1. Eczema

2. Learning objectives Recognise the features of an eczematous rash
Develop a rational method for classifying eczema
Name the main types of endogenous and exogenous eczema
Know how to distinguish irritant contact from allergic contact dermatitis
Describe the theory behind patch testing, its method and indications
Recognise and describe the distribution and morphology of atopic, discoid, varicose, pompholytic and seborrhoeic eczema
List the common exacerbating factors for atopic eczema
Develop a management plan for a patient with moderately severe atopic eczema
List the main side effects of topical steroids and the measures needed to safeguard against these

3. Eczema Features Itching Scaling Dryness Fissures Bleeding Weeping
Lichenification

4. Types of Eczema Atopic Discoid Seborrhoeic Venous/Gravitational
Irritant Contact
Allergic Contact

5. Localised or generalised
Elderly, eczema on the legs with varicose veins, mainly immobile?
Gravitational Eczema
Localised to Face and Scalp?
<2 years on first presenation, history of asthma/hayfever? No
Yes
Generalised
Localised
Seborrhoeic eczema
Mainly on the hands and working with harmful substances?
Atopic Eczema No
Yes
Discoid
Allergic Contact dermatitis
Irritant contact dermatitis

6. Atopic eczema Eczema, asthma, hay fever Family history
Normally first presentation <2 years old
50% remission by 2, 80% have remission by adolescence
Infants less than one year old:
Widely distributed eczema
The cheeks of infants are often the first place to be affected
Nappy area spared due to the moisture retention of nappies
Children:
Often affects the extensor aspects of joints, particularly the wrists, elbows, ankles and knees. It may also affect the genitals
May develop nummular pattern- mistaken for ringworm

7. Discoid Eczema Nummular dermatitis May be associated with staph aureus
Affects children and adults, males>females
Men over 50, chronic alcohol abuse
Mainly limbs and trunk, asymmetrical distribution
Two types:
Exudative acute discoid eczema: oozy papules, blisters and plaques
Dry discoid eczema: subacute or chronic erythematous, dry plaques
Tests:
bacterial swabs for staph aureus- antibiotics
Scrapings to rule out ring worm (tinea corporis)

8. Gravitational Eczema Elderly people with:
History of deep venous thrombosis in affected limb
History of cellulitis in affected limb
Chronic swelling of lower leg, aggravated by hot weather and prolonged standing
Varicose veins
Venous leg ulcers
Thought to be caused by fluid collecting in the tissues and activation of the innate immune response
May be mistaken for cellulitis - Crusting or scaling is the most important sign in eczema and this is not seen in cellulitis, small blisters may also be seen

9. Seborrhoeic Infantile and adult forms
Associated with Pityrosporum Spp- metabolites cause an inflammatory reaction
Adult
scalp, face (creases around the nose, behind ears, within eyebrows) and upper trunk
Winter flares, improving in summer following sun exposure
Blepharitis: scaly red eyelid margins
Infantile:
Cradle cap
under the age of 3 months and usually resolves by 6–12 months of age
may spread to affect armpit and groin folds
 salmon-pink patches that may flake or peel
not especially itchy- babies unperturbed by the rash even when generalised

10. Irritant Contact Causes:
Friction
Environmental factors such as cold
Over-exposure to water
Chemicals such as acids, alkalis, detergents and solvents
Damage occurring faster than the skin can heal- repeated exposure
80% occupational hand dermatitis caused by irritants
Less likely to spread to other areas
Heals when irritant removed
Patch test? Allergic and irritant can co-exist

11. Allergic contact Arises hours after contact
Contact urticaria within minutes
Reaction to a harmless substance
Commonly:
Fragrances
Dyes
Nickel
Rubber
Patch testing
Avoidance of substance

12. MANAGEMENT Principles
Reduction of exposure to trigger factors (where possible)
Regular emollients to treat dry skin
topical steroids
IMPORTANT TO HAVE STEROID FREE DAYS
Potency
steroid
Mild
Hydrocortisone 1%
moderate
eumovate
Potent
Elocon, betnovate
Very potent
dermovate
Steroid s/es – rare
Striae, telangiectasia, glaucoma and cataracts. NOT SKIN THINNING
The effects of topical steroids on various cells in the skin are:
Anti-inflammatory
Immunosuppressive
Anti-proliferative
Vasoconstrictive
The potency of topical steroids depends on:
The specific molecule
Amount that reaches the target cell
Absorption through the skin (0.25%–3%)
Formulation
use mild potency for the face and neck, except for short-term (3–5 days) use of moderate potency for severe flares

13. FINGER TIP UNIT (FTU)
The amount of cream that should be used varies with the body part:
One hand: apply 1 fingertip unit
One arm: apply 3 fingertip units
One foot: apply 2 fingertip units
One leg: apply 6 fingertip units
Face and neck: apply 2.5 fingertip units
Trunk, front and back: 14 fingertip units
Entire body: about 40 units
Index finer – very end of finger to first crease. 0.5g approx. for one FTU

14. 2nd line treatments Topical immunomodulatory
Bandaging/wet wraps – for chronic linchenified areas
Systemic treatments UV
Oral prednisolone, cyclosporine, azathioprine
Calcineurin inhibitors - Topical tacrolimus for mod-severe eczema in adults and children >2 years old
Infected eczema – flucloxacillin 1st line (or erythromycin)
Topical tacrolimus is recommended, within its licensed indications, as an option for the second-line treatment of moderate to severe atopic eczema in adults and children aged 2 years and older that has not been controlled by topical corticosteroids
Pimecrolimus is recommended, within its licensed indications, as an option for the second-line treatment of moderate atopic eczema on the face and neck in children aged 2–16 years that has not been controlled by topical corticosteroids
Localised medicated dressings or dry bandages can be used with emollients as a treatment for areas of chronic lichenified (localised skin thickening) atopic eczema in children.
Flucloxacillin should be used as the first-line treatment for bacterial infections in children with atopic eczema for both Staphylococcus aureus and streptococcal infections. Erythromycin should be used in children who are allergic to flucloxacillin or in the case of flucloxacillin resistance. Clarithromycin should be used if erythromycin is not well tolerated.
The benefits of wet wrapping include:
Reduced itching and scratching
Reduced redness and inflammation
Skin rehydration
Better skin healing process
Reduced steroid usage once the condition is controlled
Improved sleep

15. Which one of the following best describes the typical distribution of atopic eczema in a 10-month-old child?
1) nappy area and flexor surfaces of arms and legs
2) face and trunk
3) nappy area and trunk
4) flexor surfaces of arms and legs
5) scalp and arms 2)

16. 2) 1) Tinea manuum 2) Irritant contact dermatitis
A 19-year-old female who has just started work as a cleaner presents with a rash on her hands. On examination there is a generalised erythematous rash on the dorsum of both hands. There is no evidence of scaling or vesicles. What is the most likely diagnosis?
1) Tinea manuum
2) Irritant contact dermatitis
3) Allergic contact dermatitis
4) Ichthyosis vulgaris
5) Pustular psoriasis 2)