Chapter 5 Flashcards
Diagnosis?
Keratosis Punctata
- Almost exclusive to AA patients
- MC in atopic patients
Diagnosis?
Dennie Morgan Folds
- Helpful clinical sign that is indicative of atopic history (Can be seen with ANY CHRONIC lower eyelid dermatitis)
- Other helpful signs: Allergic Shiners and Prominent nasal crease
Major Criteria for Atopic Derm
(Must have 3 of following:)
- Pruritus
- Typical morphology and distribution
- Chronic or chronic relapsing dermatitis
- Personal or FHx of Atopic disease (Asthma, rhinitis, atopic derm)
Hertoghe’s Sign
Thinning of lateral eyebrows seen in AD
-Due to chronic rubbing cause by pruritus and subclinical dermatitis
Name the vascular signs and/or disorders assoc to AD
- Headlight sign: Perioral, perinasal, and periorbital pallor
- White dermatographism
- Increased risk of various forms of urticaria (including contact urticaria)–usually followed by typical eczematous lesions at the affected site
What are the associated opthalmologic abnormalities in AD patients?
- Anterior and/or posterior subcapsular cataracts (10%)
- Keratoconus (1%)
How to treat infection in AD patients?
*Key is to REDUCE nasal staph carriage and keep skin decolonized
- Bleach baths: 1/4 c 6% bleach in 20 gallons of H20
- Intranasal Mupiricion
6 year old patient with history of AD comes into office complaining of worsening eczema. Pt has been seen in office 8 times in last 2.5 years for similar complaint. Lesions appear crusted and weepy on exam. What should be considered?
Pt clearly has exacerbation due to staph colonization/infection–treat with systemic or topical antibiotics based on BSA involved; start bleach baths and intranasal mupiricion
Because she has repeated history of exacerbations–MUST CONSIDER that household contacts could be staph carriers (including pets)–need to ID and treat aggressively
In 80% of families, at least 1 parent is carrying the same staph strain as a colonized AD child
54 year old female with recurrent exacerbations of AD treated with systemic steroids in teh past comes in to office. What are important considerations in this patient?
OSTEOPOROSIS with prolonged steroid use (especially in at risk patients)
- If must start patient on steroids: Treat early with bisphosphonates (since bone loss is greatest in begining of treatment), Vit D supplements, Calcium supplements, regular exercise, and smoking cessation
- Consider DEXA scan
Cyclosporine use in AD and dosing
-Best for gaining rapid control of severe AD, affects do not last long after d/c
Kids: 3-5mg/kg
Adults: 150-300 mg in adults
* Better & more rapid response at higher end of dose range
Mgmt of acute AD flare
- Look for initiating source: Stress, staph, HSV, coxsackie, P. Rosea, contact sensitivity to meds, or photosensitivity
- Treat trigger/stressor
- Short course of steroids
- “Home Hospitalization”: Go home and get away from stressors, large doses of sedating antihistamines at night, soak BID and apply steroid under wet PJ and sauna suit (3-4 days of this treatment can break severe flare)
Diagnosis and Treatment
Chronic Otitis Externa (Ear Eczema)
Treatment:
- Remove possible causative agents (i.e. applied topical allergens)
- Examine EAC with otoscope
- If TM intact–remove scale and cerumen with gentle lavage, RX Ciprodex
- If no signs of infection can Rx otic steroid alone
- If weepy lesions Rx Domeboro
Common causes of Chronic Ear Eczema
- Seb Derm
- ACD due to Neomycin
- Metal Contact to Nickel (if ear lobes affected)
Cause of Malignant OE
Pseudomonas infection (will have ulceration and sepsis)
-MC in DM
Possible Diagnosis for Ear Eczema with perforated TM
Infectious Eczematoid Dermatitis (the purulent drainage is the source of the eczema)
-Consult Otolaryngoloist
Common causes of nipple eczema
- Atopic dermatitis (May be sole manifestation of AD in adult women)
- ACD (if baby just started eating solid food–mom could have food allergy, allergy to topical protective creams)
- Secondary infection (consider in breastfeeding women) **candida
- ICD (Jogger’s Nipples due to friction, poorly fitting bras)
45 year old female presents with 3.5 months of continuing nipple eczema despite treatment with steroids.
What should be considered?
Biopsy to R/O Paget’s Inflammatory Carcinoma
Diagnosis?
Nevoid Hyperkeratosis of the Nipples
- Can mimic eczema
- Chronic condition that does not respond to steroids
Presentation of candidal infection of areola
Can appear as normal skin, erythematous skin, or an acute or chronic eczema
- Area of the areola immediately adj to nipple is usually involved (+/- fine cracks)
- Pt c/o severe pain especially with nursing
Treatment of Candidal infection of areola
- Analgesia may be required due to severe pain
- Breastfeeding may need to be suspended–pump only
- Use of silicone nipple shield
- Culture infant for thrush (Even if asymptomatic and normal exam–Positive cx from infant in setting of nipple eczema warrants txt of mother and infant)
- Oral Fluconazole/Topical Gentian Violet 0.5% applied QD x 1 week/All purpose nipple ointment
Causes of candidal infection of breast
- Oral thrush in infant
- Abx use
- PHx of vaginal candida infection
- Poor position during breastfeeding is common cofactor in development (lactation consult)
Risk Factors for persistent hand eczema
- associated eczema at other sites at presenation
- childhood hx of AD (even respiratory atopy)
- onset < 20 years old
Diagnosis?
Vesiculobullous Hand Eczema (Pompholyx, Dishydrosis)
Diagnosis?
Pulpitis (Fingertip hand dermatitis)
- Hyperkeratotic and fissuring eczema that primarily effects the fingertips (may extend to merge with eczema of the palm)
- Vesicles can occur
- 3 fingers of dominant hand–think ICD/ACD
- Nondominant hand think vegetables and other items realted to food prep
What organisms cause secondary infection in diaper dermatitis?
- Staph aureus
- Group A Beta hemolytic strep (Pyogenes)
- Candida albicans
Describe and Diagnose
Irritant Contact Diaper Dermatitis
-Erythematous dermatitis limited to exposed surfaces
*Skin fold unaffected
Describe and Diagnose
Candida Diaper Derm
-Satelite erythematous lesions and pustules (beefy red)
Diagnose
Napkin psoriasis
- MC in 2-8 months
- Sharply demarcated borders
- Inc risk of psoriasis later in life
Diagnose
Jacquet Erosive Diaper Derm
-On spectrum of irritant contact diaper derm–superficial erosions
Diagnose
Granuloma Gluteal Infantum
-on irritant dermatitis spectrum
violaceous plaques and nodules
Treatment for Diaper Dermatitis
- Refractory cases may need biopsy
- # 1 is prevention: Absorbent gel diapers prevent wetness and buffer pH to decrease risk of Candida infection
- Frequent changes: 2hr for newborns, 3-4 hrs for infants
- Barrier Protection: Zinc oxide paste or petrolatum
- If candida infection: Zinc oxide paste with 0.25% miconazole
- Nystatin ointment + 1% Hydrocortisone ointment
What is conditioned irritability?
WHen patient with chronic localized dermatitis develops dermatitis at a distant site due to scratching or irriatating the skin
MC scenario: distant derm in patient with chronic leg ulcer
Autosensitization (Autoeczematization)
Spontaneous development of widespread dermatitis or dermatitis distant from a local inflammatory focus
-agent causing the local inflammatory focus IS NOT the cause of the distant dermatitis
MC presents as: generalized acute vesicular eruption with a prominent dyshidrosiform component on the hands with MC associated condition being a chronic eczema of the legs, with or without ulceration
What is infectious eczematoid dermatitis?
A local dermatitis that develops around infection foci
(Likely a form of autosensitization)
Pt presents with new onset of itchy and bumpy hands. On exam, patient has diffuse erythematous pruritic patches and vesicles on bilateral hands. Pt later asks you to examine his feet and you find, diffuse scaling on soles with multiple fissures between the digits. What should you include in your ddx?
Id Reaction: Infectious disorder/infestation that presents with an eczematous dermatitis
Examples
- Vesicular id rxn of hands in response to inflammatory tinea pedis
- Focal or diffuse dermatitis of upper half of body with tinea capitis
- Nummular eczematous lesions or P. rosea like lesions in patient with head/pubic louse
Treatment for dermatitis associated with id reaction
Treat the infection/infestation
+/- oral or systemic anti-inflammatory agts until triggering infection is eradicated
Diagnosis
Juvenile Plantar Dermatosis
5 year old pt with PMHx of atopic derm presents with red scaling patches involving the weight bearing and frictional areas of both feet. His mom states she noticed smooth red spots on the bottom of each big toe before the rash expanded.
You notice on exam that the toe webs and arches are spared.
What is the diagnosis?
Juvenile plantar dermatosis
- MC in atopic children
- MC in 3 years-puberty
- Forefoot much more involved than heel
Cause of Juvenile Plantar Dermatosis
- Maceration due to occlusive shoes and thin nonabsorbent socks
- Abrasive effects of pool surfaces/diving boards
- ACD–Refractory cases suggests ACD
Diagnosis?
Describe primary lesion
Xerotic Eczema/Eczema craquele/Asteatotic
Primary lesion: Erythematous patch with adherent scale
Pathophysiology/Cause of Xerotic Eczema
- Low humidity
- Hot water and harsh soaps
- Epidermal water barrier is impaired, TEWL increased
- Epidermal barrier repair begins to decrease after 55, correlated with increased epidermal pH
- Loss of barrier repair is improved by acidifying the epidermis, hence mild acids are used to treat xerosis - Heterozygous null mutation of FLG associated with xerosis in young (18-40) and old (60-75)
Treatment for asteotic/xerotic eczema
- Short tepid showers + limit use of soap to necessary areas
- Avoid harsh soaps and acid pH synthetic detergents
- Apply emolliant after bathing (White petrolatum containing 10% urea or 5% lactic acid)
- For inflamed areas-Topical steroids in ointment
Treatment of Nummular Eczema
- Soaking and greasing with occlusive ointment + QD/BID potent or superpotent steroid (ointment>cream)
- +/- Antibiotic with staph coverage (frequently colonized with s. aureus)
- Stop drinking (alcohol consumption has been associated with condition)
- For pruritus: Antihistamine, Doxepin, or Gabapentin
- Refractory Cases: Intralesional or systemic steroids
- Phototherapy (NBUVB, soak/oral PUVA)
- Refractory plaques: Topical tar (2% crude coal tar or 20% LCD)
Patient presents to office with c/o severely itchy rash on lower legs, the rash itches intermittently and more at night. On exam there is a single 3 cm coin-shaped erythematous and crusted patch.
PMHx: none
FHx: none
SHx: Drinks 6-7 beers per day
What is your diagnosis?
Nummular eczema
Diagnosis?
Nummular Eczema
FYI: Lesions are frequently colonized with staph aureus
Typical locations: lower legs, dorsal hands, extensor surfaces of arms
Common medications that cause pruritus in the elderly
Calcium Channel Blockers (-ipine, Diltiazem, Verapamil)
Hydrochlorothiazide
Diagnosis?
Keratosis pilaris rubra faceii
Presentation of acute stage eczema vs. subacute
Acute: Red edematous plaque that may have grossly visible, small, grouped vesicles
Subacute: Erythematous plaques with scale/crust
Presentation of late stage eczema
Lesions covered by drier scale or lichenified
Treatments for eyelid dermatitis
- topical steroids
- petrolatum based emollients
- transition to TCI (usually dont tolerate initially) to reduce long term ocular SE of steroids
- if assoc conjuncitivits OR failed txt–ocular cyclosporine emulsion (Restasis)
- Cromolyn sodium opthalmic drops can stabalize mast cells and reduce itch
Factors that increase risk of AD during first 6 months of life
- AA or Asian
- Male
- greater gestational age at birth
- Fx of atopy (esp maternal hx of eczema)
Factors that increase risk of developing AD due to alteration of intestinal microbiome
- Western diet
- Birth order (1st born)
- Csect delivery
**specifically gut colonization with clostridium 1
Presentation of Autoimmune progesterone dermatitis
MC is urticarial or erythema multiforme like lesions
- Appear 5-7 prior to menses and improve/resolve a few days following menses
- may worsen or clear during pregnancy
Treatment of autoimmune progesterone
- OCP to suppress ovulation
- Topical steroids for eczematous cases
- Antihistamines if urticarial
- Conjugated estrogen to suppress progesterone
- GnRH (Leuprolide, Danazol, and Tamoxifen)
- Menopause and oophorectomy have been curative
Presentation of autoimmune estrogen dermatitis
cyclical skin d/o that may appear eczematous, papular, bullous, or urticarial (so this is not helpful…)
Exacerbated premenstrually or occur only immedietly prior to menses
Characteristically clears during pregnancy and at menopause
TXT WITH TAMOXIFEN (MAYBE)
