ECZEMA

SITI NUR BAITI BINTI SHAIK

KHAMARUDIN
012013100196

OUTLINES
1.
2.
3.
4.

Defi nition of eczema/dermatitis

Pathophysiology
Causes / triggering factors
Types of dermatitis

DEFINITION
Eczema
in fl a m m a tor y epiderm a l r a sh,
acute or chronic,
characterized by vesicles (acute
stage), redness, weeping, oozing,
crusting, scaling and itch.
Eczema and dermatitis are synonymous.

HOW CAN ECZEMA / DERMATITIS

HAPPEN?
Primarily due to an impairment of the
barrier function of the skin , making
it more susceptible to irritation by soap
and other contact irritants, the
weather, temperature and non-specifi c
triggers.

PATHOPHYSIOLOGY

Pathway leading to eczematous

reaction are likely to be common to
all subtypes and to involve similar
In wound healing or
infl ammatory mediators.
pathological conditions
One hallmark is activated
keratinocyte (epidermis) :
metabolizes rapidly and associated
with increased proliferation of
basal cells & secretion of cytokines.
S o u rc e : C l i n i c a l D e rm a t o l o g y 4 t h E d i t i o n ,
B l a c k w e l l Pu b l i s h i n g

Increased proliferation of basal cells & secretion of

cytokines.

Hyperproliferation causes
epidermis to thicken
(acanthosis) and to scale.

Cytokines cause edema

(spongiosis), blistering and
weeping, and especially
itching.

Once eczema has erupted, the skin is no longer an

intact protective layer:
skin becomes more permeable & loses its own natural
moisture.
allergens & irritants penetrate more easily, causing more
infl ammation.

Genetic factors predispose

to develop abnormally high
number of TH2.
ALLERGEN
S

Ig
E

CAUSES/TRIGGERING FACTORS OF
ECZEMA
Dust mite (common)
Sweating
Extreme of hot and cold
Chlorinated water
Infection
Allergy
Stress/emotional factors
Skin irritants: wool, detergents
Perfumes
Foodstuff s: cows milk, beef, eggs

TYPES OF DERMATITIS

Exogenous

TYPES OF ECZEMA / DERMATITIS

1.Atopic dermatitis:
a)Mild
b)Moderate
c)Severe
2.Dyshidrotic eczema
3.Nummular eczema
4.Pityriasis alba
5.Asteatotic dermatitis
6.Contact dermatitis
7.Seborrheic dermatitis:
a) Infant
b)Adult

1. ATOPIC DERMATITIS
Term atopic refers to a hereditary
background
OR
Tendency to develop one or more group
of conditions such as allergic rhinitis,
asthma, eczema, skin sensitivities and
uticaria

FEATURES OF CLASSIC ATOPIC

DERMATITIS
Itch
Usually a family history of
atopy
About 3% of infants are
aff ected signs appear 3
months-2 years.
Known trigger factors are
evident
Dust mite allergy is not
always obvious especially for
peri-orbital rash
Lichenifi cation (leathery
patches) may occur with
chronic atopic dermatitis
Flexures are usually involved
Dryness is usual feature

CRITERIA FOR DIAGNOSIS

Itch
Typical morphology and distribution
Dry skin
History of atopy
Chronic relapsing dermatitis

Distribution:
Infants : cheeks of
the face, fold of the
neck, scalp, extensor
surface of limb.
Children: cubital &
popliteal fossa.
Adult: upper arms,
back, wrists, hands,
fi ngers, feet, toes.

MANAGEMENT
( NON PHARMACOLOGICAL)
Advice to parents of aff ected children
Avoid soap and perfumed products use bland bath
oil & aqueous cream, cleanser and shampoo with
low pH ( 4.5-6.0)
Emollient soon after bathing
Short and tepid shower
Avoid rubbing & scratching use gauze bandange
Avoid sudden change in temp or overheating
Wear light, soft loose cotton clothes
Dust mite covers for bedding
Wash linen in hot water >55C

MANAGEMENT
(PHARMACOLOGICAL)
Note : corticosteroid creams (acute) & ointments
(chronic)
Mild
soap substitutes aqueous cream
Emollients

sorbolene alone/ with 10% glycerol

Paraffi n cream (Dermeze)
Bath oils (Alpha Keri)
Moisturising cream in summer (QV)

1% hydrocortisone ointment once or twice daily

Moderate
As for mild
Topical corticosteroid (twice daily)

Vital for active areas

Moderate strength (fl uorinated) to trunk, limbs
Weaker strength (1% hydrocortisone) to face, fl exures
Use in cyclic fashion for chronic cases (10 days on, 4
days off )

Non steroidal alternative for facial dermatitis ;

pimecrolimus (Elidel)
Oral antihistamines at night - itch

Severe
As for mild and moderate eczema
Potent topical corticosteroid to worse areas
Consider hospitalisation
Systemic corticosteroid (rarely used)
Allergy assessment if unresponsive
EDUCATION AND REASSURANCE
Explanation , reassurance, and support are very
important
Emphasise that atopic dermatitis is superfi cial
disorder and will not scar and disfi gure
Counselling indicated where family stress and
psychological factor

WEEPING DERMATITIS (ACUTE PHASE)

Weeping is a sign that the dermatitis has become infected,
usually with Staphylococcus aureus
Source: www.betterhealth.vic.gov.au

Often has crusts due to exudate.

Management:
Burrows solution diluted to 1 in 20 or 1 in 10 to soak
aff ected areas.
Saline dressings to soak old sheets till damp and lay on the
areas
(1 teaspoon to 500mL water).

Infection is common.

General points of dermatitis management

2. NUMMULAR (DISCOID)
DERMATITIS
Chronic, red, coinshaped plaques
Crusted, scaling and
itchy
Mainly on legs, also
buttocks and trunk
Often symmetrical
Common in middle age
patients
Maybe related to stress
Persists for months
Treatment as for classic
atopic dermatitis

3. PITYRIASIS ALBA
White patches on the face of children and adolescents
Very common mild condition
Common around mouth and on cheeks
Can occur on neck, upper limbs, occasionally trunk
Subacute form of atopic dermatitis
Full repigmentation occurs eventually

Treatment :

Reassurance
Simple emollient
Restrict use of soap and washing
May prescribe hydrocortisone ointment (rarely
necessary)

4. DYSHIDROTIC DERMATITS
(POMPHOLYX)
Typically in patients aged
20-40 years
Itching vesicles on fi ngers
Commonly aff ects sides of
digits and palms
Last for few weeks and can
recur
Related to stress
Treatment : wet dressings,
as for atopic dermatitis

5. ASTEATOTIC DERMATITIS
Asteatotic means without
moisture
Common, very itchy dermatitis
Occur in elderly especially during winter
Dry crazy paving pattern
Commonly occur on legs
Treatment :
Take short bath with low water temperature
Eliminate use of soap in involved areas
Apply emollients after bath
Apply topical steroid ointment

EXOGENOUS DERMATITIS
CONTACT DERMATITIS
Contact dermatitis is a type of eczema triggered by contact with
a particular substance.
source: www.nhs.uk

2 types
Irritant (ICD)
Allergic (ACD)
70% have irritant cause.
Presence of irritant dermatitis increases the risk of
developing a contact allergy
Features:
Itchy, infl amed skin
Red and swollen
Papulovesicular (papules & vesicles)
May be dry and fi ssured

IRRITANT CONTACT
DERMATITIS (ICD)
Caused by primary irritant such as :

Acids
Alkalis
Detergent
Soaps
Oils
Solvent

Reaction results from either once

only exposure to very irritant
chemical OR repeated exposure to
weak irritants
This is irritation, not allergy

ALLERGIC CONTACT DERMATITIS

(ACD)
Provoked by allergic reaction
It is immunologically mediated
Due to delayed hypersensitivity with long time
of days to years.
Common in industrial / occupational situation.
Approximately 4.5% of population is allergic to
nickel which is found in jewellery, studs on jeans,
keys and coins.
Clinical features:
Faint erythema to water melon face edema
Worse in peri- orbital region, genitalia and hairy skin
Think of rhus, grevilla or poison ivy allergy if puff y eyes

Note: can be delayed onset

Common allergen:
Fragrances
Topical antibiotics,
anaesthetic, antihistamines
Metal salts ( nickel sulphate,
chromate)
Clothing dyes
Rubber/latex
Diagnosis
Careful history / examination
Consider occupation, family
history, vacation/ travel,
clothes, topical application
Refer dermatologist for
patch testing

Murtaghs page 1315

PATCH TESTING

MANAGEMENT
Determine the cause and remove it
Wash with water only and pat dry
(avoid soap)
If acute with blistering, apply
Burows compresses
Oral prednisolone for severe cases
Topical corticosteroid cream
Oral antibiotic if secondary
infection
Chronic phase : use fragrant- free
moisturiser
Glycerol 10% in sorbolene cream
Paraffi n
Emollient

SEBORRHOEIC
DERMATITIS
Very common skin infl ammation
Aff ects areas abundant in sebaceous glands
Common in :

Scalp
Face
Neck
Axilla
Groins
Eyelids
eyebrows
External auditory meatus
Nasolabial folds
Presternal area

Features:
Not itchy
Greasy and yellowish

SEBORRHOEIC DERMATITIS OF
INFANCY
Known as cradle cap
Aff ects scalp, nappy rash (napkin area)
Diffi cult to diff erentiate from atopic dermatitis but
seborrhoeic tends to appear very early 1 s t month
of life / within 1 s t 3 months (androgen activity is
most prevalent)
Appears red patches/ blotches with scaling
Flaky, scurf-like dandruff appears 1 s t yellowish
then greasy, scaly crust forms and associated with
reddening of skin
Can become infected
Cradle cap and nappy rash may meet in the
middle

Pro g n o s i s
C l e a r b y 1 8 m o n t h s ( ra re a ft e r 2
years)
N o n p h a r ma c o l o g i c a l t r e a t m e n t
Ke e p a re a c l ea n a nd d r y
B a t h e i n wa rm w a t er , p a t d r y
w i t h s o ft c l o t h
S k i n ex p o s ed t o a i r
Av o i d t o i l e t s o a p f o r wa s h i n g e m u l s i fy i n g o i n t m en t
Ru b s c a l es wi t h b a b y o i l , t h e n
w a s h a wa y l o o s e s c a l es
C h a n g e we t a nd s o i l ed n a p p y
o ft en
M i l d a rea s , a p p l y t h i n s m ea r o f
zi n c c re a m

Pharmacological treatment
Scalp
Infants
1-2% sulphur and 1-2% salicylic acid in aqueous cream with 2%
liquor picis carbonis added:
Apply overnight to scalp, shampoo off next day (3 times a week)
Egozite cradle cap lotion (6% salicylic acid)
Older children and adults
Zinc pyrithione 1% / selenium sulphide 2.5% shampoo/ ketoconazole
or miconazole shampoo
Face, fl exures an d trunk
Ketaconazole cream
Sorbolene cream
Hydrocortizone 1%
Betamethasone 0.02-0.05%
Desonide 0.05% lotion for face/eyelids and weeping area
Napkin area
Mix equal 1% hydrocortisone with nystatin/ ketoconazole/
clotrimazole cream

ADULT SEBORRHOIEC DERMATITIS

Teenage onwards
Head is common: scalp, ears, face, eyebrow,
eyelid, nasolabial fold.
Other area: centre of chest, centre back, scapular
area, perianal
Red rash with yellow greasy scales
Secondary candidiasis common in fl exor
Worse with stress and recurring condition
Treatment
Same like infant seborrheic dermatitis
# Oral antifungal is not recommended

LET US RECALL
ATOPIC DERMATITIS

SEBORRHOEIC DERMATITIS

PITYRIASIS ALBA

DISCOID DERMATITIS

DYSHIDROTIC DERMATITIS

ALLERGIC CONTACT
DERMATITIS

http://patient.info/health/topical-steroids-foreczema

REFERENCE
John Murtaghs General Practice 6 t h Edition.
Clinical Dermatology 4 t h Edition, Blackwell Publishing
Websites:
http://www.epiceram.ca/physician/inside_out.php
http://www.treatallergicdisorder.com/atopic-eczema/
http://www.everythingforeczema.com/blog/2014/01/29/unde
rstanding-eczema-what-happens-to-the-skin-in-eczema
/
http://
emedicine.medscape.com/article/1049085-overview?
pa=CoYiSDD2x58%2FAC9etGPM2zM%2B2I%2FfqSnXkGMQNOp
pU%2FRKPMVvK4nGsI2Vmg6nKL9Qd%2FsGPYa%2BToEoLjuhF
nUEHw%3D%3D#a5