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ECZEMA Dr. Sharon Crichlow Consultant Dermatologist Luton and Dunstable NHS Foundation Trust 22/02/2011 Definition • Controversial but loosely thought to be synonymous with the term ‘dermatitis’. Strictly speaking dermatitis is inflammation of the skin (any cause). Classification • Endogenous – Atopic – Seborrheic – Discoid (nummular) – Pompholyx – Gravitational (venous stasis) – Asteatotic – Neurodermatitis Classification • Mainly exogenous – Irritant dermatitis – Allergic contact dermatitis – Photodermatitis Atopic dermatitis- key features • Chronic relapsing dermatitis associated with intense pruritus • Can occur at any age but 70-95% of cases arise before the age of 5 years • Typically infantile, childhood and adulthood; periods of acquiescence can occur between stages • Aetiology and pathogenesis is still not fully elucidated • Often associated with atopy • Genetic basis with variable expression influenced by environmental factors • Immuno-aberration is evidenced by the common occurrence of serum IgE elevation and eosinophilia; the Th2 predominance in acute lesions evolves into a predominance of IFN gamma producing T-cells in chronic lesions. • There is enhanced reactivity to irritants, self-proteins, allergens and infectious antigens and superantigens CLINICAL APPEARANCE • Acute eczemaweeping and crusting blistering redness, papules and swelling- with an ill defined border scaling • Chronic eczema• May show all the above but • Less vesicular and exudative • More scaly, pigmented and thickened • More likely to show lichenification • More likely to fissure • ALL FORMS OF ECZEMA ARE ASSOCIATED WITH INTENSE PRURITUS • IF IT DOES NOT ITCH IT’S PROBABLY NOT ECZEMA!! DIFFERENTIAL DIAGNOSIS • SCABIES • FUNGAL INFECTION INVESTIGATIONS • • • • • USUALLY CLINICAL DIAGNOSIS PATCH TESTING- if ACD suspected SERUM TOTAL AND SPECIFIC IgE SWABS FOR STAPH AND CANDIDA MICROSCOPIC EXAMINATION OF SCALES AND FUNGAL CULTURE TO RULE OUT OTHER DIAGNOSES. Infantile eczema TREATMENT • Acute weeping eczema– Soaks with potassium permanganate . – Wet wrap dressings and/ or bandages such as icthopaste, viscopaste – Topical steroids and emollients – Tacrolimus/ pimecrolimus • Chronic eczema– Steroids in an ointment base – Emollients – Systemic or topical antibiotics – Ichthammol and zinc pastes – Anti-histamines and other anti-itch preparations SYSTEMIC TREATMENTS • • • • • Prednisolone Cyclosporine Azathiaprine Tacrolimus/sirolimus Mycophenolate mofetil Pompholyx eczema Palmar/ plantar eczema Varicose eczema Treatment • Elevate legs when sitting or standing • Emollients such as hydrommol oint • Mild topical steroids such as Betnovate RD ointment or Eumovate ointment • Check ABPIs • If suitable then compression stockings, above knee during daytime Discoid eczema Juvenile plantar dermatosis Juvenile plantar dermatosis • Occurs in pre-pubertal children from age 3 onwards, rare in adults • Worse in winter, boys more than girls • Associated with sports shoes with plastic or rubber soles • The humid environment leads to maceration of the keratin layer, which is then rubbed off with friction leading to a glazed and thinned appearance of the skin. • The balls of the feet are tender and dry with a shiny appearance, at times scaly • May develop cracks and fissures • Chronic but self-limiting • Avoid wearing impermeable socks and shoes • Emollients and keratolytics may be helpful Seborrheic dermatitis Treatment • Daktacort/ Canesten HC ointments • Tacrolimus/ pimecrolimus