Derm E1: Eczema and Dermatitis

What is another name for atopic dermatitis?

eczema

What is atopic dermatitis?

chronic pruritic, inflammatory skin disease often associated w/ atopy

What are the risk factors for atopic dermatitis?

Genetics -FMHx, environmental exposure

What is the atopic triad?

atopic dermatitis, asthma, allergies

What is the pathophysiology behind atopic dermatitis?

complex and multifactoral: filaggrin deficiency → epidermal barrier dysfunction, TH2 cell immune dysfunction → promote inflammatory IgE response, altered skin microbiome, environmental factors

What are the clinical features of atopic dermatitis?

pruritic, inflammatory, dry skin, itch-scratch cycle, lichenification

How does eczema commonly present in pts < 2 yo?

common on extensor surfaces, cheeks, scalp; pruritic, red, weeping, scaling, crusting

How does eczema commonly present in pts > 2 yo?

common on flexural distribution, more dry, lichenification

What are the secondary features of atopic dermatitis?

infra/reto auricular fissuring, dermographism, Dennie-Morgan infraorbital folds, keratosis pilaris

If you are prescribing a biologic, what do you HAVE to do?

run labs

How do you dx Atopic Dermatitis?

• clinical usually

• culture if infxn suspected

• Labs: CBC -eosinophilia

• Skin biopsy: spongiotic tissue

How do you treat mild to moderate Atopic Dermatitis?

• topical corticosteroids and emollients:

  • Low potency (group 5 & 6)

• Alternative (non-steroid) topical calcineurin inhibitors:

  • Tracrolimus, Pimecrolimus

How do you treat moderate to severe Atopic Dermatitis?

• Topical corticosteroids:

  • medium to high potency (group 3-5)

• Systemic Immunosuppressants

  • Dupixent

• Alternative

  • narrowband UVB phototherapy

How does UVB phototherapy help with eczema?

UV rays reduce histamine production

When should you use low potency TCS for eczema pts?

when its on the face/neck and skin folds due to risk of atrophy

How can you manage Atopic Dermatitis w/o pharmacologic tx?

oral antihistamines, lukewarm baths, wet dressings, topical emollients and creams > lotion, products w/ ceramides, manage stress and anxiety, avoid fragranced products

Why is it important not to scratch eczema?

can lead to secondary infection

What is Seborrheic Dermatitis?

papulosquamous disorder patterned on sebum-rich areas of the scalp, face, and trunk

What pattern does Seborrheic Dermatitis follow?

biphasic: occurs in infants btwn 2 wks-12 mo and later in the 4th decade

What is craddle cap?

Seborrheic Dermatitis on the scalp of babies

What causes Seborrheic Dermatitis?

exact cause unknown; linked to Malassezia furfur colonization

What are the risk factors for Seborrheic Dermatitis?

age, M > F, Meds (dopamin agonists, immunosuppressants, lithium, psoralen), immunocompromised

What are the clinical features of Seborrheic Dermatitis?

well demarcated, erythematous plaques, “greasy” yellow scales, pruritis, pityriasis sicca (dandruff)

Where does Seborrheic Dermatitis typically occur?

face/scalp, periocular, trunk, intertriginous areas, genitalia

How do you treat Seborrheic Dermatitis?

• OTC medications for scalp

• Infants: mineral oil/baby shampoo

• 1st line

  • topical antifungal (ketoconazole)

  • low potency TCS or Topical calcineurin inhibitor

• Severe: oral antifungal

What is allergic contact dermatitis?

contact w/ a substance elicits a delayed Type 4 hypersensitivity rxn, often occurs w/in 48hrs of contact, more exposure = greater reaction

What are the causes of allergic contact dermatitis?

poison ivy, oak, nickel, preservatives, fragrances, antibiotics, paraphenylenediamine (hair dye)

What are the risk factors for allergic contact dermatitis?

hx of atopy, age, occupation

What is the pathophysiology behind allergic contact dermatitis?

exposure to antigen → T cells activated → release pro inflammatory cytokines; has IgE involvement

What are the clinical features of acute allergic contact dermatitis?

well demarcated, pruritic, erythema, edema localized/ confined to the area of contact, papules, vesicles, and/or blistering

What are the clinical features of subacute allergic contact dermatitis?

plaques of mild erythema w/ small dry scales sometimes associated w/ small, red, firm papules; can be generalized

What are the clinical features of chronic allergic contact dermatitis?

plaques of lichenification, scaling w/ small round papules, excoriations, and erythema

How is allergic contact dermatitis diagnosed?

• usually clinical

• patch test can done

• Skin biopsy: eosinophilic spongiosis and exocytosis of eosinophils & lymphocytes

What is the tx for allergic contact dermatitis?

• 1st line: TCS

  • potency depends on location of rash

• Alternative: topical calcineurin inhibitors

• Severe: oral corticosteroids

• 2nd line

  • phototherapy or immunodilators

What is Poison Ivy/Oak Dermatitis?

subtype of allergic contact secondary to direct exposure to olioresin urushiol found inside plant leaves

What are the clinical features of Poison Ivy/Oak Dermatitis?

acute, very pruritic, eczematous dermatitis, often in linear arrangement; usually 4-96 hrs post exposure

Why should you NOT perform a patch test to see if a pt is allergic or having a response to poison ivy/oak?

can sensitize the individual

What is the tx for Poison Ivy/Oak?

calamine lotion, antihistamines, topical steroids; resolves on its own in 1-3 weeks

What is the pt education for allergic contact dermatitis?

remove the offending agent; calamine lotion and oatmeal baths may help w/ pruritis

What is irritant contact dermatitis?

type of contact dermatitis confined to areas exposed to chemical or physical irritants

What are the clinical features of irritant contact dermatitis?

erythema, burning/stinging/pain, painful fissure; sharply marginated, NEVER spreads

Where is irritant contact dermatitis most common?

hands (can also present on face or extremities)

What is the pathophysiology behind Irritant Contact Dermatitis?

direct cytotoxic damage to keratinocytes; repeated exposure damages cell membranes → PTN denaturation and cellular toxicity

What is the tx for Irritant Contact Dermatitis?

remove irritant → resolves w/in 2 weeks; mod/severe: high potency class 1-3 TCS; on face: low/medium potency class 4-6 TCS

What is Stasis Dermatitis?

common inflammatory skin condition of the LE occuring in pts w/ chronic venous stasis

What are the clinical features of Stasis Dermatitis?

erythematous, scaling, and eczematous patches or plaques over the areas of chronic edema on the legs, ulceration, atrophy, lichenification

Where does Stasis Dermatitis most commonly occur?

medial ankle, can extend up to the knee

What are risk factors for Stasis Dermatitis?

old age, FMHx of venous disease, chronic edema, obesity, Hx of DVT, HF, HTN

What is the tx for Stasis Dermatitis?

• tx underlying insufficiency!!

  • leg elevation, walking, wt loss, compression hose

• Emollients to help keep moisture in

• Acute: TCS

  • Group 3-4

  • long term = risk of ulceration

What is another name for Dyshidrotic Eczema?

pompholyx or acute palmoplantar eczema

What is Dyshidrotic Eczema?

intensely pruritic chronic and recurrent vesicular dermatitits of unknown etiology that affects the palms, soles, and lateral aspect of digits

What are the clinical features of Dyshidrotic Eczema?

intense pruritus, “tapioca-like” vesicles → may form bullae, lesions

Where does Dyshidrotic Eczema usually occur?

palms/soles

What is the tx for Dyshidrotic Eczema?

• spontaneous remissions occur in 2-3 wks

• mild/moderate

  • TCS: high potency

• Severe

  • Oral glucocorticoids (prednisone, medrol)

What is another name for Nummular Eczema?

discoid eczema, nummular dermatitis

What is Nummular Eczema?

chronic inflammatory condition characterized by coin shaped lesions, often itchy, and well defined; M > F

Where does Nummular Eczema usually occur?

extremities > trunk

What are the risk factors for Nummular Eczema?

stress, xerosis, heat, humidity, hx of skin injury, alcohol

What are the clinical features of Nummular Eczema?

highly pruritic, round, coin shaped patches of eczematous dermatitis w/ central clearing; ranging in size from 1-10 cm; composed of small papules and vesicles, crusting, dry, scaly

What is the tx for Nummular Eczema?

• 1st line: high potency TCS

  • class 1-3

• Alternative: phototherapy

• Severe/refractory

  • systemic immunosuppressants

• Non-pharm:

  • emollients, lukewarm showers, humidifier

What are Class 7 TCS?

hydrocortisone

What are Class 1 TCS?

clobetasol propionate (Clobex), halobetasol propionate (Ultravate)