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DERMATITIS -Eczema

Dr. Citra Cahyarini, SpKK



Department of dermatovenereology
Faculty of medicine YARSI University
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 unidentified
constitutional abnormalities, while others are more
obviously the result of some external set of circumstance

Constitutional : eg Atopic dermatitis

External : eg Contact dermatitis
Eflorescense of Dermatitis-Eczema
Erythem
Papule
Vesicle
Pustule
Oozing
Crust
Squama
Several types of Derm- ecz

Atopic dermatitis
Contact dermatitis
Seborrhoic dermatitis
Statis dermatitis
Neurodermatitis
Nummular eczema
Dishidrosis
Infective Eczematoid Dermatitis
Atopic dermatitis/ Eczema
Def :
Acute, subacute, or chronic relapsing skin
disorder that usually begins in infancy and is
characterized principally by dry skin and
pruritus.
Often associated with personal or family
history of atopy such as allergic rhinitis,
asthma, and atopic dermatitis (AD)
A.D may 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
Infantile
Usually begins as an itchy erythema of cheeks followed
by development of vesicle, rupture and produce moist
crusted areas

The eruptions may rapidly extend to other parts of the
body, chiefly the scalp, the neck, the forehead, the wrist
and the extremities

The buttocks and diaper area are often involved

The eruption may become generalized with erythroderma
Infantil AD
Childhood AD
The lesion to be less exudative, drier, and more papular

The classic locations are the antecubital, and the popliteal
spaces, 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 nonigested
substances, particulary wool, cat hair, dog hair, and pollens
Childhood AD
Adolescent and adult AD
Usually the eruption involves the antecubital and popliteal
fossae, the front and sides of the neck, the forehead and
the are about the eyes
Hands dermatitis occurs more frequently in atopic
individuals, and eczematous lessions of the dorsum are
usual
Pruritus : paroxysm, nocturnal, triggered by acute emotional
stress
Trigger factors : rough clothing, wool irritation, foods or
tension.
Adolescent and Adult AD
Associated features
Cutaneous stigmata : Dennie-Morgan fold, Keratosis pilaris,
and Hertoghes sign
Vascular stigmata : White dermographism
Personality traits : Nervous tension
Ophthamologic abnormalities : cataracts, keratoconus.
Susceptibility to infection :
S.aureus, generalized Herpes simplex or vaccinia virus
infections to produce Kaposis varicelliform eruption

Immunology : elevated serum IgE, decreased T-supressor
cells, decreased chemotaxis and activations of PMN
leucocyte.
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 dermatitis
4. Personal or family history of atopic diseases (asthma, allergic
rhinitis, AD)
Minor criteria :
1. Xerosis / ichthyosis/ hyperlinear palms
2. Pityriasis alba
3. Keratosis pilaris
4. Facial pallor / infraorbital darkening
5. Elevated serum IgE
6. Keratoconus
7. Tendency to non spesific hand eczema
8. Tendency to repeat cutaneous infections
Differential diagnosis

Nummular Dermatitis
Seborrhoic Dermatitis
Contact Dermatitis
Psoriasis
Scabies
General management
1. In infancy and childhood
a. It should be avoided :
External irritation
Sudden change of temperature, excessive
bathing, insufficient cleanless especially in the
diaper region, local infections

b. Food elimination ( with special attention)

b. Antihistamin systemically

c. Olive oil on absorbent cotton may used with
gentle patting for cleansing to avoide rubbing the
affected patrs. Particular attention should be given
the genitals and buttocks and the diapers should
be changed

d. Weak topical corticosteroid.
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)
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 ( Irritant
CD) or an allergen (allergic CD)
It may be affected by exposure to UV-light, resulting
into two variant reaction : Photoallergic & Phototoxic
CD
Allergic Contact Dermatitis (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

Symptom : intense pruritus

Physical exam
acute : erythema & edema
subacute : plaques of mild erythema,
dry scales
chronic : plaque of lichenification

Lab : patch test (+)

PATCH TEST
Irritant Contact Dermatitis
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 damage
result from direct chemical action

Irritants:
strong irritant severe inflamation at the first
contact
Weak irritants: less toxic substances which require
repeated or prolinged contact to
cause inflamation (detergent, organic
solvents, excessive exposure to water)

Incidence:
The incidence of cases of ICD (each type)
depending mainly on the degree of exposure and
the causative agent
In patients with atopic dermatitis there is a
relatively high incidence of ICD

acute ICD
Symptom :
- subjective : burning, stinging, smarting

Physical exam :
- < 24 h
- erythema vesiculation

* acute : sharply demarcated erythema &
superficial edema

vesicles/ blisters
chronic ICD
Cumulative ICD: slowly after repeated additive
exposure to mild irritan

Symptom : stinging & itching, fissure pain

Physical exam :
dryness chapping erythema-
hyperkeratosis & scaling fissure &
crusting

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
Contact Dermatitis
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
Infantil form Seborrhoeic Dermatitis
Cradle Cap
* 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 in
early morning
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
Adult form Seborrhoeic Dermatitis
Stasis dermatitis
dermatitis on the lower legs, commonly seen in association
with venous insufficiency
many cases seen in obese, female patients have a degree of
venous insufficiency
inner aspects of boths lower legs above and around the medial
malleous are chiefly involved
the skin is shinny, atrophic and large numbers of small blood
vessels clearly visible, purpura, pigmentation (due to
haemosiderin)
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
Stasis Dermatitis
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)
Neurodermatitis
Dishydrotic
(eczema dishydrosticum)

a very characteristic pattern of intensely itchy vesicles
of the skin of the hands and occasionally the feet and
also 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 need
to scratch) prevent secondary infection, potent
topical steroid ( a short time) ; for the moist lesion
calamine lot.
Dishydrotic
Nummular or Discoid dermatitis
a chronic, recurrent pattern of dermatitis with discrete
coin-shape lesions tending to to involve the limbs
Usually affects adults (many of whom will have a past
history of AD) ; The aetiology is unknown
Clinically : subacute with erythema, edema,
vesiculation; the surface may be moist and appear
infected bacterial eczema
Pruritus is variable
Treatment : topical steroid + antibiotic
Nummular or Discoid Dermatitis
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
Clinical appearances :
Erythema & exudation
In a dry state, there is crust. If crust is peeled, we would
see erythema & often pustules on the edges
Examples :
The earlobes of children suffering from OMP.
The area around the nose of maxilaris sinusitis sufferers

Therapy :
Rivanol 1/1000, Betadine dressing
When cleared Hidrocortisone 1 % or combination with
antibiotic
Infective Eczematoid Dermatitis
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
Therapy
Antihistamin : H1, H1 + H2
Systemic corticosteroid
Adrenalin inj subcutis/ ephedrin tab

urticaria
angioedema
Vasculitis
A heterogeneous group of clinical synd
characterized by inflammation of blood vessels
The clinical picture is essensially dependent of size
and extent of vessel involvement purpura
Test : diaskopi

Therapy
Systemic corticosteroid
CC, Sept- 2007