ECZEMA AND

DERMATITIS

BY

TUTOR: DR. MUSINGUZI

 DEFINITION
Eczema: Come from the Greek name for boiling, a
reference to the tiny vesicles (bubbles) that are
commonly seen in the early acute stage of the
disease
Dermatitis: means inflammation of skin, it’s a
broader term than eczema which is only a type of
several skin inflammations

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 Histopathology
• Acute stage – edema of the
epidermis(spongiosis)progresses to the formation
of intra epidermal vesicles which may enlarge and
rupture.
• Chronic stage – less edema and vesiculation but
more thickening of the epidermis (acanthosis)
accompanied by a variable degree of vasodilation
and T- lymphocytic infiltration in the upper dermis.

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 Classification
Exogenous
• Irritant
• Allergic
Endogenous
• Atopic dermatitis
• Seborrheic dermatitis
• Discoid dermatitis (Nummular eczema)
• Asteototic dermatitis
• Gravitational dermatitis
• Lichen simplex
• Pompholyx

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 CONTACT DERMATITIS
• CD is an acute or chronic inflammatory reaction to
substances that come in contact with the skin.
• CD is either:
1. Irritant CD caused by irritant chemicals
2. Allergic CD by an antigen (allergen)

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a) IRRITANT CONTACT
DERMATITIS
• Most common form of occupational skin disease
• Accounts for >80% of CD cases
• Individual susceptibility varies, the elderly and the
atopics are more predisposed
• Vulnerable groups: elderly, people with fair and dry
skin, atopic background e.g. asthma, hey fever and
eczema
• Strong irritants elicit an acute reaction at the site of
contact while weak irritants often cause chronic
eczema esp of the hands after prolonged exposure
• Common causes: detergent, alkalis, acids, solvents
and abrasive dust
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Clinical Features
• Itching
• Skin Findings: May occur minutes after exposure or may be delayed up
to 24 h.
• The spectrum of changes ranges from erythema to vesiculation and
caustic burn with necrosis
• Dependent on concentration of agent and state of skin barrier; occurs
only above threshold level (strong irritants –acute reaction after brief
contact while weak irritants - need long time& prolong exposure)
• Edge: Acute; Sharp, strictly confined to site of exposure
Chronic; ill-defined
• Distribution; localized to one region (The hands are the most commonly
affected area) or generalized (plant dermatitis).
• Incidence; May occur in practically everyone
• Duration; Days, weeks, depending on tissue damage.
• Patch Tests; These are negative in ICD.

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Irritant CD

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Management
Acute:
• Identify and remove the etiologic agent
• Wet dressings with gauze soaked in Burow's solution.
• Topical glucocorticoid preparations.
• Systemic glucocorticoids in severe cases, may be indicated.
Subacute and Chronic:
• Identify and remove etiologic/pathogenic agent.
• Use a potent topical glucocorticoid preparation, and provide
adequate lubrication.
• As healing occurs, continue with lubricating/protective creams or
ointments.
• Topical calcineurin inhibitors ; newer topical anti inflammatory
agents (pimecrolimus and tacrolimus) are being evaluated

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b) ALLERGIC CONTACT
DERMATITIS
• Due to delayed hypersensitivity reaction following contact
with antigens or haptens.
• Previous exposure to the allergen is required for
sensitization and the reaction is specific to the allergen.
• Epidemiology: Frequent disease. Over 3700 allergens have
been reported to cause it in humans.
• Age of Onset: is uncommon in young children and in
individuals older than 70 years.
• Occupation: One of the most important causes of
disability in industry.
• Common allergens: nickel (jewellery, watches, bra clips
and jean studs), dichromate (cement, leather and
matches), rubber chemicals (clothing, shoes and tyres) etc
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Clinical Features
• Pervious contact is needed to induce the allergy.
• Its specific to one chemical or its relatives
• Easily recognizable patterns exist
• Likely sites: hands, feet, eyelids, and lips, which commonly come in contact with
the environment.
• Acute phase: erythematous, indurated, scaly plaques
• Chronic phase: which is usually marked by lichenified erythematous plaques
• Eruption starts in a sensitized individual 48h or days after contact with the
allergen
• Itching pain
• Lesion:
Acute=Erythema ⇛ papules ⇛ vesicles ⇛ erosions ⇛ crust ⇛ scaling
Chronic; Papules, plaques, scaling, crusts
• Acute; Sharp, confined to site of exposure but spreading in the periphery; usually
tiny papules; may become generalized
• Chronic; Ill-defined, more spreads
• Patch Tests: positive - shows erythema and papules, as well as possibly vesicles
confined to the test site.
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Potassium dichromate in leather

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Poison ivy/ oak/ sumac

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Management
• Termination of Exposure
• Identify and remove the etiologic agent.
• Topical Therapy;-Topical glucocorticoid
ointments/gels are effective for early nonbullous
lesions.
• Systemic Therapy;-Glucocorticoids are indicated if
severe for exudative lesions

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 ATOPIC ECZEMA
• Is a pruritic, chronic relapsing skin disease of unknown origin that
occurs most commonly during early infancy and childhood (an
adult-onset variant is recognized).
• Genetic predisposition to form excessive IgE which leads to
generalized and prolonged hypersensitivity to common
environmental antigens eg pollen and house dust mite.
• Individuals manifest with one or more of a group of diseases eg.
asthma, hay fever, urticarial, food and other allergies.
• Age of Onset ;
60% of patients between 2 months -1yr.
30% are seen for the first time by age 5,
10% develop AD between 6 and 20 years of age.
Rarely AD has an adult onset.
• Slightly more common in males than females

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Dx criteria
• Itchy skin plus at least 3 of the following
• Hx of itch in skin creases (or cheeks if < 4yrs)
• Hx of asthma or hay fever (in 1st degree relatives if
<4yrs)
• Dry skin
• Visible flexural eczema
• Onset in the first 2years of life

Laboratory investigation
• Blood Studies; Increased IgE in serum, eosinophilia

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Distribution and character of the rash
Infancy
• Often acute and involves the face and trunk
• Napkin area is frequently spared
Childhood
• Rash settles on the backs of the knees
• Fronts of the elbows, wrists and ankles
Adults
• Face and trunk more involved
• Lichenification is common

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Atopic dermatitis

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 Complications
1. Secondary infections:
o Bacterial: Staph. aureus most common
o Viral: Herpes simplex virus can cause a widespread severe eruption –
eczema herpeticum, Papillomavirus and molluscum contagiosum are
more common in atopic eczema, especially if treated with topical
corticosteroids
2. Increased susceptibility to irritants due to defective barrier function
3. Increased susceptibility to food allergy particularly eggs, cow’s milk,
protein, fish wheat and soya
4. Psychosocial factors for the patients and their family.
5. Poor sleep, loss of schooling, behavioural difficulties, failure
to thrive in children
5. Impact on sleep, work, relationships, hobbies, psychology
and quality of life in adults

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 Management
Acute dermatitis
• Wet dressings and topical glucocorticoids; topical antibiotics (mupirocin ointment)
when indicated.
• Oral H1 antihistamines are useful in reducing itching. eg;Hydroxyzine
• Oral antibiotics (dicloxacillin, erythromycin) to eliminate S. aureus
Subacute and Chronic
• Hydration (oilated baths or baths with oatmeal powder) followed by application of
emollients (e.g. hydrated petrolatum) form the basic daily treatment needed to
prevent xerosis
• Topical anti-inflammatory agents egglucocorticoids, hydroxyquinoline preparations,
and tar are the mainstays of treatment. (glucocorticoids are the most effective)
• Topical calcineurin inhibitors. Topical tacrolimus and pimecrolimus have been
developed as nonsteroidal immunomodulators. They potently suppress itching and
inflammation and do not lead to skin atrophy
• Oral H1 antihistamines are useful in reducing itching.
• Systemic glucocorticoids should be avoided, except in rare instances in adults for
only short courses .
• In severe cases of adult AD and in normotensive healthy persons without renal
disease cyclosporin.
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SEBORRHEIC ECZEMA
• It’s a common chronic papulosquamous dermatosis that is
usually easily recognized
• Infantile and adult forms exist.
• Characterized by erythema and greasy scaling (The affected skin
is pink, edematous, and covered with yellow-brown scales and
crusts).
• Lesions favor scalp, ears, face, chest, and flexural areas.
• Caused by a yeast- like fungus, Ptyrosporum orbiculare.
• It’s a commonly presenting feature and marker of HIV disesase
and can be very severe.
• It affects the scalp with marked scaling(dandruff) and ears,
central face and nasolabial folds and eyebrows.
• On the body found in the flexures ie axillae, umbilicus, breasts
and groin.
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• Age of Onset;
• Infancy (within the first months), puberty, most
between 20 and 50 years or older.
• Sex; More common in males.
• Incidence; 2 to 5% of the population
• The disease varies from mild to severe.
• Mild scalp SD causes flaking, (i.e., dandruff).
• Generalized and even erythrodermic forms may
occur

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Seborrheic Dermatitis

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Management
• This chronic disorder requires initial therapy followed by chronic maintenance
therapy
Adults
• Frequent shampooing with shampoos containing selenium sulfide, zinc
pyrithione, are helpful. 2% ketoconazole shampoo, Tar shampoos are equally
effective in many patients.
• Low-potency glucocorticoid solution, lotion, or gels.
• Pimecrolimus, 1% cream, is beneficial.
• Antifungals
• Topical metronidazole
• topical Lithium which possess antifungal properties
• Topical Calcineurin Inhibitorstacrolimus have anti-inflammatory properties also
exhibits antifungal properties
• Vitamin D3 analogues (calcipotriol cream or lotion, calcitriol ointment, or
tacalcitol ointment).
• Oral isotretinoin (13-cis-retinoic acid) is a useful, although not officially approved

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Mgt cont’d
Infants
• SCALP; removal of crusts ; proper skin care.
• Body folds drying lotions
• In cases of candidiasis, nystatin or amphotericin B
lotion or cream .
• In cases of oozing:-Imidazole preparations (e.g., 2
percent ketoconazole in soft pastes, creams, or
lotions) may also be effective

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 DISCOID ECZEMA / Nummular eczema

• Has discrete coin- shaped lesions of eczema seen in the

limbs of young of young men, ass with alcohol excess and
of elderly men.
• Can occur in children with atopic eczema and tends to be
difficult to treat.
• A chronic disorder of unknown etiology.
• It characterized by papules and papulovesicles coalesce to
form nummular plaques with oozing, crust, and scale.
• Most common sites of involvement are upper extremities,
including the dorsal hands in women, and the lower
extremities in men.
• Pathology may show acute, subacute, or chronic eczema
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 Nummular dermatitis
• Coin shaped patches and
plaques
• Secondary to xerosis cutis
• Primary symptom itch

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ASTEATOTIC ECZEMA
• Frequently seen in hospitalized elderly esp when skin is dry, low humidity
caused by central heating, overwashing and diuretics.
• Occurs most often on the lower legs as a rippled or crazy paving patten of fine
fissuring on an erythematous background.
• The eruption is characterized by dry, "cracked," superficially fissured skin with
slight scaling.
• The incessant pruritus can lead to lichenification, which can even persist when
the environmental conditions have been corrected.
Management
• Avoiding over bathing with soap, especially tub baths, and increasing the
ambient humidity to >50%, by using room humidifiers;
• Using tepid water baths containing bath oils for hydration,
• Immediate liberal application of emollient ointments, such as hydrated
petolatum.
• If skin is inflamed, use medium-potency glucocorticoid ointments, applied
twice daily until the eczematous component has resolved.

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Asteatotic eczema
• Extreme case of xerosis
• Riverbed type cracking (eczema craquele)

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GRAVITATIONAL (STASIS)
ECZEMA
• Occurs on the lower legs and is associated with
signs of venous insufficiency ie edema, red or bluish
discoloration, loss of hair, induration, haemosiderin,
pigmentation and ulceration.
Management
• Local steroids
• Sensitization to topical antibiotics(neomycin) and
preservatives (chlorocresol)
• Associated peripheral edema – elevation of the leg
and graded compression bandages.

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Stasis dermatitis

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 Lipodermatosclerosis
Pseudokaposi’s (acroangiodermatitis)

Venous ulceration

Dispigmentation (chronic)

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 Superimposed allegic
contact

Do: 1) dry weeping lesions

2) cover for infection

Don’t: 1) apply neosporin

2) just hope steroids will fix it

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LOCALIZED NEURODERMATITIS
(LICHEN SIMPLEX)
• A plaque of lichenified eczema due to repeated
rubbing or scratching as a habit or in response to
stress.
• Common sites: nape of the neck, lower leg and
anogenital area

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 NEURODERMATITIS/LICHEN SIMPLEX
CHRONICUS

• Paroxysmal pruritus
• Habitual excoriating or
rubbing
• Skin thickens to defend
• Consider underlying
disease

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POMPHOLYX ECZEMA
• Recurrent vesicles and bullae occur on the palms, palmar
surface of fingers and soles and are excruciatingly itchy.
• It can occur in atopic eczema and in exogenous eczemas
• It can be provoked by heat, stress and nickel ingestion in
nickel- sensitive patient
• Cause is unknown, may be provoked by stress or heat or
may be allergy to nickel
• Recurrent infection & lymphangitis is a recurrent problem,
it may follow acute Tinea pedis
• Rx: antibiotics, aluminium acetate, potassium
permanganate, steroids
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 Pompholyx

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 CLINICAL FINDINGS
Acute
• Redness and swelling, usually ill-defined margin
• Papules, vesicles and rarely blisters
• Exudation and cracking
• Scaling
Chronic
• May show all the above features though usually less vesicular
and exudative
• Lichenification, a dry leathery thickening with increased skin
markings, secondary to rubbing and scratching
• Fissures and scratch marks
• pigmentation

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 Investigations
• Patch tests: In suspected cases of contact allergic dermatitis
• IgE and specific IgE: For dx of atopic dermatitis and to determine
the specific environmental allergens e.g. pet dander, horse hair
pollens and food.
• Prick tests: Similar to specific IgE
• Bacterial and viral swabs for culture and sensitivity
Diagnostic musts:
• If it is scaly, scrape the scale & perform KOH mount, examine
under microscope.
• If there is fluid, do a gram and wright’s stain; if inconclusive,
culture and PCR
• If dx is uncertain, perform a 4mm punch biopsy; send ½ in
formalin for H&E, and ½ in Michelle’s for immunofluorescence.
• Send tissue to a dermatopathologist
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 Outpatient Management
Baths
• When eczema is active, children should ideally be given a bath containing bath oil twice
daily.
• The frequency of baths can be reduced as eczema improves.
• Soap should be avoided.
• Aqueous cream or emulsifying ointment or other non-subsidised soapfree washes (e.g.
Cetaphil, Dermsoft, QV wash) can be used as a soap substitute.
• Bathing should last no more than 20mins to ensure adequate skin hydration but not long
enough to cause wrinkling. The skin should be pat dried.
• Corticosteroids (if needed) should be applied immediately after the bath to maximise
absorption and emollients afterward (ideally at least half an hour later if this is practical).
Infection
• If the eczema becomes weepy with pus, it is probably infected with Staphylococcus aureus
and systemic antibiotics should be used (as described in Inpatient section above).
• Antiseptic baths two to three times per week to reduce staphylococcal skin colonisation
can aid
with overall eczema control and reduce infective flares.
• Add bleach (Janola) to the bath water at a concentration of 1/1000 (half a cup of 3-5%
bleach to 15cm deep full-sized bath)
• Alternatively use antiseptic bath oils Oilatum Plus or QV flare up (these are not subsidised)
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• Varicella vaccination should be considered.
Emollients
• Emollients are essential and frequently underused.
• They should be applied liberally and as often as is required
to keep the skin well-hydrated to help maintain its barrier
function, even when the eczema is well-controlled.
• Ointments (e.g. emulsifying ointment, duoleum) are greasier
and more effective.
• Creams (e.g. cetomacrogol) are less greasy but may be
cosmetically more acceptable.
• Oily creams (e.g. healthE fatty cream, lipobase) are midway
between creams and ointments in
effectiveness and are usually cosmetically acceptable.
• Lotions are lighter still and generally not effective in eczema.
• Ensure adequate quantities are prescribed (at least 500g per
fortnight

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Topical steroids
In general:
• Lowest strength required to clear eczema should be used
• Steroids should be used to affected areas in adequate amounts (not sparingly)
• Steroids should be applied no more than twice a day
• Steroids should not be used continuously for weeks/months without
adequate supervision
• If applied under occlusion steroids have significantly increased absorption
Avoidance of irritants/ allergen
Foods
Other Treatments
• Oral Steroids are associated with rebound and although they can be useful in
some circumstances, should be used with caution. If oral corticosteroids are
used, they need to be replaced with another systemic agent or weaned slowly,
usually over months.
• UV therapy, cyclosporine, methotrexate and azathioprine require referral to a
dermatologist
• Long term antibiotics may be helpful in some cases with recurrent infection,
but have the risk of inducing bacterial resistance.

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 THANK U!!!

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