7/18/2017 Nummular Dermatitis: Background, Pathophysiology, Epidemiology

Nummular Dermatitis
Updated: Jun 23, 2017
Author: Jami L Miller, MD; Chief Editor: William D James, MD more...

OVERVIEW

Background
Nummular (meaning round or "coin shaped") dermatitis or eczema (NE) is an inflammatory skin
condition characterized by the presence of well-demarcated round-to-oval erythematous plaques. The
term nummular dermatitis has been used both as an independent disease and as a description of
lesion morphology that can be found in many different diseases, including atopic dermatitis, contact
dermatitis, and asteatotic eczema. This discussion focuses on the disease entity that has been
described in the literature. Other names have included discoid eczema or orbicular eczema.

Nummular eczema was first described by Deverigie in 1857 [1] as coin-shaped lesions on the upper
extremities. Since then, it has been reported in all age groups and in all body areas but is most
commonly found on the upper and lower extremities. [2] Lesions usually start as papules, which
coalesce into plaques. They are usually scaly. Early lesions may be studded with vesicles containing
serous exudate. Nummular eczema is usually very pruritic. Many precipitating factors have been
reported, including dry skin, contact allergies, weather (particularly winter), nutritional issues, and
emotional stress.

Pathophysiology
Nummular dermatitis is a condition confined to the skin.

Little is known about the pathophysiology of nummular eczema, but it is frequently accompanied by
xerosis. Like most other forms of dermatitis, the cause is likely to be a combination of epidermal lipid
barrier dysfunction and an immunologic response. Dryness of the skin results in leaking of the
epidermal lipid barrier; this allows environmental allergens to penetrate the skin and induce an allergic
or irritant response. [3, 4] This is supported by one study that showed that elderly patients with
nummular dermatitis had increased sensitivity to environmental aeroallergens compared with age-
matched controls. This impaired cutaneous barrier in the setting of nummular dermatitis may also lead
to increased susceptibility to allergic contact dermatitis to materials such as metals, soaps, and
chemicals. [5]

Nummular eczema has been associated with medications. Any medication that induces dryness of the
skin can theoretically initiate nummular eczema, particularly diuretics and statins. Onset of severe,
generalized nummular lesions has been reported in association with interferon and ribavirin therapy
for hepatitis C. [6, 7] Association with use of inhibitors of tumor necrosis factor has also been reported.
[8]

Onset has also been described in association with mercury in dental amalgams. Hypersensitivity to
the metals in the mouth is posulated to be sufficient to drive an immune response that results in
cutaneous nummular plaques.
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7/18/2017 Nummular Dermatitis: Background, Pathophysiology, Epidemiology

Because of the intense pruritus associated with nummular eczema, the potential role of mast cells in
the disease process has been investigated. Increased numbers of mast cells have been observed in
lesional compared with nonlesional samples in persons with nummular dermatitis.

One study identified neurogenic contributors to inflammation in both nummular eczema and atopic
dermatitis by investigating the association between mast cells and sensory nerves and identifying the
distribution of neuropeptides in the epidermis and upper dermis of patients with nummular eczema.
Researchers hypothesized that release of histamine and other inflammatory mediators from mast cells
may initiate pruritus by interacting with neural C-fibers. The research showed that dermal contacts
between mast cells and nerves were increased in number in both lesional and nonlesional samples of
nummular eczema compared with normal controls. In addition, substance P and calcitonin gene-
related peptide fibers were prominently increased in lesional samples compared with nonlesional
samples from patients with nummular eczema. These neuropeptides may stimulate release of other
cytokines and promote inflammation. [9, 10, 11]

Other research has demonstrated that mast cells present in the dermis of patients with nummular
eczema may have decreased chymase activity, imparting reduced ability to degrade neuropeptides
and protein. This dysregulation could lead to decreased capability of the enzyme to suppress
inflammation.

Colonization of with Staphylococcus aureus has been described both on lesional skin and in the nares
of patients and their close contacts. [12] Whether this is important in the precipitation of disease has
yet to be determined.

Epidemiology
Frequency
The prevalence of nummular eczema is two cases per 1000 people. Dermatitis in general (eg, atopic,
asteatotic, dyshidrotic, nummular, hand) is one of the most common of dermatologic conditions.

Race

No racial predilection has been observed.

Sex
Nummular eczema is more common in males than in females (see Age below).

Age

Nummular eczema has two peaks of age distribution. The most common is in the sixth to seventh
decade of life. This is most often seen in males. A smaller peak occurs in the second to third decade
of life, which is most often seen in association with atopic dermatitis. This is more often seen in
females, by two thirds in one study. [13] It is uncommon in children.

Prognosis
Nummular eczema tends to be a chronic condition that remits and relapses. Patients need to be
informed that once nummular dermatitis develops, it is often recurrent. Avoidance of exacerbating
factors and close attention to moisturizing the skin may help reduce the frequency.
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7/18/2017 Nummular Dermatitis: Background, Pathophysiology, Epidemiology

Pruritus, often worst at night, may cause irritability, insomnia, or both.

Secondary infection may result in lesions that ooze serosanguineous exudate. The most common
organism revealed by culture is Staphylococcus aureus.

Generalized flares may require systemic antibiotics and/or systemic steroids.

Increased contact sensitivity to environmental antigens (especially metals) could limit ability to tolerate
those antigens, especially clothing, metal snaps, jewelry, dental amalgams or occupational exposure.

Patient Education
Patients must be educated about the most important predisposing condition to nummular eczema
dry skin. Use of gentle soaps and copious application of moisturizers, especially while the skin is still
damp after bathing, is imperative. Once the lesions develop, use of topical steroids or calcineurin
inhibitors helps with the itch and hastens resolution.

For patient education resources, visit the Skin Conditions and Beauty Center. Also, see the patient
education article Eczema.

Clinical Presentation

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