Alange subset of nummular eczema may be related to allergic contact dermatitis. Retrospective studies of patch testing zesulls for patients with nummular ‘eczema found that 32.5% to 50% had at least one posi tive allergen of which 12% t0 67% were fle to be linically relevant!” Patients may develop num ‘ular éczemadike reactions to theit topical medi- caments2! Generalized. nummular eczema may be ‘caused by oral and/or topical exposures to allergens Microbial colonization and/or infection may play a role in nummular eczema. Nummlar eczema lesions have been repeatedly shown to be sterile How ever, patients with nurmular eczema may have higher rates of colonization with Staphulococcus aureus and methiilinesistant S. aureus in the nares and subun- gual space ® Extracutaneaus foci of infection, includ- {ng teeth, upper rspiratory tact and lower respiratory ‘tract, were found in 68% of patients in one study." A case series found that infections were present in 39% ‘of nummular eczema patien's, with dental caries and upper espicatory tract infections being most commen" However, na control groups were examined sn these studies, One study compared the frequency of infec- tions in patients with nummular eczema to a matched ‘r0up of patients with psoriasis and ehronic urticaria? Numimular eczema was associated with higher rates of dental abscesses and paradental diseases than psoas, but not with pulmonary o* nasal infections or elevated antisteptolysin titers’ In a series of 13 patients with generalized nummular eczema (without a history of Atopic eczema), the skin disease completely improved after aciontogenic infections were treated” Nummular eczema has been reported during ther apy with medications, including isotretinoin? go” combination therapy with interferon @2b and ribavi- Fin for hepatitis C,2 and infliximab,” Mereury amal- gam was implicated a eause of murnmular ez {seo patients.” Emotional stress may be a common ane! clinically relevant trigger of nummular eczema.” Ce rete CE) Woll-demarcated, coin-shaped plaques form from coalescing papules and papulovesicles. Often, studded Figure 23-1 Nummular eczema, Coin-shaped plaques with pinpoint erosions and excoriations. (Image from Division of Dermatology, University of the Witwatersrand Johannesburg, South Africa, with permission from Professor D. Modi.) ‘orsatellite papulovesicles appear atthe periphery of an expanding central plaque and should not be confused, swith the satellitosis present in fungal or yeast infec tions. Pinpoint oozing and crusting eventuate, and are distinctive (Pigs. 23-1 and 23-2), Crust may, howeves, cover the entire surface (Fig. 23-3) Plaques range from 1 to >3 em in size. The surrounding skin is generally Figure 23-2 Nummular eczema. Single plaque showing pinpoint erosions and crustingFigure 23-3 Nummular eczema in a child. Crusted plaques. (Used by permission of P. Lio, MD, Northwestern University’s Feinberg School of Medicine, Chicago, IL) normal, but may be xerotic and/or have asteatotic eczema lesions. Pruritus varies {com minimal o severe and may be worse in the evening and during periods of relaxation. Central resolution may occu, eacing to annular forms. Chronic plaques are dry, scaly, and lichenified. The classic distribution of lesions is the extensor aspects of the extremities, particularly the lower extremities" Onset of nummular eozema peaks in the winter and troughs in the summez”® |Nummular eczema is not consistently associated with atopy and serum IgE levels are not useful. Numunular ‘eczema lesions are sterile and lesional bacterial cultures are not indicated, unless there is suspicion fora superim= Posed infection. Antistreptolysin-O titers are not useful Sexe Patch testing is indicated in chronic recalcitrant cases to rule out underlying contact dermatitis. Previous studies found a variety of relevant positive allergens in patch testing, including nickel, chromates, and other Figure 23-4 Histopathology of nummular eczema, Para keratosis containing plasma and neutrophils (scale crust) and psoriasiform epidermal hyperplasia with spongiosis ‘are present, with a superficial dermal perivascular infitrate of lymphocytes, macrophages, and eosinophils. metals; rubber, fragrances, formaldehyde, and other preservatives commonly found in cosmetics and per sonal cate produets; neomycin and other topical med caments; and colophony.**" Skin biopsy ane histopathologic examination may be needed to rule out other clinical entities, such as autoimmune blistering disorders and cutaneous T-cell Iymphoma. Histopathologic changes are reflective of the stage at which the biopsy is performed. Acutely, there is. spongiosis, with or without spongiotic rmierovesicle. In subacute plaques, there is parakera- tosis, scale crust, epidermal hyperplasia, and spongio- sis of the epidermis (Fig. 23-1). There is a mixed cell infiltrate in the dermis. Chronic lesions may resemble lichen simplex chronicus microscopically. Piast PN ‘Table 25-1 outlines the differential diagnosis of num- mular eczema, TABLE 23-1 Differential Diagnosis of Nummular Eczema ‘Most Likely = Alaxge conte deematins = Stas dermats ‘ope dermatis = Thea corpons ‘Consider = impetigo = Psviss Gorgstanding plaques) Nyeoss fungoides longstanding plaques) Pagetelsease when thers ule inalement of rpcelvecle Butous pemphigcd Pemphigus vulgaris Other numular demmatore = Faeddhug eruption f Pryast run Aways Rule Out = Ties composCOMPLICATIONS Nummular eczema may be complicated by profound sleep disturbance owing to intense itch and secondary bacterial infection. PROGNOSIS AND CLINICAL COURSE Nummular eczema is associated with considerable quality-of-life impairment, particularly in more exten- sive disease."” Nummular eczema is often chronic, with either an intermittent or persistent course. One study found that nummular eczema persisted for up to 30 years, with a mean duration of 3.8 years; only 44% of patients were ever free of lesions.” Another study found that only 22% of nummular eczema patients were disease-free, 25% had some intermittent disease, and 53% were never free of lesions after 2 years of follow-up.” Recurrence at prior sites of involvement is, a feature of the disease.'° Ha Topical corticosteroids are the mainstay of treatment. Lesions are often refractory to mid-potency topical cor- ticosteroids and require superpotent topical corticoste- roids. Topical calcineurin inhibitors, such as tacrolimus and pimecrolimus, and tar preparations also may be effective. Emollients can be added adjunctively if there is accompanying xerosis. Home humidifiers may be useful for patients with winter flares; however, there is no evidence to support this recommendation. Oral sedat- ing antihistamines are useful to improve sleep when pruritus is severe. Oral antibiotics are indicated when secondary infection is present. For widespread involve- ment or lesions refractory to topical treatments, photo- therapy with broadband or narrowband ultraviolet B or systemic treatment with corticosteroids, cyclosporine, methotrexate™, and the like may be beneficial.2 ze a 0 of 4120 NUMMULAR ECZEMA Nummular eczema or discoid eczema is a morphologic term to describe coin-shaped plaques that may have multiple etiologies. The term was first coined by Dever- zien 1857.’ Nummularlesions are commonly observed in atopic dermatitis (AD), and may have a predilection for school-age children with AD and adult-onset AD.! A large proportion of patients with nummular ecaema have underlying allergic contact dermatitis. However, some use this term to describe a specific diagnosis, which excludes other common dermatoses presenting with nummular lesions.” The epidemiology ‘of nummular eczema is not well-defined, in part owing to the different definitions used in studies, Prevalence estimates for mummular eczema were found to be 1 to 2 per 1000 population in studies of the populations nummular eczema were less likely to have elevated immunoglobulin F (Ig) levels Similar to AD, nummmular eczema in elderly patients sociated with xerosis clinically and lower hydration of the stratum corneum, ‘mal inflammation occurring in nummular eezema was found to be predominated by TT cells with even higher T-cell counts compared to AD." However, in contrast AD, the water-barrier function of stratum comeum. in nummular eczema appears to be normal.” Nummu Tar eczema has been reported to be triggered by expo- sore to iitants=" and environmental factors! and mst commonly flares in the wintertime?" A role for environmental allergens, such as the house dust mite and Candida albicans bas also been touted Alarge subset of nummular eczema may be related to allergic contact dermatitis. Retrospective studies of patch testing results for patients with nummular eczema found that 32.5% to 50% had at least one posi- tive allergen, of which 12% to. 67% were felt to be clinically relevant" Patients may develop num- mular cczemalike reactions to their topical medi- ments Generalized nummular eczema may be caused by oral and /or topical exposures to allergens.” Microbial colonization and/or infection may play a role in nummular eczema, Nummular eczema lesions have been repeatedly shown to be sterile” How ever, patients with nummular eczema may have higher rates of colonization with Staphylococcus aureus and amethiillinresistant $. aureus in the nazes and subun- gual space2> Extraculaneous foci of infection, induel- ing teeth, upper respiratory tract, and lower respiratory tract, were found in 68% of patients in one study." A case series found that infections wene present in 393 ‘of nummular eczema patients, with dental caries and upper respiratory tract infections being most common.’ However, no control groups were examined in these studies. One study compared the frequency of infec- tions in patients with nummular eczema toa matched ‘group of patients with psoriasis and chronic urticaria.” Nummular eczema was associated with higher rates of Moreover, epidermal and der ETIOLOGY AND ‘The pathogenesis of nummular eczema appears to be multifactorial. Many of the proposed triggers of hummular eczema overlap with those of AD, includ: ing atopy, xerosis, exogenous insult by ircitants and/or allergens, microbiome, and infection, Num- ‘ular eczema does not appear to be consistently asso- ciated with atopy. Most studies found low or normal rates of personal (1.5% to 11%) and or family history of atopy (25% to 15%). However, a Thai study found high rates of personal (60%) and/or family history of y (38%). One study found that patients with Figure 23-1 Nummular eczema. Coin-shaped pag with pinpoint erosions and excoriations. (Image ftom Division of Dermatology, University of the Witwatersrand Johannesburg, South Atica, with permission, from Professor D. Mod, or satellite papulovesicles appear at the periphery ofan expanding central plague and should not be confused with the satellitosis present in fungal or yeast infec- tions. Pinpoint oozing and crusting eventuate, and are distinctive (Figs. 23-1 and 23-2), Crust may, however, dental abscesses and parad SET eee OCTET ce (Fig. 25-3). Plaques range from