ATOPIC DERMATITIS AND OTHER ECZEMAS  Inhalants

Lalaine R. Visitacion, MD o Dust mites

o Animal furs, dander
Scope o Pollens
I. ATOPIC DERMATITIS  Ingestants
 Etiology o Cow’s milk
 Epidemiology o Nuts; peanuts, …
 Three stages o Eggs
 Diagnostic Criteria
 Contactants
 Management
o Wool fibers
II. OTHER ECZEMAS
o Lipid solvents; soaps, detergents
 Ear eczema
 Breast Eczema o Chlorine in swimming pools
 Hand Eczema  Microbial agents
 Diaper Dermatitis o Staph aureus (superantigen)
 Xerotic Eczema o Candida
 Nummular Eczema  Climate
 Clinical Manifestations and Management o Extremes of temperature
o Dryness
ATOPIC DERMATITIS  Emotional stress
 Also known as atopic eczema, infatile eczema, flexural
eczema, disseminated neurodermatitis and prurigo
diathsique (Besnier)
 Coca: atopy means “out of place” or “strange”
 Together with asthma and allergic rhinitis forms part of
the ‘atopic triad’

Epidemiology
 Increasing prevalence – 2x to 10x in the last 3 decades
 10-20% of schoolchildren in US, northern and western
Europe, urban Africa, Japan, Australia, and other
industrialized countries and Asia
 Lower rates in Eastern Europe, Mediterranean, African
countries and Central Asia
 1-3% in adults
 Sex: female/male ratio of 1.3:1.0
 Age: 85% occurs in the first year of life; 95% before age
5 years
Etiology
 A highly pruritic inflammatory skin disease that results
from complex interactions between genetic susceptibility
genes resulting in:
o Defective skin barrier
o Defects in the immune system
o Heightened immunologic responses to allergy
and microbial antigens
Reported Immunologic Features of Atopic Dermatitis
 Increased IgE production
 Specific IgE to multiple antigens
 Increased basophil spontaneous histamine release
 Decrease CD8 suppressor/cytotoxic number and
function
 Increased expression of CD 23 on mononuclear cells
 Chronic macrophage activation with increased secretion 8. Nipple eczema
of GM-CSF, PGE2 and IL-10
 Expansion of IL-4 and IL-5 secreting Th 2-like cells
 Decreased numbers of IFN-gamma-secreting Th 1-like 18. Intolerance to wool and lipid solvents
cells
Pathophysiology
 IL4/IL5/IL10 are all increased
 Laboratory findings suggest an abnormality of T helper 2 22. White dermographism or delayed blanch to
(TH2) cells resulting in increased production of
interleukin 4 (IL-4) and increased IgE. The excess IL-4
causes decreased interferon γ levels. Cells may react
with environmental anrigens to produce increased levels
of IgE
 Serum histamine is increased
 Stratum corneum abnormalities of lipid (particularly
ceramide production)
 Abnormality of prostaglandin metabolism
Exacerbating Factors (Triggers)
Diagnostic Criteria by Hanifin and Rajka
A. MAJOR CRITERIA: Must
have three of the following:
1. Pruritus
2. Typical morphology and distribution
a. Flexural lichenification in adults
b. Facial and extensor involvement
3. Chronic and chronically relapsing dermatitis
4. Personal and family history of atopic disease
(asthma, allergic rhinitis, atopic dermatitis)
B. MINOR CRITERIA: Mus have three of the following:
1. Xerosis
2. Icthyosis/hyperlinear palms/keratosis pilaris
3. IgE reactivity (Immediate skin test reactivity, RAST
test positive)
4. Elevated serum IgE
5. Early age of onset
6. Tendency for cutaneous infections (esp S. aureus and
herpes simplex virus)
7. Tendency to nonspecific hand/foot dermatitis
……
17. Itch when sweating
19. Perifollicular accentuation
20. Food hypersensitivity
21. Course influenced by environmental and/or
emotional factors
cholinergic agents
Criteria Modification for young Infants
A. THREE MAJOR FEATURES:
1. Family history of atopic dermatitis
2. Typical facial or extensor dermatitis
3. Evidence of pruritus
B. THREE MINOR FEATURES:
1. Xerosis/Icthyosis/hyperlinear palms
2. Perifollicular accentuation
3. Postauricular fissures
 4. Chronic scalp scaling
Three Stages of Atopic Dermatitis
 Infantile atopic dermatitis – 2 months to 2 years
of age
 Childhood atopic dermatitis – 2 to 10 years old
 Adolescent and adult atopic dermatitis - >10 y/o
1. Infantile Atopic Dermatitis
 60% of atopics >2 mos to 2 years of age
 Begins as itchy erythema of the cheeks 
minute intraepidermal vesicle  rupture  moist
crusted areas extend to other parts of the body:
scalp, neck, forehead, wrists and extensor of
extremities
 Areas spared: buttocks and diaper area
Sites of predilection
 Moist lesions – most common type
 Significant exudates and secondary effects from
scratching: crusts, pustules and infiltrated areas 
lichenified
 Lesions may become generalize with erythroderma and
desquamation
Course
 Symptoms disappear before or towrd the end of second
year – able to eat food which previously cause flares
without exacerbation – appear to outgrow sensitivity
 Worsening observed after immunizations and viral
infections
 Summer: partial or complete remission – relate to the
therapeutic effects of UVB in atopics
 Winter: relapse – aggravation of wool and low humidity
of forced air in winter
Role of Food (also applicable to children)
 60% of patients had at least 1 positive food challenge
 85% of challenges are associated with cutaneous
symptoms
 Majority of positive tests: egg, peanut, milk, wheat, fish,
soy and chicken
 Positive challenges correlate with rise in plasma
histamine
 Withholding the implicated food: clinical improvement
and decrease in histamine
 45% lost food sensitivity over a 1-2 year period
 A negative skin prick test: reliable indicator of absence of
food sensitivity
 Food allergy may play a role in a selected population of
young atopic patients
 Withholding cow’s milk: conflicting results
 Withholdingcow’s milk and eggs during pregnancy and
lactation: conflicting results
 Restrictive measures may be considered only when the
risk for atopy in a child is high or where infantile AD is
severe
2. Childhood Atopic Dermatitis
 Locations: antecubital and popliteal fossa, flexor
wrists, eyelids, face and around the neck
 Pruritus: constant feature
 Lesions: les acute – less exudative, drier, more
popular, often lichenified scaly infiltrated plaques
 Vicious cycle established: itch  scratch  itch
 Results to lichenification, secondary bacterial
infection
 Other factors:
o Wool irritation: winter
o Feather sensitivity – onset at age 2
o Sensitivity to cat & dog dander
3. Adolescent and adult atopic dermatitis
 Forms:
o Localized eryhthematous, scaly, popular
or vesicular plaques
o Lichenified pruritic plaques
Adolescent: classic antecubital and popliteal
fossae, front and sides of the neck, forehead, area
about the eyes
 Infiltrated, erythematous facial skin with scalines
in an adolescent with atopic dermatitis. Note
lateral thinning of eyebrows and intra-ocular
(Dennie-Morgan) fold
Adults: less characteristic distribution –generalized
but more severe in the flexures
 Universally lichenified
 Paroxysmal pruritus
 Typical lesions: dry scaly papules coaslescing
into lichenified scaly plaques
 Maybe become exudative, crusted or infected
 Dry skin
 Flares in adults: triggered by
o Acute emotional upsets: stress, anxiety
and depression decreased the threshold
for itch
o Exercise due to inability to sweat
 Hand dermatitis
o 20-80% of pxs
o Hands and wrists
o Palmar and dorsal surfaces
o Clinically indistinguishable from contact
dermatitis
o Triggered by increased exposure to
soaps and water
Associated Features and Complications of Atopic
Dermatitis
1. CUTANEOUS STIGMATA:
a. Dennie Morgan sign – a linear
transverse fold just below the edge of
the lower eyelids
b. Xerosis – skin dryness
 Represents low-grade
dermatitis
 Transepidermal water loss is
decreased
 Water barrier is diminishes
 Decreased threshold to
irritancy
c. Icthyosis – fish-like scales
d. Pityriasis alba – a form of subclinical
dermatitis
 Poorly, marginated slightly scaly
patches on the cheeks, upper
arms and trunk in young
children
e. Keratosis pilaris – horny follicular lesions
of the outer aspects of the upper arms
and legs
 Associated with dry skin
 Refractory to treatment
 f. Hertoghe’s sign – thinning of the lateral  Humidifiers in rooms are helpful
eyebrows  AVOID emotional stress
g. Keratosis punctata palmaris et plantaris – chiefly
in black atopic patients Specific Therapeutic Strategy
h. “Dirty neck” – reticulated pigmentation of the Step I – Induction of remission
neck Step II – Stabilization and maintenance
i. Ear eczema Step III – Rescue of flares
j. Nipple eczema
k. Cheilitis Topical Therapy –Mainstay of therapy
l. Exaggerated palmar creases  Wet compresses for oozing lesions:
o Aluminum acetate 5% (Burow’s solution)
2. VASCULAR STIGMATA 20-30 minutes, 4-6 times daily
a. “Headlight sign” – perinasal or periorbital pallor  Topical corticosteroids (problems!)
b. White dermographism  Hydrating agents for dry skin:
 Blanching of the skin at the site of stroking o 10% urea in hydrophilic cream
with a blunt instrument o Eucerin cream
 Caused by local accumulation of edema  Tar preparations
which obscures color of underlying vessels  Macrolide immunomodulators:
o Tacrolimus 0.3% ointment
3. OPHTHALMOLOGIC ABNORMALITIES o Ascomycin macrolactam derivatives
a. Cataract – 10% of patients – anterior or (Pimecrolimus 1%)
posterior subcapsular  General principles on the use of topical steroids
b. Keratoconus – 1% in Atopic eczema:
c. Atopic keratoconjunctivitis o Provide symptomatic relief and safe in
4. SUSCEPTIBILITY TO INFECTIONS
the short term
a. Staphylococcus aureus
o Regular review of steroid use in terms of
b. Eczema herpeticum –herpes simplex 1 infection
potency and quantity
 Usually in young children
o Few days to 1 week in acute eczema
 Transmitted from a parent or a sibling with
cold sore or fever blister o Up to 4-6 weeks for induction of
 May have recurrences remission in chronic eczemas
c. Fungal infection: Tinea faciale o Constant education of parent/caregiver
d. Molluscum contagiosum on appropriate use
e. Verruca vulgaris o Potency should match the disease
severity and the affected site
Differential Diagnosis of Atopic Dermatitis - Weaker steroids: infants, face,
 Contact dermatitis (allergic and irritant) flexures
 Seborrheic dermatitis - Stronger steroids: palms and
 Scabies soles
 Psoriasis
 Ichthyosis vulgaris Systemic Therapy
 Keratosis pilaris  Antihistamines
 Dermatophytosis o Sedating; hydroxyzine, doxepin
 Antistaphylococcal antibiotics
Investigations o Penicillins, cephalosporins, erythromycin
 Skin prick test  Systemic corticosteroids
 Total IgE (RIST) o Side effects!
 Specific IgE (RAST) o Only for acute flare-ups
 Eosinophilia; blood, lesions  Phototherapy: PUVA, UVB
 Th2 cytokine profile; IL-4, IL-5, IL-13  Cyclosporine
 Reduced Th1 response ; interferon-g, DTH to contact o Side effects!
allergens o Expensive
 Interferon-g: Th1 promoter
Management of Atopic Dermatitis  Papaverine: PDE inhibitor
General Management in Infancy and Childhood  Evening Primrose oil: g-linolenic acid, PG
 To prevent precipitation of attack, AVOIDANCE of modulator
external irritation:
o Excessive bathing, vigorous rubbing or chafing
o Heavy, tight or soiled clothing
o Insufficient cleanliness in the diaper region
o Irritating, secretions
o Medicated baby oils
 PROTECTION of affected parts from Scratching
 EMOLLIENT SOAPS
 ANTIHISTAMINES with accompanying sedative effects
– esp at night to reduce pruritus Approach to a patient with atopic dermatitis
 DIETARY RESTRICTIONS – in cases where specific Patient presents with history of pruritic dermatitis
food allergies are implicated – elimination diet

General Management in Adults

Patient presents with history of pruritic dermatitis
 AVOID extremes of cold and heat
 AVOID overbathing (+) (-)
 USE of non-irritating emollient soaps
 AVOID dryness of skin: use EMOLLIENTS
Evaluate for
other conditions
 o Removal of scales and cerumen by
lavage
o Instillation of antibiotic-corticoid
preparations

Eyelid dermatitis
 Causes:
o Nail polish – one eye involvement
(upper eyelid)
General skin care measures o Atopic dermatitis – one or both eyes;
 Education
 Appropriate skin hydration and use of emollients/skin barrier upper and lower eyelid involvement
repair measures o Allergens like mascara, eye shadow,
 Avoidance of irritants eyelash cement, eyeliner, or rubber
 Identification and avoidance of proven allergens
 Anti-inflammatory therapy steroids, (topical calcineurin tipped instruments use to apply
inhibitors) cosmetics – lids of both eyes
 Antipruritic interventions (sedating antihistamines, behavioral o Hair dye, rinse, tint, lacquer and hair
modification) spray contact dermatitis – eyelids and
 Identification and treatment of complicating bacterial, viral, or
fungal infections other sites
(+) (-) o Volatile gases: insect sprays, lemon
peel oil, benzalkonium chloride,
Titration of topical therapy, using preservatives of rinsing solution for
emollients/barrier repair measures
topical steroids or topical calcineurin
contact lenses, plastics in spectacle
inhibitors as needed intermittently frames
 Many cases are caused by substances
transferred by hands to the eyelids
 Re-assess diagnosis of
AD Breast Eczema (Nipple Eczema)
 Consider role of  Sites affected: nipples, areolae, skin or the folds
unrecognized infectious agents,
beneath
allergens, etc
 Eczema of the nipples: moist type with oozing
 Consider poor
and crusting
(+)  Nursing mothers: painful fissuring
Successful outcome?  If persistent for >3 months, unilateral = biopsy is
mandatory to rule out Paget’s disease of the
(-) breast
 Differential diagnosis: circumscribed
 Consultation with AD
specialist
neurodermatitis, atopic dermatitis and contact
 Consider skin biopsy dermatitis
 Consider hospitalization  Treatment: topical/IL steroids
 Consider cyclosporine A,
Hand Eczema
ultraviolet therapy etc
 Diagnosis: complete history, careful examination
of the rest of the body surface and patch testing
 Usually have 2 causes: atopic diathesis +
contact dermatitis
 A major occupational problem
 A major cause of emotional and financial stress
ECZEMA  In health care workers: increases risk for
 From the Greek word eksein: to “boil down” or to infection by blood-borne pathogens
“effervesce”  Frequently the initial or only adult manifestation
 Baer described eczema as: a pruritic papulovesicular of atopic dermatitis
process which in its acute phase is associated with  Types:
erythema and edema and which in its chronic phase, 1. Irritant Hand Dermatitis
while retaining some of its papulovesicular nature, is o Seen in homemakers, bartenders, food
dominated by thickening, lichenification and scaling service workers and health workers –
 Recognized as a descriptive term and not a diagnosis results from or aggravated by excessive
 Unifies a group of disorders into a morphologic category and prolonged exposure to soaps or
that is clinically characteristic detergents and water (defatting action
 Pruritus is the most common and prominent symptom and maceration)
 The itch threshold is lowered by stress o Also in occupation with exposure to
chemicals, solvents, acids or alkali:
Ear Eczema or Otitis Externa custodians and metal workers
 Helix, postauricular fold, and external auditory canal o The impaired barrier ICD induced may
 External ear canal – frequent affected site enhance development of allergic
 Traumatization by rubbing, wiping, scratching and reactions
picking – induces edema and infection with inflammation o Eruptions starts as dryness and redness
 Frequent causes: Atopic dermatitis and seborrheic
of the fingers
dermatitis
o Tips of the fingers: dry scales with
 Contact dermatitis from neomycin, benzocaine and
peeling
preservatives may result from topical remedies
o Backs of the hands: chapping
 Causes of infection: Staph, Strep, Pseudomonas
 Earlobe dermatitis: nickel allergy in pierced ears o Palms: hardening with fissures
 Treatment: 2. Vesiculobullous Hand Eczema (Pompholyx,
o Removal of causative agents Dishydrosis)
 o Pompholyx or cheiropompholyx
- an uncommon disorder
- severe sudden outbreaks with long disease free
periods
- primary lesions: macroscopic, deep-seated
vesicles on the sides of the fingers, palms and
soles – coalescence lead to bulla formation
- eruption: symmetrical and pruritic
- patch testing: to rule out allergic contact
dermatitis
o Chronic vesiculobullous hand
eczema
- common and difficult to manage
- Sex: Female: Male – 3:1
- Vesicular eruption of the palms and soles
characterized by eczematous, weeping patches asteatotic eczema)
containing intraepidermal vesicles and by
burning or itching
- Bilateral and roughly symmetrical
- Cyclic with exacerbations and relapses and may
persist for long periods
3. Hyperkeratotic Dermatitis of the Palms
o Male: Female ratio – 2:1
o Age: older adults >45
o Hyperkeratotic, fissure prone infiltrated lesions of the
middle or proximal palm
o Volar surfaces of the fingers may also be involved
o Plantar lesions: 10% of patients
o Atopic dermatitis and allergic contactants are not
found
o Occasionally will develop to psoriasis
Treatment of Hand Eczema
 Wearing white cotton gloves under vinyl gloves
 Moisturizing: critical component of management
 Soaking in drying solution for acute vesicular disease:
potassium permanganate solution 1:5000, Burow’s
solution
 Superpotent and potent topical steroids are the initial
therapy – enhanced by occlusion
 Use of systemic steroids – dramatic improvement but not
safe for long term use
 Phototherapy – UVA or PUVA – have some success
Diaper (Napkin) Dermatitis
 A common cutaneous disorders – 7% to 35% on infants
in diapers
 Highest prevalence: between 6 and 12 months of age
 Also seen in elderly incontinent patients and children
and adults with urinary and fecal incontinence
 Erythematous and papulovesicular dermatitis distributed
over the lower abdomen, genitals, thighs and the convex
surfaces of the buttocks
 Folds remain unaffected – not in direct contact with
diaper
 Factors: moist skin is more easily abraded by friction of
the diaper
o Wet skin is more permeable to irritants such as
ammonia
o Skin wetness allows the growth of bacteria 
increase local pH  increase the activity of fecal
lipases and proteases (major irritants in feces)
 Candida albicans is a frequent secondary invader
ABCs in the Treatment of Diaper Dermatitis
 A = Air. The diaper should be left open as much as
possible when the infants sleeps to allow drying of the
skin
 B = Barrier ointments. Zinc oxide pastes, petrolatum,
and other bland, unmedicated barrier preparations are
mainstays of therapy. A continuous layer of barrier paste
or ointment should be maintained, reapplying with every
diaper change, if necessary. Baby powder on the diaper
area offers no antimicrobial benefit to the infant
and adds a risk of aspiration
 C = Cleansing and anti-candidal treatment.
Gentle cleansing with plain water, mineral oil, or
unscented gentle cleanser is recommended.
Avoidance of friction or rubbing is important. A
topical anti-candidal agent should be added for
any signs of candidiasis. Oral nystatin is
indicated if oral thrush is present.
 D = Diapers. Diapers should be changed as
frequently and as soon after soiling as possible,
especially if cloth diapers are used.
 E = Education of parents and caregivers
Xerotic Eczema (Winter itch, eczema craquele,
 Dehydrated skin showing redness, dry scaling
and fine crackling that may resemble crackled
porcelain or the fissures in the soil in the bed of
a dried lake or pond
 Favored sites; anterior shins, extensor arms and
flank
 Factors; elderly, wintertime, excessive bathing
 Management: Moisturizers, topical steroid
ointments for inflamed areas
Nummular Eczema (Nummular Neurodermatitis)
 Sites: lower legs, dorsa of the hands, extensors
of the arms
 Age: middle aged men – 60’s to 70’s
 Lesions: discrete, coin-shaped, erythematous,
edematous, vesicular and crusted patches 5-50
mm dm
 Manifests Koebner phenomenon
 Symptom: severe pruritus – paroxysmal,
compulsive quality and nocturnal timing
 Emotional stress maybe present
Management of Nummular Eczema
 Topical steroids in the mid- to high-potency
range are the mainstay of treatment
 The calcineurin inhibitors, tacrolimus and
pimecrolimus, and tar preparations are also
effective
 Emollients can be added adjunctively if there is
accompanying xerosis
 Oral antihistamines are useful if pruritus is
severe
 Oral antibiotics are indicated when secondary
infection is present
 For widespread involvement, phototherapy with
broad or narrow band ultraviolet B may be
benificial
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