Dr.MOHAMED NASRDr.MOHAMED NASR

Lecturer Of Lecturer Of Dermatology & VenereologyDermatology & Venereology

Zagazig UniversityZagazig University

Dr.MOHAMED NASRDr.MOHAMED NASR

Lecturer Of Lecturer Of Dermatology & VenereologyDermatology & Venereology

Zagazig UniversityZagazig University

EczemaEczema

ECZEMA (DERMATITIS)ECZEMA (DERMATITIS)

Inflammation of the skin Inflammation of the skin characterised by itching, characterised by itching, redness, scaling and clustered redness, scaling and clustered papulovesicles. papulovesicles.

Stages of eczema:Stages of eczema:

Acute eczema:Acute eczema: there is erythema, minute papules and there is erythema, minute papules and vesicles which may rupture leading to oosing and vesicles which may rupture leading to oosing and crust formation. crust formation.

Subacute eczema:Subacute eczema: edema and vesiculation are less edema and vesiculation are less apparent while papules, erythema and some scales are apparent while papules, erythema and some scales are predominantpredominant

Chronic eczema:Chronic eczema: no oosing or crusting are present. no oosing or crusting are present. The skin is dry, scaly and may be fissured. The The skin is dry, scaly and may be fissured. The repeated attacks of pruritic skin may lead to repeated attacks of pruritic skin may lead to lichenificationlichenification which means: thickening, which means: thickening, hyperkeratosis, hyperpigmentation and increased skin hyperkeratosis, hyperpigmentation and increased skin markings.markings.

Classification of eczema: Classification of eczema:

A-exogenous eczemaA-exogenous eczema due to external triggering factors. due to external triggering factors. 1-contact dermatitis1-contact dermatitis 2-infective eczema (infective eczematoid dermatitis)2-infective eczema (infective eczematoid dermatitis) B-endogenous eczemaB-endogenous eczema due to some chemical processes due to some chemical processes

originating in the body.originating in the body. 1-Atopic eczema1-Atopic eczema 2-Seborrheic eczema2-Seborrheic eczema 3-Discoid eczema3-Discoid eczema 4-Stasis eczema4-Stasis eczema 5-Asteatotic eczema5-Asteatotic eczema 6-Pompholyx 6-Pompholyx

Contact dermatitisContact dermatitis

Allergic contact dermatitis: Allergic contact dermatitis: This type is an immunological process (delayed This type is an immunological process (delayed

hypersensitivity) and results from exposure of hypersensitivity) and results from exposure of sensitized individuals to contact allergens. These sensitized individuals to contact allergens. These sensitizers do not produce dermatitis on first exposure sensitizers do not produce dermatitis on first exposure but after repeated exposures. but after repeated exposures.

It is diagnosed using It is diagnosed using the patch test;the patch test; the sensitizer is the sensitizer is applied to non affected test area of the skin of the applied to non affected test area of the skin of the patient. If the test is positive this area will show patient. If the test is positive this area will show dermatitis. dermatitis.

Irritant contact dermatitis:Irritant contact dermatitis: This type results from exposure of the skin to This type results from exposure of the skin to

the external irritant agent with no the external irritant agent with no immunologic inflammatory reaction. It is of immunologic inflammatory reaction. It is of varied morphology usually limited to the site varied morphology usually limited to the site of contact. of contact.

Infective eczematoid dermatitisInfective eczematoid dermatitis

It is an inflammatory reaction of the skin It is an inflammatory reaction of the skin adjacent to the site of oosing pyogenic adjacent to the site of oosing pyogenic infection e.g purulent otitis or discharging infection e.g purulent otitis or discharging wound or ulcer. wound or ulcer.

Eczema is caused by microorganisms or their Eczema is caused by microorganisms or their products and clear when the organisms are products and clear when the organisms are eradicated. eradicated.

Atopic eczemaAtopic eczema

Atopic eczema is an itchy chronic or Atopic eczema is an itchy chronic or chronically relapsing condition chronically relapsing condition characterised by itchy papules which characterised by itchy papules which become excoriated and lichenified. It may become excoriated and lichenified. It may be associtated with other atopic be associtated with other atopic conditions in the same individual or other conditions in the same individual or other family members. family members.

Atopy:Atopy: means the genetically determined or familial means the genetically determined or familial tendency to develop a group of spontaneous allergic tendency to develop a group of spontaneous allergic diseases including atopic eczema, asthma, hay fever diseases including atopic eczema, asthma, hay fever and allergic rhinitisand allergic rhinitis

AllergyAllergy:: is an acquired specific alteration in the is an acquired specific alteration in the

capacity of the individual to react when exposed to capacity of the individual to react when exposed to foreign substance and is manifested as augmentation foreign substance and is manifested as augmentation of the reaction.of the reaction.

Stages according to age group:Stages according to age group:

1- Infantile atopic dermatitis;1- Infantile atopic dermatitis; occuring from 2 months to 2 years of occuring from 2 months to 2 years of age.age.

2- Childhood atopic dermatitis2- Childhood atopic dermatitis from 2 years to 12 years.from 2 years to 12 years.

3- Atopic dermatitis in adolescents 3- Atopic dermatitis in adolescents and adultsand adults from 12 years onwards. from 12 years onwards.

1-1-Infantile atopic dermatitis:Infantile atopic dermatitis:

It ususally begins as erythema and It ususally begins as erythema and scaling of cheecks. scaling of cheecks.

2-2-Childhood atopic dermatitisChildhood atopic dermatitis::

The classic locations are the cubital The classic locations are the cubital and popliteal fossae, sides of the and popliteal fossae, sides of the neck, eyelids, flexor wrists and neck, eyelids, flexor wrists and ankles. ankles.

33--Adulhood stage Adulhood stage (atopic neurodermatitis)(atopic neurodermatitis);;

It is similar to later childhood in the It is similar to later childhood in the form of localized erythematous scaly form of localized erythematous scaly papular or exudative plaques but papular or exudative plaques but lesions are more dry and thick and lesions are more dry and thick and showing more lichenification showing more lichenification especially on flexures and hands. especially on flexures and hands.

Localised neurodermatitis Localised neurodermatitis (lichen simplex chronicus)(lichen simplex chronicus) : :

In some cases one area is affected with In some cases one area is affected with frequent severe itching and rubbing frequent severe itching and rubbing leading to circumscribed lichenified leading to circumscribed lichenified plaques. plaques.

Sites mostly affected are nape of neck, Sites mostly affected are nape of neck, hands, feet, or manifested as pruritus ani, hands, feet, or manifested as pruritus ani, pruritus vulvae or scroti.pruritus vulvae or scroti.

Diagnosis of atopic dermatitis:Diagnosis of atopic dermatitis:

The first important criterion is: an itchy skin condition, The first important criterion is: an itchy skin condition, with scratching or rubbing.with scratching or rubbing.

Plus three or more of the following:Plus three or more of the following: Onset below 2 years of age.Onset below 2 years of age. History of skin crease involvement (including cheecks in History of skin crease involvement (including cheecks in

children under 10 years)children under 10 years) History of a generally dry skin.History of a generally dry skin. Personal history of other atopic disease or history of atopic Personal history of other atopic disease or history of atopic

disease in a first degree relative in children under 4 years.disease in a first degree relative in children under 4 years. Visible flexural dermatitis (or dermatitis of cheecks/ forehead Visible flexural dermatitis (or dermatitis of cheecks/ forehead

and outer limbs in children under 4 years). and outer limbs in children under 4 years).

Seborrhoeic eczemaSeborrhoeic eczema

SeborrhoeaSeborrhoea means excessive production of means excessive production of sebum.sebum.

Seborrhoeic eczemaSeborrhoeic eczema is a chronic condition is a chronic condition with a characteristic red sharply marginated with a characteristic red sharply marginated lesions covered by greasy scales and lesions covered by greasy scales and diagnostic distribution in the areas of rich diagnostic distribution in the areas of rich supply of sebaceous glands (scalp, face, upper supply of sebaceous glands (scalp, face, upper trunk and flexures). trunk and flexures).

Clinical picture:Clinical picture:

Discoid (Nummular) eczemaDiscoid (Nummular) eczema

Gravitational eczemaGravitational eczema(venous - varicose - stasis eczema)(venous - varicose - stasis eczema)

This eczema is secondary to venous This eczema is secondary to venous hypertension and stasis which is hypertension and stasis which is predisposed to by prolonged predisposed to by prolonged standing, ususally occurs around the standing, ususally occurs around the medial malleoli. medial malleoli.

Asteatotic eczemaAsteatotic eczema(winter eczema-senile eczema)(winter eczema-senile eczema)

This is a type of eczema associated with This is a type of eczema associated with decrease in the skin surface lipids. decrease in the skin surface lipids.

It may occur in old age, cases of It may occur in old age, cases of malnutrition, chapping, dry cold winds malnutrition, chapping, dry cold winds and low environmental humidity and and low environmental humidity and degreasing of the skin by industrial or degreasing of the skin by industrial or domestic cleansers or solvents. domestic cleansers or solvents.

PompholyxPompholyx

This is a type of eczema in which sudden This is a type of eczema in which sudden attacks of crops of deep clear vesicles attacks of crops of deep clear vesicles with no erythema develop on palms, with no erythema develop on palms, fingers, or soles. fingers, or soles.

A sensation of heat and irritation may A sensation of heat and irritation may precede the attack. precede the attack.

It subsides spontaneously with It subsides spontaneously with desquamation in 2-3 weeks but is usually desquamation in 2-3 weeks but is usually recurrent.recurrent.

Treatment of eczema:Treatment of eczema:

1- Correction of underlying factors e.g 1- Correction of underlying factors e.g Avoidance of exposure to sensitizers and solventsAvoidance of exposure to sensitizers and solvents Treatment of varicose veins, foci of infection, etc…Treatment of varicose veins, foci of infection, etc…2- Broad spectrum antibiotics if secondary infection supervenes.2- Broad spectrum antibiotics if secondary infection supervenes.3- Oral antihistamines.3- Oral antihistamines.4- Topical cortisosteroids of appropriate strength for the patient's 4- Topical cortisosteroids of appropriate strength for the patient's

age and affected area twice daily for 10-21 days. Creams are used age and affected area twice daily for 10-21 days. Creams are used for acute and subacute cases and ointments for dry chronic cases. for acute and subacute cases and ointments for dry chronic cases.

5- Topical emolients as vaseline for dry skin and in chronic cases.5- Topical emolients as vaseline for dry skin and in chronic cases.6- Topical immunomodulators: tacrolimus ointment 0.03% or 6- Topical immunomodulators: tacrolimus ointment 0.03% or

pemicrolimus 1% cream twice daily.pemicrolimus 1% cream twice daily.7- Short course of systemic steroids in acute, severe and wide spread 7- Short course of systemic steroids in acute, severe and wide spread

cases.cases.8- Ultraviolet rays therapy with PUVA and narrowband UVB 8- Ultraviolet rays therapy with PUVA and narrowband UVB

(NBUVB).(NBUVB).

URTICARIA AND ANGIOEDEMAURTICARIA AND ANGIOEDEMA

UrticariaUrticaria are attacks of itchy well demarcated reddish are attacks of itchy well demarcated reddish evanescent swellings of the skin (wheals=hives) and evanescent swellings of the skin (wheals=hives) and are usually associated with pruritus or burning are usually associated with pruritus or burning sensation.sensation.

AngioedemaAngioedema is characterised by swellings of deep is characterised by swellings of deep dermal and subcutaneous/submucosal tissues. dermal and subcutaneous/submucosal tissues. Swellings are painful rather than itchy, poorly defined Swellings are painful rather than itchy, poorly defined and pale or normal skin coloured.and pale or normal skin coloured.

AcuteAcute if it has been present continuously or if it has been present continuously or intermittenly for less than 6 weeks.intermittenly for less than 6 weeks.

ChronicChronic if it has been present for at least 6 if it has been present for at least 6

weeks or more. When no underlying cause is weeks or more. When no underlying cause is identified it is termed chronic idiopathic identified it is termed chronic idiopathic urticaria.urticaria.

Pathophysiology:Pathophysiology:

1- Allergic:1- Allergic: histamine is an important mediator in urticaria. Mast histamine is an important mediator in urticaria. Mast cells are the major histamine releasing cells in the skin. cells are the major histamine releasing cells in the skin. Allergens react with IgE molecules which are bound to the Allergens react with IgE molecules which are bound to the surface of mast cells leading to mast cell degranulation and surface of mast cells leading to mast cell degranulation and release of histamine and other mediators. This results in local release of histamine and other mediators. This results in local increase of permeability of capillaries and venulesincrease of permeability of capillaries and venules . .

2- Non allergic:2- Non allergic: direct degranulation of mast cells occurs direct degranulation of mast cells occurs without antigen antibody reaction due to the effect of without antigen antibody reaction due to the effect of substances like aspirin, neuropeptides, nonsteroidal anti-substances like aspirin, neuropeptides, nonsteroidal anti-inflammatory drugs (NSAID), opiates, ciprofloxacin, inflammatory drugs (NSAID), opiates, ciprofloxacin, polymixin, rifampicin and vancomycin. polymixin, rifampicin and vancomycin.

Causes of urticaria:Causes of urticaria:

1- Food:1- Food: food additives or preservatives, fishes, banana, nuts, eggs, chocolate food additives or preservatives, fishes, banana, nuts, eggs, chocolate and cheese.and cheese.

2- Drugs:2- Drugs: aspirin, NSAIDs, antibiotics eg; penicillin..etc aspirin, NSAIDs, antibiotics eg; penicillin..etc3- Inhalants:3- Inhalants: pollens, dust or animal fur pollens, dust or animal fur4- Intestinal parasites4- Intestinal parasites5- Stress5- Stress6- Septic foci6- Septic foci eg; in teeth, tonsils or urinary tract eg; in teeth, tonsils or urinary tract7- Physical causes:7- Physical causes: heat, cold, water, vibration, sunlight or pressure heat, cold, water, vibration, sunlight or pressure8- Cholinergic urticaria:8- Cholinergic urticaria: is a specific type in which small weals occur in is a specific type in which small weals occur in

association with sweating due to heat or emotional stressassociation with sweating due to heat or emotional stress9- Insect bites or stings9- Insect bites or stings10- Contact urticaria10- Contact urticaria eg; occupational exposure eg; occupational exposure11- Medical causes:11- Medical causes: like hepattitis, obstructive jaundice and Helicobacter like hepattitis, obstructive jaundice and Helicobacter

pyloripylori infection infection12- Serum sickness12- Serum sickness

Treatment:Treatment:

1-Treatment of the cause if possible.1-Treatment of the cause if possible.2- 2- AntiH1 antihistamines are the first line of treatment:AntiH1 antihistamines are the first line of treatment: a- a- traditional classic antiH1traditional classic antiH1 eg; chlorpheneramine maleate, eg; chlorpheneramine maleate,

diphenhydramine, and hydroxizine diphenhydramine, and hydroxizine b- b- non sedating antiH1:non sedating antiH1: cetrizine hydrochloride, loratadine, cetrizine hydrochloride, loratadine,

fexofenadine, desloratadine and acrivastinefexofenadine, desloratadine and acrivastine3- 3- AntiH2 antihistaminesAntiH2 antihistamines may be needed in addition to antiH1 may be needed in addition to antiH1

eg; eg; cimetidine and ranitidinecimetidine and ranitidine4-4- Systemic steroids in severe cases; Systemic steroids in severe cases; prednisolone 0.5 to 1mg /kg. prednisolone 0.5 to 1mg /kg.5- 5- Locally:Locally: calamine lotion is used for soothing the sensation of calamine lotion is used for soothing the sensation of

pruritus. pruritus. 6- 6- In angioedemaIn angioedema:: distressing the respiratory passages from distressing the respiratory passages from

oropharyngeal-laryngeal edema; epinephrine (adrenaline) in oropharyngeal-laryngeal edema; epinephrine (adrenaline) in 1/1000 solution is the first line of management. It is given 1/1000 solution is the first line of management. It is given subcutaneously in a dose 0.2-0.5 ml.subcutaneously in a dose 0.2-0.5 ml.

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