14ATOPIC DERMATITIS Clinically manifested by: ASTHMA “ATOPY” is a genetically determined tendency to produce increased amounts of reagens (IgE), in response to allergens.Clinically manifested by: ASTHMA HAY FEVER ATOPIC DERMATITIS
18Major features (must have 4) PruritusEarly age of onsetTypical morphology and distributionInfants & Children: Face & extensorsAdults: Flexureal lichenification & linearityChronic coursePersonal or family history of atopy (asthma, rhino-conjuctivitis, dermatitis).
19Minor features Dryness of skin Ichthyosis , palmar hyperlinearity/keratosis pilarisHand/foot dermatitisLip dermatitisNipple eczemaIncreased cutaneous infections e.g. Staph. aureus & H.Simplex)
21ACUTE vs Chronic AD Acute AD Chronic AD Redness Swelling Papules VesiclesExudationCrackingLess vesiculation/ exudationMore Thickening, pigmentation & Lichenification (due to rubbing & scratching)FissuresScratch marks
23Infantile/childhood AD Adult AD Red Itchy scaly lesions on scalp, cheeks, wrists & trunkDiaper area sparedExtensor aspects of limbs (begins to Crawl)Irritable & restlessnessCrustsPustulesLichenified, pigmented papules, plaques scattered all over bodyBothering itchProminent infra-orbital creaseGeneral dry skin
35Irritant Contact Dermatitis Non-allergic reaction of the skin caused by exposure to irritating substanceAny person can develop ICD if concentration & duration of contact sufficientAbout 80% of occupational dermatitis is irritant in natureC/F: Erythema, Edema, Vesiculation, Weeping
36ALLERGIC CONTACT DERMATITIS Immunologically-mediated, Delayed (type IV) hypersensitivityOccurs in persons already sensitizedNot dose related, Not restricted to area of contactC/F: erythema, edema, papules, papulovesiclesit is difficult to distinguish C/F of ACD from irritant or constitutional dermatoses(AD, SD)
53Avoid IrritantsAllergen avoidance during pregnancy and or infancy (mild benefit shown from avoiding cow’s milk, eggs, and dust mites)Big Five: dryness, dust mites, animal dander, cigarette smoke, woolOthers include water and chemicals
54Dry Skin Care Baths and showers not hot and short Mild soap (Dove) – best to avoid alkali soapsBlot dry and immediately moisturize (skin should still be slightly damp)Creams and ointments better than lotions and oils
55Itch Control Avoid topical antihistamines Products containing menthol, camphor & weak conc: of phenol may be helpfulCool compressesAvoid hot/sweaty conditions
56AntihistaminesIn children generally sedating AH used. No role of non-sedating AH in children with ADA combination of sedating & non-sedating AH indicated in adults with eczema.For AD: Zonalon=topical doxepin – qid for maximum of eight days. Never occlude, some systemic absorption, very sedating, risk of ACD
57TOPICAL STEROIDS Steroid Potency Vehicle Amount Site Clinical stage of eczemaWeatherDuration of treatmentDisease
70Nodular PrurigoCharacterized clinically by chronic, intensely itchy papules & noduleslesions range from small papules to hard nodules, 1–3 cm in diameter, with a raised, warty surface.The early lesion is red later becoming pigmented.Tr: superpotent steroids, oral steroids, UVB, PUVA, thalidomide
72Pompholyx Pompholyx is characterized by the sudden onset of clear vesicles over hands.Symptoms: No erythema, less pruritus but more heat and prickling sensation.Sites: sides and dorsa of fingers & handsVesicles may become confluent and present as large bullae, especially on feet.Itching may be severe, preceding the eruption of vesicles
75Pityriasis Rosea (P. rosea) An acute, self-limiting disease, probably infective in origin, affecting mainly children and young adults.The first lesion is “Herald patch” a large circular, sharply defined eryhematous patch with fine scales on thigh/trunk.This is followed by an eruption of discrete oval lesions, dull pink in colour, covered by fine, dry, silvery scales forming a collarette at edges.The centre tends to clear and assumes a wrinkled, atrophic appearance.The lesions appear in crops.
76P.Rosea contd…….The lesions tend occur in ‘chrismas tree’ pattern along the rib cage.There are usually no symptoms. Some pts. have mild to moderate pruritusTr: The common asymptomatic, self-limiting cases require no treatment. If itch is severe or the appearance distressing, a topical steroid (moderate potent) or UVB can be helpful.
80Asteototic Eczema Eczema developing in dry skin Seen on legs, arms and hands.Tends to be more marked in the winter and in elderly people.Skin is dry, scaly showing a criss-cross skin markings. Finger pulps are dry and cracked; retaining a prolonged depression after pressure (‘parchment pulps’).Associated with hypothyroidism, zinc deficiency, diuretic use and cimetidine use
83Pityriasis alba D/D: vitiligo, P. versicolor, PIH A mild eczema in which hypopigmentation is the most conspicuous feature. (NO CALCIUM DeficiencyPredominantly seen in children b/w ages of ys.The individual lesion is circular, oval or irregular hypopigmented patch with NOT well defined edges.Lesions often slightly erythematous & have fine scaleCommon sites: cheeks & around the mouth & chin Less commonly on neck, arms, shoulders & trunk.D/D: vitiligo, P. versicolor, PIHTr: mild steroids, emollients
87DiseaseTypical morphologyDiagnostic cluesIrritant CDAllergic CDAtopic DermatitisSebhorroic dermatitisXerotic/asteotic eczemaNummular /discoid eczemaPompholyxSharply demarcated macular erythema, little vesiculationExzematous, scaly edematous plaques with vesiculationEczematous, honey-crusted scaly plaques, lichenified in chronic casesGreasy scaly papules, minimal itchCrackled parchment like patches, no edema, no vesiculationCoin-shaped, well demarcated, scaly or weepy plaques, bilateral, symetrical, kissing lesionsDeep seated papulo-vesicles on palmar plantar surfaces, volar edgesMore burning less itch, only at area of contactPruritis, primary lesion at area of contact,Flexural areas, neck predominanceHair bearing areas, glabella, nasolabial foldsLower legsArms, legs, dorsal handsPalms, soles, typical dorsal involvement
88ConclusionsEczema management rests on three pillars: avoid irritants, moisturize, topical managementUse steroids to quiet a flare then switch to a nonsteroidal therapyTreating hot spots can prolong remissionsControl itch!
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