1. DERMATITIS Dr. Ruth Westra Dr. Ruth Westra June 4, 2008

2. TYPES OF DERMATITIS Atopic Dermatitis (Eczema) Atopic Dermatitis (Eczema) Contact Dermatitis Contact Dermatitis Seborrheic Dermatitis Seborrheic Dermatitis Stasis Dermatitis Stasis Dermatitis Photodermatitis Photodermatitis Multifactorial Multifactorial

3. ATOPIC DERMATITIS Chronic, pruritic eczematous condition of the skin that is associated with a personal or family history of atopic disease (asthma, allergic rhinitis) Chronic, pruritic eczematous condition of the skin that is associated with a personal or family history of atopic disease (asthma, allergic rhinitis) Etiology unknown Etiology unknown

6. INCIDENCE OF ATOPIC DERMATITIS Disease of childhood – 10% of children affected in U.S. Disease of childhood – 10% of children affected in U.S. Uncommon for adults to develop atopic dermatitis without a history of eczema in childhood Uncommon for adults to develop atopic dermatitis without a history of eczema in childhood

7. EPIDEMIOLOGY OF ATOPIC DERMATITIS Increased prevalence may be due to exposure to pollutants, indoor allergens, and decline in breast feeding Increased prevalence may be due to exposure to pollutants, indoor allergens, and decline in breast feeding ?Autosomal dominant gene ?Autosomal dominant gene

8. ALLERGENS FOR A.D. Food allergens Food allergens Aeroallergens Aeroallergens Microbes Microbes

9. CLINICAL FEATURES OF ATOPIC DERMATITIS Pruritis Pruritis Facial and Extensor Papulovesicles in Infancy Facial and Extensor Papulovesicles in Infancy Flexural Lichenification in Adults and Older Children Flexural Lichenification in Adults and Older Children Chronic-relapsing Course Chronic-relapsing Course Personal or Family History of Atopic Dx Personal or Family History of Atopic Dx

10. TABLE 1 Diagnostic Features of Atopic Dermatitis* Major features Pruritus Chronic or relapsing dermatitis Personal or family history of atopic disease Typical distribution and morphology of atopic dermatitis rash: Facial and extensor surfaces in infants and young children Flexure lichenification in older children and adults Minor features Eyes Cataracts (anterior subcapsular) Keratoconus Infraorbital folds affected Facial pallor Palmar hyperlinearity Xerosis Pityriasis alba White dermatographism Ichthyosis Keratosis pilaris Nonspecific dermatitis of the hands and feet Nipple eczema Positive type I hypersensitivity skin tests Propensity for cutaneous infections Elevated serum IgE level Food intolerance Impaired cell-mediated immunity Erythroderma Early age of onset *--The diagnosis of atopic dermatitis should be suspected if three major criteria and three minor criteria are present.

11. DIFFERENTIAL DIAGNOIS OF A.D. Congenital Disorders Congenital Disorders Chronic Dermatoses Chronic Dermatoses Infections and Infestations Infections and Infestations Malignancies Malignancies Immunodeficiencies Immunodeficiencies Metabolic Disorders Metabolic Disorders Immunologic Disorders Immunologic Disorders

12. TREATMENT FOR A.D. Cutaneous hydration Cutaneous hydration Topical Glucocorticoid Rx Topical Glucocorticoid Rx Identify and Eliminate Flare Factors Identify and Eliminate Flare Factors

13. NEW RX Protopic (tacrolimus),topical immunomodulator, inhibits T-cell activation by preventing transcription of early cytokines (CREAM) Protopic (tacrolimus),topical immunomodulator, inhibits T-cell activation by preventing transcription of early cytokines (CREAM) Elidel (pimecrolimus), a calcineurin inhibitor Elidel (pimecrolimus), a calcineurin inhibitor Both for short-term and intermittent long- term therapy without occlusive dressings Both for short-term and intermittent long- term therapy without occlusive dressings

14. Treatment of atopic dermatitis. FIGURE 5. Treatment of atopic dermatitis

15. TREATMENT OF PRURITIS Antihistamines Antihistamines Tar Preparations Tar Preparations

16. ELIMINATE AGGRAVATING FACTORS Specific allergens Specific allergens Emotional Stressors Emotional Stressors Infectious Agents Infectious Agents

17. POORLY CONTROLLED A.D. Wet Dressings and Occlusion Wet Dressings and Occlusion Systemic Glucocorticoids Systemic Glucocorticoids Ultraviolet Light (PUVA) Ultraviolet Light (PUVA) Leukotriene Inhibitors Leukotriene Inhibitors Immunosuppressants and Anitneoplastics Immunosuppressants and Anitneoplastics Hospitalization Hospitalization

18. COMPLICATIONS OF ATOPIC DERMATITIS Eye Eye Infections Infections Hand Dermatitis Hand Dermatitis Exfoliative Dermatitis Exfoliative Dermatitis

19. PROGNOSIS Spontaneous resolution after age 5 in 40% Spontaneous resolution after age 5 in 40% 84% of children “outgrow” by adolescents 84% of children “outgrow” by adolescents Predictive factors of Poor Prognosis Wide spread AD in childhood Associated allergic rhinitis or asthma Early age at onset of AD and female sex Family history of AD in parents or siblings Predictive factors of Poor Prognosis Wide spread AD in childhood Associated allergic rhinitis or asthma Early age at onset of AD and female sex Family history of AD in parents or siblings

28. CONTACT DERMATITIS Inflammatory reaction of the skin precipitated by an exogenous chemical Inflammatory reaction of the skin precipitated by an exogenous chemical Two types of contact dermatitis Irritant - direct toxic effect on the skin Allergic - immunologic reaction that causes tissue inflammation (Type IV Hypersensitivity) Two types of contact dermatitis Irritant - direct toxic effect on the skin Allergic - immunologic reaction that causes tissue inflammation (Type IV Hypersensitivity)

29. INCIDENCE OF CONTACT DERMATITIS Environmental Allergens Environmental Allergens Occupationally related illness Occupationally related illness

30. SENSITIZERS OF CONTACT DERMATITIS Poison Ivy Poison Ivy Paraphenylenediamine Paraphenylenediamine Nickel Nickel Rubber Compounds Rubber Compounds Ethylenediamine Ethylenediamine

33. CLINICAL FEATURES OF CONTACT DERMATITIS Acute – linear streaks of vesicles Acute – linear streaks of vesicles Chronic - lichenification, eczematous reaction Chronic - lichenification, eczematous reaction

34. LOCATION OF CONTACT DERMATITIS Head and neck-cosmetics Head and neck-cosmetics Scalp-hair dyes, permanents and shampoos Scalp-hair dyes, permanents and shampoos Eyelids-eye cosmetics and nail polish Eyelids-eye cosmetics and nail polish Dorsum of hands-industrial chemicals Dorsum of hands-industrial chemicals Dorsum of feet-shoes, rubber, leather Dorsum of feet-shoes, rubber, leather

35. DIFFERENTIAL DIAGNOSIS OF CONTACT DERMATITIS Atopic Dermatits Atopic Dermatits Seborrheic Dermatitis Seborrheic Dermatitis Stasis Dermatitis Stasis Dermatitis Fungal Infections Fungal Infections Bacterial Cellulitis Bacterial Cellulitis

36. LABORATORY No testing for Irritant Contact Dermatitis No testing for Irritant Contact Dermatitis Patch Testing for Allergic Contact Dermatitis - North American Contact Dermatitis Group Standard Patch Test Series Patch Testing for Allergic Contact Dermatitis - North American Contact Dermatitis Group Standard Patch Test Series

38. MOST FREQUENT ALLERGENS Nickel sulfateQuaternium-15 Nickel sulfateQuaternium-15 Fragrance mixBacitracin Fragrance mixBacitracin Neomycin sulfateCobalt Neomycin sulfateCobalt Balsam of PeruPara-phenylenediamine Balsam of PeruPara-phenylenediamine ThimerosolThiuram mix ThimerosolThiuram mix FormaldehydeCarba mix FormaldehydeCarba mix

39. TREATMENT FOR CONTACT DERMATITIS Prevention-Allergen Avoidance Prevention-Allergen Avoidance Symptomatic Therapy Symptomatic Therapy Physicochemical Barriers Physicochemical Barriers Tolerance Induction Tolerance Induction

48. SEBORRHIEC DERMATITIS Chronic, superficial inflammatory process affecting the hairy regions of the body (scalp, eyebrows and face especially) Chronic, superficial inflammatory process affecting the hairy regions of the body (scalp, eyebrows and face especially) Affects infants and adults Affects infants and adults Wide range from mild to severe Wide range from mild to severe One of most common skin manifestations in patients with HIV infection One of most common skin manifestations in patients with HIV infection

50. INCIDENCE OF SEBORRHEIC DERMATITIS Two peaks - Infancy in the first 3 months Adult in the fourth to seventh decade Two peaks - Infancy in the first 3 months Adult in the fourth to seventh decade In adults more common than psoriasis 2-5% of the population In adults more common than psoriasis 2-5% of the population Men affected more than women Men affected more than women 85% incidence in HIV infection patients 85% incidence in HIV infection patients

51. ETIOLOGY OF SEBORRHEIC DERMATITIS Unknown Unknown Associated with oily-looking skin but not a disease of the sebaceous gland Associated with oily-looking skin but not a disease of the sebaceous gland Associated with Parkinson’s Disease Associated with Parkinson’s Disease

52. CLINICAL FEATURES OF SEBORRHEIC DERMATITIS Bilateral and Symmetrical Bilateral and Symmetrical Predilection for Hairy Regions Predilection for Hairy Regions Patches and Plaques with indistinct margins Patches and Plaques with indistinct margins Uncommon to have hair loss Uncommon to have hair loss

53. CLINICAL FEATURES OF S.D. Infantile Scalp (cradle cap) Trunk (including flexures and diaper area) Leiner’s disease (non-familial and Familial Complement 5 dysfunction) Infantile Scalp (cradle cap) Trunk (including flexures and diaper area) Leiner’s disease (non-familial and Familial Complement 5 dysfunction)

54. CLINICAL FEATURES OF S.D. Adult Scalp Face Trunk - Petaloid, Pityriasiform, Flexural, Eczematous plaques, Follicular Generalized Adult Scalp Face Trunk - Petaloid, Pityriasiform, Flexural, Eczematous plaques, Follicular Generalized

55. FIGURE 7. Typical symmetrical distribution of seborrheic dermatitis on the head (top), and on the body (bottom).

56. DIFFERENTIAL DIAGNOSIS SEBORRHEIC DERMATITIS Atopic Dermatitis Atopic Dermatitis Psoriasis Psoriasis Tinea Capitis Tinea Capitis SLE SLE Rosacea Rosacea Histiocytosis X Histiocytosis X

57. DRUGS CAUSING S.D. RASH Produce Seborrheic Dermatitis like lesions Arsenic Gold Methyldopa Cimetidine Neuroleptics Produce Seborrheic Dermatitis like lesions Arsenic Gold Methyldopa Cimetidine Neuroleptics

58. NEUROLOGIC ABNORMALITIES AND S.D. Variety of Neurologic Abnormalities associated with seborrheic dermatitis Parkinson’s Disease Facial Paralysis Poliomyelitis Quadriplegia Variety of Neurologic Abnormalities associated with seborrheic dermatitis Parkinson’s Disease Facial Paralysis Poliomyelitis Quadriplegia Epilepsy Epilepsy

59. PHYSICAL FACTORS Seasonal variation Seasonal variation Relation to PUVA Relation to PUVA

60. IMMUNODEFICIENCY AND S.D. Clue to the presence of HIV Distribution is extensive, severity remarkable and treatment often difficult Clue to the presence of HIV Distribution is extensive, severity remarkable and treatment often difficult

61. TREATMENT GOALS OF S.D. Loosening and removal of scales and crusts Loosening and removal of scales and crusts Inhibition of yeast colonization Inhibition of yeast colonization Control of secondary infection Control of secondary infection Reduction of erythema and itching Reduction of erythema and itching Control rather than cure Control rather than cure

62. TREATMENT FOR INFANTS Scalp Removal of crusts with 3-5% salicylic acid in olive oil or water soluble base Warm olive oil compresses Application of low potency glucocorticoids Mild baby shampoos Scalp Removal of crusts with 3-5% salicylic acid in olive oil or water soluble base Warm olive oil compresses Application of low potency glucocorticoids Mild baby shampoos

63. TREATMENT FOR INFANTS Intertriginous areas Drying lotions (0.2-0.5% clioquinol in zinc lotion or zinc oil) Candidiasis- Nystatin Cream Intertriginous areas Drying lotions (0.2-0.5% clioquinol in zinc lotion or zinc oil) Candidiasis- Nystatin Cream Gentian Violet 0.1-0.25% if oozing Gentian Violet 0.1-0.25% if oozing

64. TREATMENT OF ADULTS Chronic Condition Chronic Condition Anti-inflammatory Anti-fungal Kerolytics Anti-inflammatory Anti-fungal Kerolytics

65. TREATMENT OF ADULTS Scalp - Daily Shampoo containing 1-2.5% selenium sulfide, antifungals, zinc, benzoyl peroxide, salicylic acid, coal or juniper tar Scalp - Daily Shampoo containing 1-2.5% selenium sulfide, antifungals, zinc, benzoyl peroxide, salicylic acid, coal or juniper tar Crusts - can be removed by overnight application of topical glucocorticoids or salicylic acid in water soluble base Crusts - can be removed by overnight application of topical glucocorticoids or salicylic acid in water soluble base Tinctures and alcoholic solutions in hair tonics aggravate Tinctures and alcoholic solutions in hair tonics aggravate

66. TREATMENT OF ADULTS Face and trunk - low potency glucocorticoids (1% hydrocortisone) Face and trunk - low potency glucocorticoids (1% hydrocortisone) Avoid greasy ointments Avoid greasy ointments Lotion – Cream – Ointment (strongest) Lotion – Cream – Ointment (strongest)

67. TREATMENT OF ADULTS Anti-fungals - Imidazoles 95% improvement with ketaconazole inhibition of cell wall synthesis no proof of fungal etiology Anti-fungals - Imidazoles 95% improvement with ketaconazole inhibition of cell wall synthesis no proof of fungal etiology Metronidazole - topical 0.75% gel (Metrogel) some improvement Metronidazole - topical 0.75% gel (Metrogel) some improvement