Eczema Flashcards
What does eczema mean?
Inflammation of the skin, it means the same as dermatitis
How can the causes of eczema be divided?
Exogenous causes e.g. Photosensitive, Contact Dermatitis (Allergic or Irritant Dermatitis)
Endogenous causes- Atopic, Seborrhoeic, Venous, Asteatotic, Discoid
What are the three atopic diseases?
Atopic eczema
Asthma
Hayfever
What are the symptoms of eczema?
Itch- can be very unpleasant Weeping skin Crusting when fluid dries out Scaling/thickening of the skin Sleep disturbance due to itch Colour change- especially in pigmented skin due to itch Bleeding (may become darker or lighter)
Describe some of the differences between eczema and psoriasis
Eczema has a tendency to affect the flexor surfaces rather than the extensor surfaces seen in psoriasis ( but this is mostly in white people, less so in ethnic minorities)
Eczema lesions are not well demarcated with clear boundaries like the plaques seen in psoriasis
Eczema is less scaly whereas psoriasis is associated with silvery scales
Eczema is very very itchy and so has associated excoriations
What are some complications of eczema? What would indicate this?
Infection- often with Staph Aureus (>90%) or Group A Strep.
Weeping, crusting or pustules
What could be a sign of secondary infection in eczema?
Weeping, crusting or pustules
What is a concerning infection in children with eczema that can cause multiple punched out lesions?
Herpes Simplex Virus leading to Eczema Herpeticum
HSV infects the skin of patients who are susceptible, such as with atopic eczema due to the breaks in the skin surface.
What does eczema herpeticum look like?
Eczema herpeticum is caused by HSV-1
Groups of small blisters initially and then more can form
Blisters contain a clear fluid that then develops into pus
They may weep or blead
Heal which rarely can result in scaring
Multiple punched out lesions
How is eczema herpeticum diagnosed?
Clinical diagnosis
Swab the blisters and send for PCR, MC+S if could be bacterial too
What is the treatment for eczema herpeticum?
Acyclovir- anti-viral therapy
What are the features of seborrhoeic eczema?
Red scaly rash that is itchy and affects the scalp, eyebrows, naso-labial folds, cheeks and flexures
What should be tested for in patients with severe seborrhoeic eczema?
HIV- Severe forms of seborrhoeic eczema are associated with being HIV positive
What is the cause of seborrhoeic eczema?
Overgrowth of skin yeasts- e.g. Malassezia
What is the treatment for seborrhoeic eczema?
Mild topical steroids or anti-fungal preparations
What are the two types of contact dermatitis?
Allergic
Irritant
What type of hypersensitivity is an allergic contact dermatitis?
Type IV
What are some causes of allergic contact dermatitis?
Nickel- jewellery, watches, coins, keys,
Rubber- marigold gloves
Latex
Lanolin- creams, cosmetics
Chromate- leather, cement (builders hand eczema)
Hair-dye allergy (due to PPD)
Dermatitis is seen where the object is in contact with the skin, there is often a sharp cut-off where the contact ends
For allergic contact dermatitis do patients develop it the first time they come into contact with the allergen?
No sensitisation must occur first
This is an example of a type IV hypersensitivity reaction
How can you test for allergic contact dermatitis?
Patch testing +ve reaction is redness and blistering
Note- This is difficult from Type I which is IgE mediated and occurs instantly. It is done for allergies such as food allergies and the result is urticaria.
What is irritant contact dermatitis?
Prolonged exposure to irritants begins to cause dermatitis, everyone is prone to developing this
Common irritants include- hand soap, detergents, washing up liquid, solvents, cleaning solutions
What is the management for irritant contact dermatitis?
Avoid exposure to the irritant where possible
Gentler hand washes
Hand care- regular moisturising
Gloves for cleaning
PRN use of topical steroids for acute flares
What is venous eczema?
This occurs when there is poor venous drainage and venous hypertension. There is failure of the valves within veins, leading to varicose veins and venous hypertension. Triggers inflammation in the skin.
What does venous eczema look like?
Occurs on the lower legs Redness Dry flaky skin Itching Scaling Weeping skin White patches may form- called Atrophie Blanche Thickening of the skin- Lipodermatosclerosis Venous ulcers may also form
What is the name given to the thickening of skin seen with venous eczema?
Lipodermatosclerosis
What is the name given to pale patches that form with venous eczema?
Atrophie Blanche
Describe the features of a venous ulcer
Large shallow irregular border
Pain improves on raising the leg, unlike arterial ulcers where this worsens pain
Exudative granulating base
Sloped edge (arterial ulcers appear punched out)
Associated varicosities, atrophie blanche, lipodermatosclerosis
Commonly in malleolar area- especially medial (found in gaiter area)
How is venous eczema managed?
Must do ABPI before consideration of compression stockings/bandages
Raise legs Compression bandages Moisturising creams/Topical emollients Avoid damaging the skin Varicose vein repairs
What is pompholyx eczema?
Eczema found on the hands and/or feet
Intensely itchy
Burning sensation
Small Bilsters
What is the treatment for pompholyx eczema?
Avoid contact with potential irritants
Emolients (moisturisers)
Steroid creams
Anti-histamines to relieve itching
Specialist treatments:
Phototherapy, Oral steroids, Tacrlimus cream, Ciclosporin tablets, azathioprine, alitretinoin (retinoid)
What is asteatotic eczema?
Eczema that occurs with age due to skin drying out
Often settles with moisturisers
What are the features of photosensitive eczema?
Eczema (redness, itching, flaking, scaling, exudate) is seen in areas exposed to the sun
Note- Phytophoto Eczema can occur when sap from plants comes into contact with the skin and then there is sun exposure. E.g. Giant Hogweed, and Fig Tree
What are the diagnostic points for atopic eczema?
A child must have itchy skin and at least three of:
Onset for 2 years of age
Past flexural involvement
History of generally dry skin
Personal history of other atopy or atop in 1st degree relative
Visible flexural dermatitis (or on cheeks/forehead) and outer side of limbs if less than 4)
What should parents be asked to urgently report if their child has eczema?
Any weeping or blistering or punched out lesion that develop over the face. This could be eczema herpeticum and this can be fatal.
What are the core treatment modalities of eczema?
Emolients (moisturisers) Soap substitutes Topical corticosteroids Topical immunomodulators (Systemic if very severe)
What is the best emollient?
The one the patient prefers
How should emollients be used?
Liberally applied to the skin and the most greasy one tolerated should be used (greasier emollients may be okay to use at nighttime)
Massage emollients in the direction of hair growth the avoid blocking hair follicles
When should topical steroids be used for the management of eczema?
Topical steroids should be used for exacerbations of eczema, or in severe cases high potent steroids should be used for flares and potency reduced when required- use the weakest steroid that is effective.
Give an example of a mild topical steroid
1-2.5% corticosteroid cream
Give an example of a moderate topical steroid
Eumovate or Modrasone
Give an example of a potent topical steroid
Betnovate, Elocon, Synalar
Give an example of a very potent topical steroid
Dermovate
How should secondary infections be treated in eczema?
Oral antibiotics
Might consider adding in antiseptic creams (e.g. Dermol 500) or antiseptic bath oils (olatum plus)
What can be given for the management of itch?
Anti-histamines- but this is often sedating ones that are for the getting to sleep at night. E.g. Hydroxyzine
What are some side effects of steroid cream?
SEs depend upon potency
Skin thinning Irreversible striae Telangiectasia Worsening of any untreated infections due to local immune suppression Adrenal Suppression (rare)
Describe the finger tip unit
The amount of cream squeezed from a standard 5mm nozzle along the palmar surface of a distal phalanx in an adult hand. 1 FTU will cover the palmar surface (including fingers) of two adult hands.
What might be considered if eczema is not controlled by steroids?
Topical tacrolimus/pimecrolimus
Systemic Treatments- Ciclosporin, Azathioprine, Methotrexate
When might systemic therapies be considered for eczema?
For very severe eczema.
Oral prednisolone, methotrexate, ciclosporin (nephrotoxic), azathioprine (bone marrow suppression)
Where should topical steroids not be used?
Not on the face-
Topical immunomodulators such as tacrolimus may be used on the face.
