ECZEMA Eczema, a common inflammatory skin condition Eczema is a Greek word for boils.

s. It is called so because of the characteristic bubble-like blisters which appear on the skin surface. The term eczema and dermatitis may be used interchangeably. Common convention is to describe eczema: endogenous or constitutional & dermatitis: exogenous or due to contact ETIOLOGY: There is stong hereditary factor with the paternal factor being more dominant than the maternal factor. Genetic, environmental and immunological factors interplay 30-50% of the patients will gradually develop hay fever or asthma Almost all immunocytes suffer some extent of derangement of function There is increased trans-epidermal water loss and decreased skin integrity requiring the need for continuous moisturization.

PATHOPHYSIOLOGY: Histological features are common irrespective of the causes and differ in acute & chronic phases Acute eczema: Fluid escapes from dilated dermal blood vessels to produce edema in the epidermis They form blisters or vesicles at the thicker region of skin (palms,toes etc.). these vesicles may combine to form larger blisters. In the thinner skin regions, the vesicles may rupture causing exudation and crusting. Chronic eczema: The chronic stage has lesser edema & vesiculation and more thickening of epidemis & horny layer(stratum corneum) caused by the prolonged rubbing & scratching by sufferer. CLINICAL TYPES 1) ATOPIC ECZEMA: (Atopy: genetically determined hypersensitivity to environmental allergens. Group of diseases like asthma, hay fever and dermatitis) Activation of Langerhans cells in the epidermis by Ag-IgE complex

 Presentation of this complex to T-lymphocytes of the skin Production of inflammatory mediators which causes tissue rxn & destruction. Symmetrical in distribution Affects mainly face and flexures ( bending areas like elbow, wrist, back of knees etc.) But may also become generalized Lichenification (dry, thickened, leathery skin) may occur as the child grows Provoking factors: Dryness and extremes of temp. Irritants and allergens Stress Due to impaired cell-mediated immunity they are prone to infections which may exacerbate the condn.

2) CONTACT DERMATITIS: (exogenous eczema) 2 types: rashes caused due to: 1. external substance (cell-mediated immune rxn-type IV)-Allergic Contact Dermatitis 2. wear and tear or irritation-Primary Irritant Dermatitis Allergic Contact Dermatitis: -Due to compounds used in day-to day life ( dyes, topical medications,rubber, preservatives etc.) -rxn rarely start after 1st contact. May take months to yrs -if the allergy is uncontrolled, may spread to other areas and become generalized. -avoid the allergens since this type of allergy is lifelong Primary Irritant Dermatitis: -contact with items that dehydrate the skin ( detergents, soaps etc) removes the natural protective oil from the skin allowing evaporation of water and entry of irritants. - those with atopy are more prone to this problem - Strong irritants cause an acute reaction where as weak irritants most often cause chronic reaction

Eg: Napkin eczema in babies due to ammoniacal feces and urine

3) SEBORRHOEIC ECZEMA: -In areas of body with high density of sebaceous glands ( face, scalp, flexures etc) -occurs after puberty when the glands become active -due to overgrowth of Pityrosporum ovale (yeast) -skin is red with greasy yellow scales and scalp shows severe dandruff

4) DISCOID ECZEMA: -intense itchy circular patches -in forearms and lower legs -intense itching cause excoriation (stripping of skin) which may lead to secondary infections 5) VARICOSE/STASIS ECZEMA : -result of varicose veins,venous stasis and oedema in lower leg which may progress to varicose ulceration. 6) ASTEATOTIC ECZEMA: Frequently seen in hospitalized elderly with dry skin (lack of oil) Occurs most often on the lower legs Aggravated by the use of soap

TREATMENT 1) EMOLLIENTS: -basic problem is due to the lack of lipid layer of skin -moisturizers in adequate qty will reduce the need for topical streroids -soap should be avoided and an emollient cream should be applied before, during & after-bath Dose: paediatric-100g Adult- 200g

2) TOPICAL CORTICOSTEROIDS -it is an immunologically mediate inflammatory condition -so anti-inflammatory agents which has immune-modulating effect should be given (corticosteroids) -topical fluorinated corticosteroids dose ADR Potency of the steroid depends upon the vasoconstrictive properties Typically, with high-potency steroids: Use no longer than 3 weeks Use on thickened lesions Not for use on face, skinfolds, or mucous membranes The vehicle is as important as the steroid concentration Occlusives can increase percutaneous absorption Strength: Ointments > creams> lotions Cream-oozing type & ointment-dry type Gels may be beneficial for hairy or oily areas Use with moisturizers Apply corticosteroid first the goal is to increase moisturizers while decreasing corticosteriod use Low-potency products (hydrocortisone 1%) have a weak anti-inflammatory effect and are safest for long-term application Medium-potency (betamethasone 0.05%) products are used in moderate inflammatory dermatomes High-potency (dexamethasone 0.1%) preparations are used primarily as alternatives to systemic corticosteroids when local therapy is feasible Mech of action: corticosteroids may halt synthesis and mitosis of DNA in epidermal cells and appear to inhibit phospholipase A, lowering the amounts of arachidonic acid, prostaglandins, and leukotrienes in the skin. These effects, coupled with local vasoconstriction, reduce erythema, pruritus, and scaling ADR: Long-term topical corticosteroiduse primarily results in : cutaneous abnormalities (skin atrophy, striae, hypopigmentation, and steroidinduced acne) Systemic effects :hypothalamic-pituitary-adrenal axis suppression, growth retardation, and other adrenal abnormalities Dose: 170g per week

3) OTHER TOPICAL IMMUNOMODULATORS: They include Tarcolimus & Pimecrolimus. They act by inhibiting calcineurin which is a cytoplasmic enzyme essential for the activation of T-lymphocytes. They are sufficiently low molecular weight to penetrate the stratum corneum Have advantage over corticosteroids that they dont produce cutaneous atrophy Pimecrolimus is less potent than tacrolimus, nut has better penetration

ADR: skin cancer, lymphoma on long term use. Other: pruritis, erythema, skin infections, discolouration Tacrolimus can cause burning sensation when used for the 1st time Dose: Tacrolinmus- 0.1% ointment b.i.d 4) Antibiotics Staphylococcus aureus erythromycin or flucloxacillin for 10 days Herpes simplex virus acyclovir (5%-Q4H x 5-10days)

5) Drying agents Use in case of exudates Using potassium permangante baths, soaks or wet compresses Dose: 1 in 10,000 soln 6) Coal tar preparations An effective antipruritic, used at night in impregnated bandages in atopic children to prevent scratching Should not be used on oozing lesions as it may cause irritation Tar creams and ointments are useful in discoid eczema Eg: crude coal tar (1% to 3%) 7) Topical imidazole Ketoconazole 2% as a shampoo or cream for Pityrosporum ovale on the skin and control seborrhoeic eczema and dandruff Dose: twice weekly appln for 2-4 weeks

Systemic therapy 8) Systemic steroids Acute exacerbations of atopic eczema, acute allergic contact dermatitis, erythrodermic eczemato bring the condition rapidly under control Ciclosporin Mainly in adults for short-term treatment (2.5-5mg/kg) Azathioprine Antimitotic drug used in cases of severe treatment-resistant eczema at a dose of 50-150 mg/day Used for long term therapy Suppresses bone marrow and immune system

9) Anti-histaminies: A sedative anti-histamine should be used to relieve the itching as well as to prevent sleep disturbances

10) Other immunomodulators Interferone gamma severe refractory eczema Methotrexate unresponsive adult atopic eczema 11) Phototherapy PUVA (psoralen + UVA) or UVB can be employed Narrow band UVB (290 320 nm) is widely available and may be as effective and safer than PUVA Two or three times per week, usually for several weeks Side effects of phototherapy include o burning o premature aging of skin o increased risk of skin cancer