Eczema Flashcards
A strong genetic link with which gene is associated with atopic eczema? [2]
Fillagrin
- Filaggrin is a protein present in normal epidermis. Following processing from its precursor protein, profilaggrin, it binds and condenses the keratin cytoskeleton - therefore is important in skin barrier formation
SPINK-5
- involved with the regulation of desquamation within the epidermis
Mutations in which of the following genes are associated with atopic eczema?
Select all the correct options from the list below, then Submit.
Possible answers:
A. Filaggrin
B. SPINK5 – serine protease inhibitor
C. IL-4
D. IL-4R
E. IL-13
F. Mast cell chymase (CMA1)
All of them
Evidence suggests that [] cells are responsible for the development of acute lesions, but that [] cells and their cytokines predominate in older lesions.
Which group of drugs uses the above mechanisms to act as a treatment? [1]
Evidence suggests that Th2 cells are responsible for the development of acute lesions, but that Th1 cells and their cytokines predominate in older lesions.
Therefore:
- Ciclosporin and topical calcineurin inhibitors are effective treatments in the management of allergy related eczema flares as both work via the inhibition of T cell activation.
Roughly what proportion of individuals with atopic eczema have a raised total IgE?
Possible answers:
A. None
B. 40%
C. 80%
D. 100%
C. 80%
Should individuals with severe atopic eczema be advised to undertake a trial of house dust mite avoidance? [1]
Yes.
A role of house dust mites in the provocation of atopic eczema has been shown by the application of Der p1 to the skin of affected individuals (atopy patch test). In 30-40% of patients with atopic eczema, eczematous lesions indistinguishable from typical lesions developed.
Patients with atopic eczema are particularly susceptible to a number of cutaneous infections, of which [] is the most common
Patients with atopic eczema are particularly susceptible to a number of cutaneous infections, of which Staphylococcus aureus is the most common
Studies have shown that [] and [] clothing are associated with a worsening of atopic eczema in affected children, with the worsening being more apparent in covered sites.
Studies have shown that nylon and wool clothing are associated with a worsening of atopic eczema in affected children, with the worsening being more apparent in covered sites.
Describe the clinical features of eczema in adults
Pruritis
- Always occurs; can lead to sleep disturbance and reducing QoL
Erythema (due to increased cutaneous blood flow due to release of histamines)
Skin lesions
Which diagnostic factors / characterisitic features are associated with acute [3] subacute [1] and chronic [3] flares of eczema?
Acute:
- Scaling
- Vesicles
- Papules
Subacute:
- Represent an intermediate stage where acute lesions begin to resolve; characterized by erythematous scaling plaques with possible crusting.acacu
Chronic:
- Lichenification
- Hyperpigmentation or hypopigmentation
- Fissures
Name and describe this secondary condition associated with eczema [2]
Lichen Simplex Chronicus
- secondary to chronic scratching or rubbing in response to pruritus
- well-demarcated plaques with lichenification, hyperpigmentation, and scaling.
Name and describe this secondary condition associated with eczema [2]
Prurigo nodularis:
- Chronic skin condition characterised by very itchy firm lumps
- Characterized by multiple firm, itchy nodules that result from repeated scratching or picking at eczematous lesions.
PN can occur at any age but is more common in the elderly. When PN occurs in younger patients, it is more likely to be associated with inflammatory skin diseases, usually eczema (also called atopic dermatitis).
Describe the characteristics needed for a diagnosis of eczema
An itchy skin condition in the last 12 months
Plus three or more of
* Onset below age 2 years’
* History of flexural involvement’’
* History of generally dry skin
* Personal history of other atopic disease’’’
* Visible flexural dermatitis
‘not used in children under 4 years
‘‘or dermatitis on the cheeks and/or extensor areas in children aged 18 months or under
‘'’In children aged under 4 years, history of atopic disease in a first degree relative may be included
Describe the treatment regime for an acute flare of atopic dermatitis / eczema [6]
- Emollients (warn patients about fire hazard risk)
- Consider topical steroid cream / ointment. Start on low to medium potency and go up
- Consider topical calcineurin inhibitor; tacrolimus; pimecrolimus. Useful for long term tx of pruritis without giving steroids for long time
- Consider Phototherapy: Narrow Band UVB (NB-UVB) small part of the UVB light spectrum is used to tx; where UVA radiation is combined with a chemical called psoralen that increases the effect of UVA on the skin). PUVA (UVA + psoralen)
- Systemic therapies: methotrexate (1x week medication, given with folic acid); ciclosporin (shorter time for treatment to work; can only use for 1 or 2 years before moving to biologics
- Biologics: JAK inhibitors - Baricitinib, Upadacitinib; IL-13/4 – Dupilumab, Tralokinumab.
What are the common side effects of topical calcineurin inhibitors? [4]
About 50% of patients develop some local skin irritation or a burning or itching sensation when these treatments are started, particularly with tacrolimus ointment.
Small increased risk of developing cold sores (herpes simplex infection) on the treated skin during the first few weeks of treatment.
Due to suppressesion of the immune system, one possible consequence of immune suppression is an increased risk of non-melanoma skin cancer and lymphoma.
Gingival hyperplasia
Why can calcineurin inhibitors be useful on the face and neck and in the folds of the skin, particularly if the atopic eczema is very persistent at these sites? [1]
Topical calcineurin inhibitors do NOT cause skin thinning or stretch marks or some of other side-effects associated with using strong topical corticosteroids for a long period
Describe two bedside monitoring needs to be used when giving calcineurin inhibitors [2]
BP - know to cause hypertension (caused by ciclosporin vasoconstriction and salt retention)
Urine dipstick - has nephrotoxic effects
Describe two bedside monitoring needs to be used when giving calcineurin inhibitors [2]
FBC - bone marrow suppression (e.g., neutropenia, thrombocytopenia).
CXR - assess for TB
LFTs - methotrexate is renally excreted
Folate levels
Fibroscan
[] is a severe complication caused by herpes simplex virus infection on areas affected by eczema.
Eczema herpeticum is a severe complication caused by herpes simplex virus infection on areas affected by eczema.
Name and describe an ophthalmological complication of eczema [1]
Keratoconus, the clear, protective outer layer at the front of the eye (called the cornea) becomes thinner and changes shape over time.
- cornea becomes thinner and weaker and begins to bulge, leading to blurred and distorted vision
- Instead of having a curved football shape, it becomes pointed like a rugby ball.
NB: due to vigorous and long term itching or rubbing of the eyes.
State an example of low, mid, high and very high potency corticosteroids used in the tx of eczema
Low-potency: hydrocortisone, desonide
Mid-potency: fluticasone, triamcinolone, fluocinolone
High-potency: mometasone, betamethasone, desoximetasone
Very high-potency: clobetasol, ulobetasol, diflorasone.
What type of eczema is depicted
Discoid
Atopic dermatatis
Asteatotic eczema
Venous / stasis
Seborrhoeic dermatitis
Asteatotic eczema
- Asteatotic eczema often has a distinctive crazy-paving appearance.
- Diamond-shaped plates of skin are separated from each other by red bands forming a network
- There may also be scratch marks. It may start on one shin but soon spreads to affect the skin around both lower legs.
What type of eczema is depicted
Discoid
Atopic dermatatis
Asteatotic eczema
Venous / stasis
Seborrhoeic dermatitis
Seborrhoeic dermatitis
- Seborrhoeic dermatitis is a common, chronic, or relapsing form of eczema/dermatitis that mainly affects the sebaceous gland-rich regions of the scalp, face, and trunk.
What type of eczema is depicted
Discoid
Atopic dermatatis
Asteatotic eczema
Venous / stasis
Seborrhoeic dermatitis
Asteatotic eczema
What type of eczema is depicted
Discoid
Atopic dermatatis
Asteatotic eczema
Venous / stasis
Seborrhoeic dermatitis
Discoid eczema usually affects the limbs, particularly the legs, but the rash may be widespread.
- The majority of patches are round or oval. The plaques are usually very itchy. The skin between the patches is usually dry and irritable.
There are two clinical forms of discoid eczema:
- Exudative acute discoid eczema: oozy papules, blisters, and plaques
- Dry discoid eczema: subacute or chronic erythematous, dry plaques
What type of eczema is depicted
Discoid
Atopic dermatatis
Asteatotic eczema
Venous / stasis
Seborrhoeic dermatitis
Venous Eczema
- Venous eczema appears to be due to fluid collecting in the tissues and activation of the innate immune response.
What type of eczema is depicted
Discoid
Atopic dermatatis
Asteatotic eczema
Venous / stasis
Seborrhoeic dermatitis
What type of eczema is depicted
Discoid
Atopic dermatatis
Asteatotic eczema
Venous / stasis
Seborrhoeic dermatitis
What type of eczema is depicted
Discoid
Atopic dermatatis
Asteatotic eczema
Venous / stasis
Seborrhoeic dermatitis
What type of eczema is depicted
Discoid
Atopic dermatatis
Asteatotic eczema
Venous / stasis
Seborrhoeic dermatitis
Describe this pattern of eczema [1]
Follicular eczema
What is the treatment for this manifestation of eczema? [2]
Eczema herpeticum - multiple punched out lesions
(1) Oral aciclovir 5 times daily for 10-14 days
Alternative: valaciclovir twice daily for 10-14 days
(2) If patient vomiting or unable to take tablets: IV aciclovir
Dx? [1]
Seborrheoic eczema
- often situated around the nose
Severe seborrheoic eczema - think [] infection
Severe seborrheoic eczema - think HIV infection
Name this investigation and what type of HS it investigates [2]
Skin prick test (Type 1 HS)
Sk1n prick
Patch testing (HS type 4)
P4tch testing
What is this type of eczema? [1]
Pompholyx eczema
- Pompholyx eczema (also known as ‘dyshidrotic eczema’) is a type of eczema that affects the hands and feet. It involves the development of intensely itchy, watery blisters, affecting the sides of the fingers, the palms of the hands and soles of the feet.
