic therapy
Treatment(2)
 General advice (therapy) (1)
 Removing or avoiding the possible
causes (irritant food, cosmetic, et al);
 Rest should be complete or local
according to the severity and extent of the
eczema. An affected leg should be
elevated or well supported, and affected
hands should be used as little as is
practicable. Complete bed rest is
advisable for severe eczema
Treatment(3)
 General advice (therapy)(2)
 Explanation, reassurance and sympathy will
help to alleviate anxiety. Patients should be
taught current knowledge of the disease, the
types of trigger factors, the treatment options
and their likely benefits and risks.
Treatment(4)
 Topical therapy(1)
 Topical medicaments include
 wet dressing,
 emollients,
 topical corticosteroid cream or paste,
 tar,
 intralesional steroid injection,
 tacrolimus et al.
Treatment(5)
 Topical therapy(2)—actue eczema
 For the patient with acute eczema, topical
applications should be bland. Wet dressings,
aqueous cream or zinc cream are soothing and
valuable. Topical corticosteroids are generally
used to speed resolution. Generally speaking,
medium-strength preparations are adequate.
When secondary infection is thought likely to
occur, combined steroid antibacterial agents
may be used.
Treatment(6)
 Topical therapy(3)—subacute eczema
 At the subacute stage, paste bandages are of
special value in occluding areas and may help
to break the itch-scratch vicious circle. All
dressings should be firmly applied but be light
and comfortable. Corticosteroids under
polythene occlusion may be helpful, if only for a
few days, to lessen itching.
Treatment(7)
 Topical therapy(4)—chronic eczema
 At this stage, emollients should be applied
thinly, evenly and, above all, frequently. Mild
topical corticosteroids are helpful, and are
often used in combination with a tar paste.
Occlusive dressings may be useful.
Treatment(8)
 Systemic therapy(1)
 Antihistamines, such as chlorpheniramine,
diphenhydramine, cetirizine, are used to
alleviate pruritus.
 systemic steroids in severe cases .

 Immunomodulators, methotrexate or
cyclosporine, can be used for the patients
with severe disease in whom conventional
therapy is ineffective.