Dermatitis Dr Citra 260907

7/30/2019 Dermatitis Dr Citra 260907

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DERMATITIS -Eczema

Dr. Citra Cahyarini, SpKK

Department of dermatovenereology

Faculty of medicine YARSI University


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DERMATITIS -Eczema A common type of inflamation of skin

( epidermo- dermatitis ) which is not caused by micro-organism. Itching is the most symptom

Some types appear to be due to as yet unidentifiedconstitutional abnormalities, while others are moreobviously the result of some external set of circumstance

Constitutional : eg Atopic dermatitis

External : eg Contact dermatitis


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Eflorescense of Dermatitis-Eczema

ErythemPapuleVesiclePustule

OozingCrust

Squama


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Several types of Derm- ecz

Atopic dermatitis

Contact dermatitis

Seborrhoic dermatitis Statis dermatitis

Neurodermatitis

Nummular eczema

Dishidrosis

Infective Eczematoid Dermatitis


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Atopic dermatitis/ EczemaDef :

Acute, subacute, or chronic relapsing skin

disorder that usually begins in infancy and ischaracterized principally by dry skin and

pruritus.

Often associated with personal or family

history of atopy such as allergic rhinitis,

asthma, and atopic dermatitis (AD)


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A.Dmay divided into three stages, namely : Infantile ( 2 months 2 years) Childhood ( 2 years 10 years) Adult

Pathogenesis : ???

Complex interaction of skin barrier, genetic,environmental, pharmacologic and immunologic factors


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Infantile

Usually begins as an itchy erythema of cheeks followedby development of vesicle, rupture and produce moistcrusted areas

The eruptions may rapidly extend to other parts of thebody, chiefly the scalp, the neck, the forehead, the wristand the extremities

The buttocks and diaper area are often involved

The eruption may become generalized with erythroderma


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Infantil AD


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Childhood AD

The lesion to be less exudative, drier, and more papular

The classic locations are the antecubital, and the poplitealspaces, the wrist, eyelids, and the face and in collarette about

the neck

The other area, however, are frequently affected

Itching

There is a decrease in the frequency of sensitization to egg,wheat and milk, but an increase in sensitization to nonigestedsubstances, particulary wool, cat hair, dog hair, and pollens


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Childhood AD


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Adolescent and adult AD

Usually the eruption involves the antecubital and poplitealfossae, the front and sides of the neck, the forehead andthe are about the eyes

Hands dermatitis occurs more frequently in atopicindividuals, and eczematous lessions of the dorsum areusual

Pruritus : paroxysm, nocturnal, triggered by acute emotional

stress Trigger factors : rough clothing, wool irritation, foods or

tension.


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Adolescent and Adult AD


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Associated features

Cutaneous stigmata : Dennie-Morgan fold, Keratosis pilaris,

and Hertoghes sign

Vascular stigmata : White dermographism

Personality traits : Nervous tension

Ophthamologic abnormalities : cataracts, keratoconus.


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Susceptibility to infection :

S.aureus, generalized Herpes simplex or vaccinia virusinfections to produce Kaposis varicelliform eruption

Immunology : elevated serum IgE, decreased T-supressorcells, decreased chemotaxis and activations of PMNleucocyte.


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Diagnosis

Hanifin & Rajka , Svenson, SCORAD criterias

Hanifin & Rajka criteria :Major criteria

1. Pruritus

2. Typical morphology and distribution

3. Tendency toward chronics or chronically relapsing dermatitis4. Personal or family history of atopic diseases (asthma, allergic

rhinitis, AD)


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Minor criteria :

1. Xerosis / ichthyosis/ hyperlinear palms

2. Pityriasis alba

3. Keratosis pilaris4. Facial pallor / infraorbital darkening

5. Elevated serum IgE

6. Keratoconus

7. Tendency to non spesific hand eczema8. Tendency to repeat cutaneous infections


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Differential diagnosis

Nummular Dermatitis

Seborrhoic Dermatitis

Contact Dermatitis

Psoriasis

Scabies


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General management

1. In infancy and childhood

a. It should be avoided :

External irritation

Sudden change of temperature, excessivebathing, insufficient cleanless especially in thediaper region, local infections

b. Food elimination ( with special attention)


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b. Antihistamin systemically

c. Olive oil on absorbent cotton may used withgentle patting for cleansing to avoide rubbing the

affected patrs. Particular attention should be giventhe genitals and buttocks and the diapers shouldbe changed

d. Weak topical corticosteroid.


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2. In adults :

a. The emosional stress should be controlled

b. Avoid extremes cold and heat

c. Hydrated xerotic skin

d. Antihistamin

e. Topical steroid ( be ware of the potentiallity)

f. Antiobiotics ( if nedded)


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Contact Dermatitis (CD)

An exogenous dermatitis which develops as a reaction

of the skin to contact with a foreign substance / an

environmental agent, either a primary irritant ( IrritantCD) or an allergen (allergic CD)

It may be affected by exposure to UV-light, resulting

into two variant reaction : Photoallergic & Phototoxic

CD


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A llerg ic Con tact Dermat i t is(ACD)

Occur in predisposed individual

Sensitization occurs within a week after contact with a

substance (allergen), but there are no visible skin changes

Subsequent contact with allergen, even in small amounts,

causes an dermatitis

Once established, sensitivity may persists for months,

years, or even a lifetime


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Symptom : intense pruritus

Physical exam

acute : erythema & edema

subacute : plaques of mild erythema,dry scales

chronic : plaque of lichenification

Lab : patch test (+)


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PATCH TEST


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Irr i tant Con tac t Dermatit is

Occure in any individual provided the chemical irritant

is applied in a potent enough concentration for a

sufficient length of time

Inflamation of the skin develops at the site of contact

There is non allergic mechanism involved, the damageresult from direct chemical action


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Irritants:strong irritant severe inflamation at the first

contact

Weak irritants: less toxic substances which requirerepeated or prolinged contact tocause inflamation (detergent, organicsolvents, excessive exposure to water)


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Incidence:

The incidence of cases of ICD (each type)

depending mainly on the degree of exposure andthe causative agent

In patients with atopic dermatitis there is a

relatively high incidence of ICD


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acute ICD

Symptom :

- subjective : burning, stinging, smarting

Physical exam :- < 24 h

- erythema vesiculation

* acute : sharply demarcated erythema &superficial edema

vesicles/ blisters


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chronic ICD

Cumulative ICD: slowly after repeated additiveexposure to mild irritan

Symptom : stinging & itching, fissure pain

Physical exam :

dryness chapping erythema- hyperkeratosis & scaling fissure &

crusting


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Treatment

Preventive :

Once the causative agent has been identified, further

contact should be avoided

Topical therapy :

in acute state : wet dressing : Burowi solution 1/20 1/40,

Permanganate 1/10.000, followed by topical steroid.

in chronic state : moderate topical steroid

Systemic therapy :Antihistamin (severe pruritus) and steroid (severe /

extensive eruption


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Contact Dermatitis


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Seborrhoic dermatitis

Two distinct subset of patients :

* The Infantile form *

Characterized by large yellowish scale mainly on the scalp,face, axilla and napkin rash

May cause confusion with Infantile Atopic Dermatitis

No link between the infantile and adult form

No pruritus eat & sleep well


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Infantil form Seborrhoeic Dermatitis


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Cradle Cap


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* The adult form *

Affect the face, scalp, anterior chest, axilla, sub

mammary fold, groins, external ear

Facial lesion, particularly in the nasolabial fold, in

men, maybe very persistent the scalp is frequently involved presenting

complaint, esp severe and persistent dandruff

Eyebrow/ eyelid

stickness of the eyelid inearly morning


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Differential diagnosis :Contact dermatitis, psoriasis and Pityriasis versicolor

Treatment : Tends to recure whatever treatment is chosen

Topical : imidazol antifungal ketokonazol(cream/shampoo) , weak potency topical steroid


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Adult form Seborrhoeic Dermatitis


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Stasis dermatitis

dermatitis on the lower legs, commonly seen in associationwith venous insufficiency

many cases seen in obese, female patients have a degree ofvenous insufficiency

inner aspects of boths lower legs above and around the medialmalleous are chiefly involved

the skin is shinny, atrophic and large numbers of small bloodvessels clearly visible, purpura, pigmentation (due tohaemosiderin)

pruritus may be severe and cause scratch marks which are

slow to heal

Treatment :

treatment of underlying varicose veins, topical steroid (weak)

be ware of side effects atrophy


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Stasis Dermatitis


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Neurodermatitis

(liken simplex chronicus) a well demarcated are of chronic lichenified dermatitis which is

not due to either external irritants or identified allergens

In predisposed persons, the lesions are induced by continual

scratching or rubbing of a localized area of itching skin stress / emotional disturbance pruritic stimulus scratch

itch-scratch-itch cycle stimulate a reactive hyperplasia,recognized clinically as lichenification

clinically, neurodermatitis are seen as a well-circumscribe,

lichenified, slightly elevated plaque, seen on the nape of neck,forearm, or the legs

Treatment :Reduce pruritus, topical steroid (ointment/ intra lesion)


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Neurodermatitis


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Dishydrotic

(eczema dishydrosticum)

a very characteristic pattern of intensely itchy vesiclesof the skin of the hands and occasionally the feet andalso the side of finger

Deep-seated vesicle ; often easier to feel than to see

The cause is not understood ( contact dermatitis /stress? )

Treatment ; systemic antihistamins ( control the needto scratch) prevent secondary infection, potenttopical steroid ( a short time) ; for the moist lesioncalamine lot.


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Dishydrotic


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Nummular or Discoid dermatitis

a chronic, recurrent pattern of dermatitis with discretecoin-shape lesions tending to to involve the limbs

Usually affects adults (many of whom will have a pasthistory of AD) ; The aetiology is unknown

Clinically : subacute with erythema, edema,vesiculation; the surface may be moist and appearinfected bacterial eczema

Pruritus is variable

Treatment : topical steroid + antibiotic


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Nummular or Discoid Dermatitis


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INFECTIVE ECZEMATOID DERMATITIS IED is exogen in nature, can be defined as fluid/ exudate

which originates from inflammation or disorders such as:

OMP, sinusitis, chronic ulcers, etc

IED is thought as autosensitisation dermatitis which occurs

from skins sensitivity toward chemical substances

originating from tissues/ bacteria in the bodys own exudate


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Clinical appearances : Erythema & exudation

In a dry state, there is crust. If crust is peeled, we would

see erythema & often pustules on the edgesExamples :

The earlobes of children suffering from OMP.

The area around the nose of maxilaris sinusitis sufferers


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Therapy :

Rivanol 1/1000, Betadine dressing

When cleared Hidrocortisone 1 % or combination with

antibiotic


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Infective Eczematoid Dermatitis


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URTICARIA & AGIOEDEMA Def:

*URTICARIA

is compoused of wheals (transient edematous papules &plaques, usually pruritic and due to edema of papilary

body). The wheals are superficial, well defined.

*ANGIODEMA

is a large edematous area that involves the dermis and

subcutaneous tissue, is deep and ill defined


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Therapy

Antihistamin : H1, H1 + H2

Systemic corticosteroid

Adrenalin inj subcutis/ ephedrin tab


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urticaria

angioedema


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VasculitisA heterogeneous group of clinical synd

characterized by inflammation of blood vessels

The clinical picture is essensially dependent of size

and extent of vessel involvement purpuraTest : diaskopiTherapy Systemic corticosteroid


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CC, Sept- 2007

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Dermatitis Dr Citra 260907