Eczema

Question 1

What % of children will be diagnosed with eczema in their childhood?

Answer 1

24%

Question 2

How is eczema also known as?

Answer 2

Atopic dermatitis

Question 3

What % of cases of eczema in children have cleared by the time they reach adulthood?

Answer 3

60%

Question 4

What are some theories for the increasing prevalence of eczema, particularly in developed countries?

Answer 4

– Social class effect?
– Commoner in cooler climates?
– Pollution? Other environmental factors?

Hygiene hypothesis?

Question 5

Describe the Modified Hanifin and Rajka criteria for the definition of atopic dermatitis

Answer 5

An itchy skin condition in the last 12 months + 3 of the following:
• Onset before age 2
• History of flexural involvement
• History of generally dry skin
• History of other atopic disease
– History in 1st degree relatives if under 4 yo

Question 6

What gene plays a key role in the pathogenesis of eczema?

Answer 6

Filaggrin gene

Question 7

What components are involved in the pathogenesis of eczema?

Answer 7

Genetics
–	Many genes implicated
–	Key role for Filaggrin gene
–	Atopic family history 
•	Atopic eczema, asthma, allergic rhinitis, food allergy

Epidermal barrier dysfunction

Environmental factors

Question 8

What 3 processes are involved in the pathology of eczema?

Answer 8

Spongiosis (intercellular oedema) within the epidermis.

Acanthosis (thickening of the epidermis).

Inflammation - Superficial perivascular lymphohistiocytic infiltrate.

Question 9

What are the clinical features of eczema?

Answer 9

Itch!!
• Distribution
– Flexures, Neck, Eyelids, Face, Hands and feet
– Tends to spare nappy area

Acute changes
– Pruritus, Erythema, Scale, Papules, Vesicles
– Exudate, crusting, excoriation

Chronic changes
– Lichenification, Plaques, Fissuring

Question 10

List some external/exogenous types of eczema

Answer 10

Contact dermatitis - irritant or allergic

Lichen simplex

Photoallergic or photoaggravated eczema

Question 11

List some endogenous/internal types of eczema

Answer 11

–	Atopic
–	Discoid
–	Venous
–	Seborrhoeic dermatitis
–	Pompholyx
–	Juvenile plantar dermatitis

Question 12

What type of eczema does contact dermatitis come under?

Answer 12

Exogenous/external eczema

Question 13

What type of eczema does lichen simplex come under?

Answer 13

Exogenous/external eczema

Question 14

What is lichen simplex?

Answer 14

Hyperpigmented, lichenified plaque with accentuated skin lined caused by repeated rubbing of the area. Lichen simplex chronicus (LSC) is a localized, well-circumscribed area of lichenification (thickened skin) resulting from repeated rubbing, itching, and scratching of the skin

Question 15

What type of eczema does Photoallergic or photoaggravated eczema fall under?

Answer 15

Exogenous/external eczema

Question 16

What type of eczema does Atopic dermatitis fall under?

Answer 16

Endogenous/internal eczema

Question 17

What type of eczema does discoid eczema fall under?

Answer 17

Endogenous/internal eczema

Question 18

What type of eczema does venous eczema fall under?

Answer 18

Endogenous/internal eczema

Question 19

What type of eczema does Seborrhoeic dermatitis fall under?

Answer 19

Endogenous/internal eczema

Question 20

What type of eczema does Pompholyx or vesicular eczema full under?

Answer 20

Endogenous/internal eczema

Question 21

What type of eczema does Juvenile plantar dermatitis fall under?

Answer 21

Endogenous/internal eczema

Question 22

Describe asteatotic eczema

Answer 22

Asteatotic - diminished or arrested action of the sebaceous glands

Characterized by pruritic, dry, cracked, and polygonally fissured skin with irregular scaling, often on shins of elderly patients

Question 23

Describe allergic contact dermatitis

Answer 23

Type 4 Hypersensitivity
Delayed hypersensitivity – can take 48-72 hrs to develop reaction

Antigen presenting cells take hapten/ allergen to LN and present to naive T cells
Clonal expansion of these T cells, released into blood stream
When these T cells next encounter hapten
– Mast cell degranulation, vasodilatation and neutrophils

Question 24

What type of reaction is involved in allergic contact dermatitis?

Answer 24

Type 4 Hypersensitivity (delayed)

Question 25

How long after exposure does allergic contact dermatitis flare?

Answer 25

Delayed hypersensitivity – can take 48-72 hrs to develop reaction

Question 26

Describe irritant contact dermatitis

Answer 26

Skin injured by: – Friction – micro-trauma, cumulative – Environmental factors e.g.Cold, over-exposure to water chemicals such as acids, alkalis, detergents, solvents

Question 27

What occupations are at risk of irritant contact dermatitis

Answer 27

– Hairdressers – NHS staff – Cleaners

Question 28

How do we test for allergens?

Answer 28

Patch testing Potential allergens are applied on the monday and covered Washed off on wednesday Examine on friday for results

Question 29

Describe Seborrhoeic eczema

Answer 29

Symptoms include red, scaly, greasy, itchy, and inflamed skin. Areas of the skin rich in oil-producing glands are often affected including the scalp, face, and chest In babies, when the scalp is primarily involved, it is called cradle cap. Dandruff is a milder form of the condition, without associated inflammation

Question 30

How does Seborrhoeic eczema present in infants?

Answer 30

* Distinctive pattern * Predilection for scalp (cradle cap), proximal flexures. * <6months age usually.

Question 31

What type of eczema is linked to cradle cap and dandruff?

Answer 31

Seborrhoeic eczema

Question 32

Describe discoid eczema

Answer 32

* Circular plaques of eczema. * Cause often unknown. * May develop at sites of trauma/irritation.

Question 33

Describe Pompholyx/vesicular eczema

Answer 33

* Affects palms and soles with vesicles/bullae * Intensely itchy. * Sudden onset of crops of vesicles. * Resolution can include desquamation (peeling)

Question 34

What age group is most commonly affected with Pompholyx/vesicular eczema?

Answer 34

< 40yo

Question 35

What is Asteatotic eczema linked to?

Answer 35

* Climate – heat | * Excessive washing/soaps

Question 36

Describe Venous eczema/venous stasis eczema

Answer 36

* Stasis eczema or varicose eczema. * Increased venous pressure. * Oedema. * Ankle and lower leg involved. * Resolution of oedema can help – compression stockings.

Question 37

How can venous eczema be treated in addition to classic eczema therapy?

Answer 37

Compression stockings

Question 38

What is eczema herpaticum?

Answer 38

* Disseminated viral infection * Fever and often unwell * Itchy clusters of blisters and erosions * Herpes Simplex 1 and 2 * Swollen lymph glands * Consider admission, antivirals, consider secondary bacterial infection.

Question 39

What viruses are involved in eczema herpaticum?

Answer 39

HSV 1 and 2

Question 40

Describe the signs of infected eczema

Answer 40

``` o Fluid oozing from the skin o A yellow crust on the skin surface o Small yellowish-white spots appearing in the eczema o The skin becoming swollen and sore o Fever and generally feeling unwell ```

Question 41

What increases the risk of infected eczema?

Answer 41

Scratching | Not using treatment properly

Question 42

How is eczema treated?

Answer 42

Patient education Avoid Causative / exacerbating factors Emollients (moisturisers) Soap substitutes Topical steroids e.g. Hydrocortisone, Betamethasone Sometimes need antihistamines or antimicrobials Calcineurin Inhibitors e.g. topical Pimecrolimus, Tacrolimus

Question 43

Describe the different types of emollients used in eczema treatment

Answer 43

– Ointment – greasy but effective – Creams – lighter – Lotions – more watery

Question 44

Describe a low potency intermittent topical steroid used in eczema treatment

Answer 44

Hydrocortisone

Question 45

Describe a high potency intermittent topical steroid used in eczema treatment

Answer 45

Betamethasone

Question 46

What are calcinuerin inhibitors?

Answer 46

Immunomodulators

Question 47

Give two examples of calcinuerin inhibitors

Answer 47

Topical Pimecrolimus and Tacrolimus

Question 48

How is severe eczema treated?

Answer 48

``` Ultraviolet light. Immunosuppression. – Azathioprine – Ciclosporin – Mycophenolate mofetil – Methotrexate ```

Question 49

List 4 immunosuppressive agents used in severe eczema

Answer 49

– Azathioprine – Ciclosporin – Mycophenolate mofetil – Methotrexate

Question 50

Name the topical PDE-4 inhibitor recently approved by the FDA for eczema

Answer 50

Crisaborole

Question 51

What is Dupilumab?

Answer 51

– 1st biologic for eczema patients | – IL-4/IL-13 inhibitor

Question 52

What is the first ever biologic developed for eczema, and acts as a IL-4/IL-14 inhibitor?

Answer 52

Dupilumab