Eczema (Dermatitis)

Eczema is a common inflammatory skin disease. It is an epidermal reaction to

specific injurious agents; these agents may be internal or external, acting
singularly or in combination Dermatitis & eczema are usually used
interchangeably as both conditions have similar clinical & histopathological
pictures.
Stages of eczematous inflammation:
1- Acute stage: There are numerous vesicles, sometime blister on a background
of intense erythema, edema, weeping and oozing associated with sever itching
& may lead to secondary bacterial infection with accumulation of crust &
purulent material.
Rx: Wet compression, topical steroid, antihistamine & antibiotic.
2- Subacute stage: There are erythematous lesions with fissuring & scalded
appearance, itching is slight to moderate.
Rx: Topical steroids, antihistamine, antibiotic & lubricants.
3- Chronic stage: There are thickening & lichenification of skin with
excoriation & fissure, itching is moderate to intense.
Rx: Topical steroids with occlusion, lubricants, intralesional steroid &
antihistamine.
Classification
Dermatitis can be divided into exogenous & endogenous types each one can
pass into acute, subacute or chronic.
1- Exogenous eczema: When the eczematous condition is caused by external or
exogenous factors or substances. Those substances act as irritant (irritant
dermatitis) or allergen (allergic dermatitis), other factors infective dermatitis,
photodermatitis.
2- Endogenous eczema: The eczematous conditions are mediated by processes
originating within the body, those include atopic dtt, seborrheic dtt, stasis
eczema, nummular eczema, pompholyx, neurodermatitis, pityriasis alba,
asteototic eczema, discoid eczema.
Irritant contact dermatitis
It is the most common type of contact dermatitis, the irritant is any physical or
chemical agents that capable of producing epidermal cell barrier damage if
applied for sufficient time or concentration & causing non immunological
eczematous inflammation e.g. irritant house wife hand dtt. From detergents, lip
licking dtt from saliva, diaper dtt from urine fecal enzyme.
Allergic contact dermatitis
It is a delayed type hypersensitivity reaction that affects a limited number of
individuals after one or few exposure to an allergic substance (an
immunological aspect is present), it had 2 phases:
1- The sensitization (induction) phase: in which a hapton (a low molecular wt
substance) penetrates into the epidermis & combined with an epidermal protein
to form an antigen & this binding take place either on or near the langerhan's
cells. The langerhan's cells are met by macrophages & T cells in the epidermis
& an initial process take place & a message is directed to T cell precursor in the
lymph node & so a sensitized T cells are formed. This phase takes 14-21 days.
2- The elicitation phase: which occur when there is a re-exposure to the same
hapton-protein complex leading to release lymphokines which recruit
inflammatory cells & causing an eczematous inflammation. This phase take 12-
48 hours e.g. shoe dermatitis in feet & cosmetic dermatitis in face.
Atopic dermatitis (AD)
The term atopy designates a group of patients who had personal or family
history of one or combination of hay fever, asthma, dry skin & eczema. AD is
an eczematous eruption that is itchy, recurrent & symmetrical.
Pathogenesis of AD
 1- Genetic factor: The pattern of inheritance is unknown but it may be
polygenic, 70% of patient with AD have positive family history of atopy.
2- Immunological abnormality: a- ↑ IgE level b- blood eosinophilia c- T
cell defect result in high incidence of infection d- excessive release of
histamine & other inflammatory mediators from mast cells &
eosinophiles.
3- Biochemical epidermal cell defect : Abnormality in essential skin binding
lipids especially leinolic & leinolinic acids.
4- Environmental factors: Emotional stress, seasonal variation, excessive
washing, infection, allergenic food can be initiate or exacerbate AD.
Diagnosis of AD
3 minor + 3 major
Major criteria
- Pruritus
- Personal or family history of atopy
- Typical morphology & distribution
- Chronic dermatitis
Minor criteria
- Xerosis
- Keratosis pilaris
- Recurrent conjunctivitis
- Irritant hand dermatitis
- ↑ IgE level
- Cutaneous infection
- Ichthyosis
- White dermographism
- Orbital darkening
- Palmar hyperlinearity
- Anterior subcapsular cataract
- Infraorbital skin folds (Dennie-Morgan lines)
AD is divided into 3 phases
1- Infantile phase (from birth to 2 yr): It affect mainly the face especially the
checks, scalp & may extend to involve other area of the body mostly the
extensor part. The lesion consists of discrete or confluent oedematous papules
which are intensely itchy so that they become exudative & crusted. Secondary
infection is common. The disease usually resolves in 50% of infants by the 18
months of age, others may progress to 2ed phase
2- Childhood phase (2-12 yr): The flexor surface is typically involved ( neck,
wrist, ankles, antecubital fossa). The lesions are dry, scaly, and erythematous
with lichenfication.
3- Adult phase (12yr to adult): This phase begins near the onset of puberty &
may persist for life. It affects the flexor surface & dorsal aspects of the hands
around the eyes. The lesion is itchy with lichenfication (thickening &
pigmentation of skin).
Bad prognostic sign
1- Persistence into adult life
2- Wide spread dtt in childhood
3- Family history of AD
4- Female sex
5- Associated bronchial asthma or allergic rhinitis
6- Early age of onset.
Associated disorders
Ichthyosis vulgaris, ↑ dryness (xerosis), food & drug allergy, alopecia, ↑
incidence of asthma & allergic rhinitis, urticarira, ↑ incidence of staph, herpes &
molluscum contagiosum infections. Growth retardation
Treatment
1- Reassurance of patient.
2- Avoidance of trigger factors (clothes, temp, soap, food).
3- Topical steroid, skin emollient & tar.
4- Oral & topical antibiotic for secondary infection.
5- Antihistamine.
6- In sever resistant & generalized cases may need hospitalization, systemic
steroid, PUVA & oral cyclosporine.
Seborrheic dermatitis
It is a common chronic superficial inflammatory disease with characteristic
pattern for different age groups. It present in about 2-5% of general population.
Pathogenesis
1- The yeast pityrosporum ovale probably is the causative factor which
aggravates or triggers the condition.
2- Genetic & environmental factors seem to influence the onset & course of the
disease.
3- Androgen may have a role in pathogenesis.
4- Seb dtt can follow Parkinson's disease.
5- AIDS can also present with SD which may be extensive.
C/F: The disease usually undergoes periods of relapse & remission especially in
adults. many clinical pattern of SD are present there are:
1- Infantile SD
Appear in the first few weeks of life & regresses gradually later. It appears as
greasy adherent scales on the vertex of the scalp (cradle cap), face & trunk.
Flexural area could be involved such as axilla, napkin's area which could be
complicated by super added candidiasis.
2- Adult SD
Appear at time of puberty or years later, it affect the seborrheic area (rich in
sebaceous glands but hypersecretion of sebum is not present) like scalp present
as either with dry fine white scales or with an inflammatory erythematous
greasy yellowish scales, eyebrow, eyelashes (seb blepheritis), nasolabial fold,
forehead, presternal, upper back, retroauricular area, interscapular area, axilla &
groin. One or more of these areas are usually affected or it can be generalize &
may progress to erythroderma.
DDx
Psoriasis, lichen simplex chronicus, AD, PR, fungal infection, PV &drug
eruption.

Rx
1- Frequent washing of the affected area.
2- Topical steroid & antifungal combination.
3- Antiseborrheic shampoo like selenium sulphide, ketoconazol shampoo,
zinc pyrethium & tar preparation.
4- For generalize & resistant cases; systemic corticosteroid, oral antifungal
or UVB phototherapy.
Pityriasis alba
It is a low-grade type of eczema common in children and adolescents aged bet.
3 to 16 years. Characterized by erythematous or hypopigmented patch with fine
scale, common site are face, neck, & upper arm. It often coexists with dry skin
and atopic dermatitis, excessive bathing & ultraviolet radiation. It is more
obvious in summer when the area dose not tanxb.
DDx: vitiligo, TV.
Discoid eczema
Coin shape erythematous plaque of unknown etiology mostly appears on the
extremities, back of the hand & feet. Itching is moderate to sever, individual
lesion tend to remain & recurred at previously involved area.
Rx: emollient, Antihistamine & steroid.
Lichen simplex chronicus (neurodermatitis)
It is a localized plaque of chronic eczematous inflammation that created by
habitual rubbing & scratching due to emotional & other factor. It appear at the
site that are easily reached by the patient like wrist, ankles, elbow, back of the
neck, scrotum, vulva & perianal area. Clinically it appears as well demarcated
lichenfied pigmented lesion.
Pompholyx
Symmetrical vesicular eruption of the hand & foot with moderate to sever
itching. The vesicles resolve slowly within 3 weeks by scaling.
Stasis dermatitis (Gravitational eczema)
It is eczematous eruption that occurs on the lower leg in some patient with
venous insufficiency. Clinically there is dilatation & varicosity of superficial
vein, edema, purpra, diffuse brown pigmentation, ulceration & small patch of
atrophy.