5 Shapes of LesionsThe shape of a lesion frequently gives clues to the etiology of the skin lesion.Shapes include lesions that are: round, polygonal, polycyclic, annular, iris, serpiginous, umbilicated,and target.Margination is also important – are the lesions well or ill definedArrangement – are the lesions grouped or disseminated
6 Distribution of Lesions A significant number of skin diseases are limited to specific regions of the bodyAre the lesions isolated, localized, regional, or generalizedAre the lesions symmetrical; limited to exposed areas, sites of pressure, or intertriginous areas
8 Eczema - Common Definitions Any itching rashAny red itching rashAny red itching rash that has scales or is dryThe itch that rashesAny rash that cannot otherwise be identified
9 Eczema-Dermatological Definition An acute, subacute but usually chronic pruritic inflammation of the epidermis and the dermis, often occurring in association with a personal family history of hay fever, asthma, allergic rhinitis or atopic dermatitis. 11 Color Atlas and Synopsis of Clinical Dermatology
10 Characteristics of Acute Eczema Well demarcated plaques of erythema and edema on which are superimposed and closely spaced small vesicles filled with clear fluid with punctate erosions and crustingDistribution may be isolated and localized or general
11 Acute Eczema (Note the erythema, vesicles and swelling) Term dyshidrotic is a misnomer as sweat glands are not involvedAlso known as pompholyx
13 Characteristics of Subacute Eczema Plaques of mild erythema with small dry scales and or superficial desquamation, sometimes associated with small red, pointed or round papulesDistribution may be isolated and localized or general
14 Subacute EczemaNote erythema, swelling and desquamation
15 Characteristics of Chronic Eczema Plaques of lichenification with deepening of the skin lines with satellite, small, firm flat or round top papules, excoriations and pigmentations or mild erythemaDistribution – isolated and localized or generalized
16 Chronic EczemaNote lichenification, scaling and fissuring
17 Acute - Subacute - Chronic Swelling and erythemaPunctate erythema,desquamationLichenification
18 Acute, Subacute or Chronic? Check for erythema, swelling, desquamation, lichenification
19 Acute, Subacute or Chronic? Check for erythema, swelling, desquamation, lichenification
20 Classification of Eczema/Dermatitis HistoricallyEndogenous (occurring from within) dermatitis was given the name “eczema”Exogenous dermatitis (occurring from without) was termed “dermatitis”
21 Classifications of Eczema EndogenousAtopic or IgESeborrheicDiscoid or nummularPompholyxVenousAsteatoticJuvenile plantarErythodermaExogenousAllergicToxic irritant contactPhotosensitive
22 Atopic/IgE Eczema (endogenous or exogenous?) Characteristics:60% have onset in the first year of lifeInfluenced by genetics and environmental factorsMore common in males that femalesEthnicity may be a factor –less common in Asians; more common in Westerners and higher socioeconomic familiesTheory is - manifestation of well nourished immune system rarely challenged by infectionRare to have adult onset2/3 of patients have family history of asthma, hay fever or allergic rhinitis
23 Atopic/IgE Eczema cont. Characteristics:May persist months to yearsAll patients have dry skinExacerbations caused by allergens, stress, hormones, climate, skin dehydrationPhysical characteristic may include all phasesDistinctive Characteristics:Lesions are usually bilateralLocated frequently in skin folds/creases and flexor surfaces
24 Atopic/IgE Eczema Distribution Note:BilateralSkin folds and flexor surfaces
25 Atopic/IgE Eczema cont. Triggers:IrritantsDry skin; bathing without moisturizingHarsh/perfumed soaps, detergentsDisinfectantsContact with wool, occupational chemicals/fumesAllergensDust mitesPet dander (cat more allergenic than dog)Pollens, seasonal and moldsFoods- strawberries, carrots
26 Atopic/IgE Eczema cont. Triggers (cont’d):InfectionsBacterialViralCold and other URI virusesGI virusesFungalEnvironmentalExtremes in temperature and/or humidityPerspirationStress
30 Allergic (Contact)Eczema (exogenous or endogenous?) Characteristic:Delayed, cell mediated hypersensitivityStrong sensitizer results in reaction soon after exposureWeak sensitizer my take months or years to develop reactionAge does not influence capacity for sensitization but more common in adultsBlack skin is less susceptibleImportant cause of disability in industryNon seasonal
31 Allergic (Contact) Eczema cont. Characteristics:usually clears quite rapidly on withdrawal of offending agentmay appear as erythematous papules, vesicles or bullousmore common where epidermis is thinnerDistinctive Characteristics:Initial lesions usually limited to contact areanot bilaterallesions with sharp borders or angles are pathognomonic
32 Causes of Allergic/Contact Eczema Metals- nickel, platinum (10% of women)DetergentsPlants and fibersChemicals and dyesPolyethylene glycol and polysorbate 60Topical antibiotics and medicationsAnimal keratin
33 Allergic/Contact Eczema cont. Treatment – remove causative agent, Burow’s soaks 1:40, or saline 1tsp/pt warm water, Aveeno or oatmeal baths, calamineSystemic antihistaminesTopical steroids, oral steroid taperAntibiotics for secondary infectionConfused with – Atopic eczema, seborrhea, HSV
40 Subacute Allergic Eczema Note slight swelling and erythemaNo lichenificationLocation – what could be the cause?
41 Chronic Allergic Eczema Note the hyperkeratosis, lichenification and fissuring
42 Toxic / Irritant Eczema (occurring in non allergic skin) Characteristics:Accounts for 75% of exogenous eczemaAge, race and sex are insignificantResults from repeated exposure to toxic or subtoxic agentsSeverity of skin symptoms vary with the individual and the type of irritant and the length of contactIncludes sx of itching, stinging and burningUsually associated with chronic disturbance of the barrier function of the skin
43 Toxic/Irritant Eczema cont. Common causes:Repeated exposure to alkaline detergentsRepeated exposure to organic solventsCorrosive agentsIndustrial chemicalsChronic self perpetuating habits that irritate the skin
44 Toxic/Irritant Eczema cont. Treatment:Remove the causeApplication of emollientsUse of soap substitutesBarrier creamsBorrow’s or potassium permanganate soaks twice dailyBiopsy/testing- usually not necessary
45 Acute Toxic/Irritant Eczema Note: distribution, swelling and weeping
46 Subacute Toxic/Irritant Eczema Lip lickingoften seen in children who have atopic eczemaVariant of irritant eczemacompare
47 Chronic Toxic/Irritant Eczema Note:papulosquamous dermatosis with hyperkeratosis, maceration, fissuring and erosionsEruptions tend tobe sore rather thanitching
48 Acute, subacute, or chronic? Swelling? Erythema? Desquamation? Lichenification?
49 Comparison of Classifications of the 3 common types of eczema ACUTEAtopicIgEToxic/IrritantAllergicContactErythemaXPapulesNAVesiclesErosionsCrustsScalesSharp/ confinedSpreading peripherallyFlexor surfaces, neck, eye lids, d footOnset rapidBefore age 12Usually as adultOnset slowConcentration L/HHLIncidenceOther signsAnyoneSensitized
50 Comparison of Classifications ChronicAtopicIgEToxic/IrritantAllergic/ContactscalingXfissuescrustsNApapulesexcoriationlichenificationPeriorbital pigmentationInfraorbital folds in the eyelidsFoillicular papulesX more common in the black pop.
51 Pompholyx (from Greek word meaning blister) Characteristics:Intense itching and burning proceed lesionsBlisters and vesicles on hands/ feetBecomes highly exudativeDries up in about 2 wks leaving painful fissuringAcute symptom of a chronic problemUsually no cause but can be due to trichophytin and associated with fungal infection of the feet
52 Pomhpolyx cont. Treatment: Avoidance of soap Emollients Soaks ( burrows or potassium permanganate)Potent or very potent topical steroids with or with occlusionAntibiotics for infectionSystemic steroidsCoal tar extractsBiopsy/testing- usually not necessary
53 PompholyxWhere else should you look?What else might this be call?
54 Nummular Eczema Characteristics: usually -personal or family history of allergy, especially asthma, hay fever, and childhood eczemaDistinctive Characteristics - Coin-shaped papulovesicular patches that develop in to scaling and crusting lesions; lesions may be as large as 4-5cm in diameter with distinct margins, initial eruptions on arms and legs; intense itching; tends to be chronic
55 Nummular Eczema cont. Characteristics: Most severe during winter; may be aggravated by systematic administration of iodine or bromine; secondary bacterial infections are commonTreatment: skin hydration, topical corticosteroids, intralesional injection, coal tar ointments, UVB treatment, treat secondary infection
56 Nummular Eczema cont.Confused with – contact dermatitis/eczema, atopic eczema, psoriasis, impetigo, tinea corporisBiopsy/testing – not usually necessary
59 Seborrehea Characteristics: Positive family history is common Seen in all age groups equallyMay occur on presternal area and mid upper backStress may increase symptomsPityrosporum ovale may be causative factorDistinctive Characteristics:Red greasy scaling rash consists of patches and plaques with indistinct margins and an underlying red glazed look to the skinMost commonly located in the hairy areas, nasolabial folds, retroauriclar foldsExcoriations from scratching are rare
60 Seborrhea cont. Treatment: Scalp – try OTC preps first (antidandruff, tar or ketoconazole shampoo)Steroid lotions for very short term use10% Liquor Carbonis Detergens HS and shampoo in AM with Dawn DetergentSkin -try OTC’s firstcorticosteroids (mild to moderate potency) and/or ketoconazole topically
61 Seborrhea cont. Eye lashes- Warm compresses and gentle debridment with Q tipSulfacetamide ophthalmic ointment applied topically** Areas that become exudative may be treated with potassium permanganate or burrow’s soaksConfused with – atopic dermatitis, eczema, psoriasis, discoid lupus, tineaBiopsy/testing – usually none
66 Asteatotic Eczema (Xerotic Eczema, “Winter Itch”) Characteristics:Seen mainly in elderlyWorse in the winterPrecipitated by excessive washingTreatment:Avoid excessive washing and use of soapEmollientsIncrease humidity in the environmentTopical steroids for a short periods of time
67 Localized Neurodermatitis Cont. Treatment:Stop the scratchingOcclusive steroid dressings esp. at nightLubricationDoxepin ointment and/or po 10-20mgHydroxyzine at nightIntralesional steroid injectionStress management and/or medicationTreatment is longterm and may be unsatisfactoryConfused with – atopic eczema, psorasis, tinea, seborrheaBiopsy / testing – none usually necessary
68 Localized Neurodermatitis (known as Lichen Chronicus Simplex) Characterisitcs:Origin often small patch of dermatitis or insect bite starting the itch –scratch- itch cycleCondition unrelated to allergies or family historyMore common in womenNonseasonalaggravated by stressworse at nightmay be secondary to atopic eczema, contact dermatitis, lichen planus, psoriasis, or insect bite
69 Localized Neurodermatitis (known as Lichen Chronicus Simplex) CONT. Distinctive Characteristics:Lesions lichenified or excoriatedusually limited to a single patch at hairline of nape of neck or on wrists, ankles, ears, or anal areaNot bilateralLlichenification of dark skin develops a “follicular pattern”
70 Localized Neurodermatitis Distribution (known as Lichen Chronicus Simplex)
75 Education Chronicity of eczema Association of other conditions: AR, asthmaVast number of sensitizing chemicals used currently in our soaps, shampoos, detergents, foods, etc.Likelihood of finding a trigger lowDetailed sensitizers/triggers (see Pocket Guide to Medications used in Dermatology by Scheman and Severson)
76 Patient ResourcesThe Eczema Survival Guide – 30 page guide by the NEASE– the single best general patient medical resource on the internet – sponsored by NIH- National Eczema Society– National Eczema Assoc. for Science and Education- online dermatology atlas from Johns Hopkins Univ.
77 Prevention Checklist Moisturize daily Wear cotton, avoid wool and tight clothesTake lukewarm showers, using mild soap or nonsoap cleansersPat dry – do not rubApply moisturizer within 3 min. to “lock in” moistureAvoid extremes of heat/humidity and perspirationLearn triggers and how to avoid themKeep fingernails shortRemove carpets and pets from the home
78 Soaps and CleansersAny product that removes skin oils (sebum), dirt, other undesirable substancesRange from very moisturizing to neutral to very drying“If it is dry, wet it; and if it is wet, dry it” – derm mantraNormal skin pH is ; most soaps are basic and therefore can be irritatingRinsing may be an issue if irritatingChoose the appropriate cleanser to match your patient’s skin type (most eczema patients will need hydration of the skin and neutral or acidic pH)Again, see Pocket Guide to Medications used in Dermatology for detailed ingredients of skin products
79 Soap Free Cleansers Indications: CetaphilAquanilAveeno Daily MositurizerEucerin Gentle Hydrating CleanserLobana Body ShampooMoisturelpHisodermIndications:For use in those eczema patients who may be sensitive to one or more of the various potential sensitizers in soaps and shampoos.To cleanse, reduce irritation (if sensitive to soaps), and reduce dryness (thereby increase absorption of other topicals).
80 Emollients/Moisturizers AquaphorBalmex DailyAmLactinCutemolDML ForteEucerin OriginalHydrisinolLanolorIndication: To soften and soothe rough, dry skin and increase absorbability of topical medicationsDirections: Apply as necessary or as prescribed; generally after showering/bathing and pat drying; apply liberally to affected areasNeutrogena Norwegian FormulaLac-HydrinAveenoPen-KeraCurelLubriderm Advanced TherapyMinerin
81 AstringentsAstringents – reduce secretions (by causing contraction of tissues) and are antibacterialBest used in eczema where vesicular or draining lesions are presentAcetic Acid 5% (white vinegar) – especially useful in Pseudomonas infectionsBurow’s Solution (Domeboro and others)Potassium Permanganate
82 Burow’s Solution (aluminum acetate) Indication:Used as an astringent wet to dry dressing for relief of inflammatory conditions of the skin such as insect bites, poison ivy, allergy, eczema, and athlete’s foot.Directions: One tablet or one pack per pint of water = 1:40 solutionActions:Collagenase enzyme activity may be inhibited by aluminum acetate solution because of the metal ion and low pH.
83 Burow’s SolutionAs a compress or wet dressing: Saturate a clean, soft, white cloth in the solution. Gently squeeze and apply loosely to affected area. May cover with dry dressing. Saturate the cloth in solution every 15 to 30 minutes and apply to affected area. Repeat as often as necessaryAs a soak: Soak affected area in solution for 15 to 30 minutes. Discard solution after each use. Repeat 3 times a day
84 Burow’s Solution Precautions: Discontinue use if intolerance, irritation, or extension of inflammatory condition being treated occurs. If symptoms persist >7 days, discontinue use and consult physicianDo not use plastic or any other impervious material to prevent evaporationAvoid contact with the eyes
86 OTC Meds Antiinflammatory topicals Hydrocortisone creams, 0.5% to 1% Antipruritics and othersBenadryl (diphenhydramine 25-50mg q6h prn)Calamine Lotion (zinc oxide and ferric oxide used as a mild astringent)Caladryl Lotion (both of above)Burow/s solution
90 Basic Rules of Dermal Absorption The larger the surface area the formulation is applied to, the greater the absorptionFormulations or dressings that increase the hydration of the skin generally improve absorptionThe greater the amount of rubbing in of the formulation, the greater the absorptionThe more active inflammation or open vesicles or ulcers present, the greater the absorptionThe longer the formulation remains in contact with the skin, the greater will be the absorption
92 Topical Vehicles Creams: Less greasy and most acceptable to patient Applies more easilyPenetrates skin wellWorks well in intertriginous and hairy areasCan be dryingHave a cooling effectEasy to wash offLotions: more water content and less viscous than creamsOintments:Petrolatum basedAlleviates dryness by prevention of evaporationRemoves scalesEnables medication to penetrates skin wellWater repellantRemains on the skinOcclusive and protectiveSoothing and lubricating
93 Prescription Topical Steroids Low and Medium Potency Do consider use in:Allergic/Contact DermatitisSeborrheic DermatitisIntertrigo of axillary, crural or inframammary regionsAtopic EczemaNeurodermatitisOtic eczemaDo not use:Large body areas because of expense, difficulty with application, and question of internal absorption
94 Prescription Topical Steroids High Potency and Fluorinated Do consider use:With or without occlusive dressing in palmar or plantar atopic dermatitisLocalized neurodermatitisDo not use:FaceIntertriginous areas** prolonged use in any area may cause thinning of the skin, telangiectasia, striae
96 Elidel Elidel (pimecrolimus) 1% cream Indications: Short term and repeated courses for mild to moderate eczema in nonimmunocompromised patients greater that 2 years of age in whom the use of alternative conventional treatment is inadvisable or those with are none responsive to conventional treatment.Can be used anywhere on the skinPrecautions:Do not use in treatment of infected atopic dermatitis, including eczema herpeticumPatients who develop lymphadenopathy should have a complete evaluation to R/O lymphomaAvoid sun light exposure as sun exposure and use of pimecrolimus shortens time of skin lesion to skin tumor formation in animalsDo not use occlusive dressings
97 Elidel (cont’d)Adverse Effects (often resolve after a few days of therapy):Warmth or burning where appliedHeadacheCold-like symptoms (st, cough, rn)FeverViral skin infectionDosage:Apply BIDDiscontinue when symptoms resolvedFurther evaluation needed if symptoms persist > 6 weeksMOA:Calcineurin inhibitorCost:30 grams: $63; 60 grams $117
98 Protopic Protopic (tacrolimus) adults 0.03% & 0.1% ointment Indications:Protopic ointment 0.1% for adults onlyProtopic ointment 0.03% for children age 2 and olderShort term and repeated courses of moderate to severe eczema in whom the use of alternative conventional treatment is inadvisable or those who are not responsive to conventional treatmentCan be used anywhere on the skinPrecautions:Do not use in treatment of infected atopic dermatitis, including eczema herpeticumPatients who develop lymphadenopathy should have a complete evaluation to R/O lymphomaAvoid sunlight, tanning salons, phototherapy (PUVA), as sunlight shortens time of skin lesion to skin tumor formation in animalsDo not use occlusive dressings
99 Protopic (cont’d)Adverse reactions ( often resolve after few days of application):Skin stinging and burning (dependent on degree of eczema)Increased skin infectionsDosage:Apply BIDDiscontinue 1 week after symptoms resolvedFurther evaluation needed if symptoms persist > 6 weeksMOA:Calcineurin inhibitorCost:30 grams: $62; 60 grams $130
100 Potential problem with both TIM’s (Elidel and Protopic) Feb. 15th 2005: the Pediatric Advisory Committee of the FDA met and recommended that a “black box warning” be added to both Elidel and Protopic due to “potential cancer risk”This is due to animal studies where animals swallowed large amounts of both drugs over a long period of time, achieved significant blood levels of the drugs, and developed lymphomas.March 10, 2005: The FDA issued a Public Health Advisory warning the public about potential carcinogenic safety issues involving both TIM’s.The American Academy of Dermatology, the Nat’l. Eczema Assn. for Science and Education (NEASE), and the Inflammatory Skin Disease Institute (ISDI) all have issued statements declaring the FDA action premature and all feel that the drugs are safe when used appropriatelyThere are already websites dedicated to class action litigation against both manufacturersBottom Line: I would not adivse using in any pediatric patients, or in any patient that can be controlled with less expensive and efficacious therapy.
101 Nontraditional Agents Problem: these are not deemed safe or effective by the FDAHerbal remediesLicorice as topical gelGuava leaves (as tea)Chinese herbal teasSt. John’s wort (as lotion or tea)Probiotics – thought to help relieve inflammationHomeopathic – arsenicum alba and calcara carbonicaHypnosisAcupunctureGamma linoleic acid oilsEvening primrose oilBorage oil
102 PO Prescription Drug Therapy AntipruriticsHydroxyzine 10-25mg q6h prn itchingDoxepin 10-25mg q12-24h prn itching (off label) also can be compounded as a cream)Oral SteroidsMay give in tapering short courses for selected episodes of acute and/or severe eczemaEffective, inexpensive, qd dosing, few side effects in most people with short term useCyclosporine – reserve for specialty useMethotrexate – reserve for specialty use
103 Coal Tar Preparations Tegrin cream and lotion Medotar ointment PsoriGel gelPolytar and Tegrin soapsTegrin, T/Gel, and other shampoosIndication: to relieve and control itching, and flaking skin associated with psoriasis and seborrhea as well as eczemaDirections: Depending on product 1-4 times daily
104 Coal Tar Preparations (cont’d) Contraindications:HypersensitivityPrecautions:Do not use on broken skin, genital or rectal area except on the advise of your health care provider.Photosensitivity x 24hr after applicationMay stain light colored hairWarning:High concentrations of some chemicals in coal tar may cause cancer. Concentrations of 0.5% to 5% appear to be safe.
105 PUVA TherapyIndications: Psoriasis, eczema, pruritic rashes of other causesConsists of PO psoralen (photosensitizing agent) followed by UVA phototherapyMust avoid sunlight for 24h after po psoralenSessions are 3d/wk, may be from sessions, increasing in durationSide effects are redness, burning, occasional nauseaLitigation very high in some states
106 Summary of Treatment Conservative Therapy Education (chronicity, prevention, and trigger id)Use of astringents and emollients/moisturizersOTC products (hydrocortisone, Benadryl, Calamine, etc.)Low to mid potency steroid creamsHigh potency steroid creamsImmunomodulators - Elidel and Protopic creamsNontraditional agentsPO therapy: antiprurutics, steroids, cyclosporine, methotrexateCoal TarPUVA therapy (phototherapy)
107 Midlevel Provider’s Role in theTreatment of Eczema IdentificationTreatmentEducation
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