Eczema

Question 1

How common is eczema in children?

Answer 1

It’s common

24% of children will be diagnosed with eczema at some point in their childhood

Question 2

What is atopic eczema?

Answer 2

Also known as atopic dermatitis
Inflammatory skin condition.
Commonly affects flexural areas.
Multiple types and a spectrum of severity

Wide range of external (exogenous) or internal (endogenous) factors can induce the condition.

Barrier dysfunction + inflammation

Question 3

Definition of atopic eczema- Diagnostic Criteria

Answer 3

An itchy skin condition in the last 12 months

Plus 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 relative if under 4 yrs

Question 4

Pathogenesis of Atopic Eczema

Answer 4

Genetics
Many genes implicated
Key role for Filaggrin gene
Atopic family history 
atopic eczema, asthma hay fever (allergic rhinitis), food allergy
Epidermal barrier dysfunction
Environmental factors
Immune system dysregulation

Question 5

Atopic Eczema Histopathology

Answer 5

Spongiosis (intercellular oedema) within the epidermis
Acanthosis (thickening of the epidermis)
Inflammation Superficial
–> perivascular lymphohistiocytic infiltrate.

Question 6

Clinically presenting features of atopic eczema
General/distribution:
Acute:
Chronic:

Answer 6

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 7

Affected areas of atopic eczema in CHILDREN UNDER 2 Yrs

Answer 7

CHEEKS

LINES UNDER EYES

Question 8

ATOPIC ECZEMA

Affected areas

Answer 8

FLEXURES

Question 9

Other types of Eczema

Answer 9

Endogenous (internal)

Exogenous (external)

Question 10

Endogenous Eczema (internal)

Answer 10

Endogenous (internal)
Atopic
Discoid
Venous
Seborrhoeic dermatitis
Pompholyx
Juvenile plantar dermatitis
Asteatotic

Question 11

Exogenous Eczema (external)

Answer 11

Exogenous (external)
Contact dermatitis
Irritant 
Allergic
Lichen simplex
Photoallergic or photoaggravated eczema (UV/visible light)

Question 12

Allergic contact dermatitis

Answer 12

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
neutrophil aggregation

Question 13

Irritant contact dermatitis

Skin injured by……

Answer 13

Skin injured by……

1) Friction – micro-trauma, cumulative

2) Environmental factors
cold
over-exposure to water
chemicals such as acids, alkalis, detergents and solvents

Occupation
Hairdressers
NHS staff
Cleaners
Dermatitis – under a ring on finger – soaps can accumulate –irritant
Nappy rash

Question 14

Investigation for suspected Eczema

Answer 14

Patch testing

Question 15

Describe Patch testing

Answer 15

Potential allergens applied (no needles involved!)
Baseline/standard series – applied to all patients
Apply Monday
Remove Wednesday
Re-assess Friday

Question 16

Seborrhoeic dermatitis - Infants

Answer 16

Distinctive pattern
Predilection for scalp, proximal flexures.
<6months age usually.
Clears within weeks of treatment

Question 17

Seborrhoeic eczema - adults

Answer 17

Chronic dermatitis.
Malassezia yeast increased in the scaly epidermis of dandruff and seborrehoic dermatitis.

Red, sharply marginated lesions covered with greasy looking scales
Distinctive distribution – areas rich in supply of sebaceous glands (scalp, face, upper trunk).

Question 18

Seborrhoeic eczema

Precursor

Answer 18

Dandruff can be a pre-cursor. May gradually progress through redness  irritation increased scaling

Question 19

Seborrhoeic eczema

Treatment

Answer 19

Treat with TOPICAL ANTI-YEAST:(Ketoconazole)

If severe, consider HIV test – immunocompromised?

Question 20

Discoid eczema

Answer 20

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

Question 21

POMPHOLYX
VESICULAR
|eczema

Answer 21

Palms and soles.
Intensely itchy!
More common under 40 years.
Sudden onset of crops of vesicles.
Resolution can include desquamation.

Question 22

ASTEATOTIC eczema

Answer 22

Very dry skin.
Cracked SCALY appearance.
Most commonly SHINS affected.
Climate – heat
Excessive washing/SOAPS

Question 23

Venous eczema

Answer 23

STASIS eczema or VARICOSE eczema.
Increased venous pressure.
Oedema.
Ankle and lower leg involved.
Resolution of oedema can help:– compression    stockings.

Question 24

Eczema Herpeticum

Answer 24

Disseminated viral infection
Fever and often unwell
Itchy clusters of blisters and erosions
Herpes Simplex 1 and 2
Swollen lymph glands

Consider:admission, antivirals, secondary bacterial infection.

Question 25

Treatment of eczema

Answer 25

Patient education
Avoid Causative / exacerbating factors
Emollients (moisturisers)
Ointment – greasy but effective
Creams – lighter 
Lotions – more watery
Soap substitutes

Intermittent topical steroids
Different potency
hydrocortisone (low)
Betamethasone (potent)

Sometimes need antihistamines or antimicrobials

Calcineurin Inhibitors
Topical Pimecrolimus and Tacrolimus

In short:

• Topicals
• Phototherapy
• Systemic immunosuppression

Question 26

Treatment of severe eczema

Answer 26

Ultraviolet light - (phototherapy)
Immunosuppression.
Azathioprine
Ciclosporin
Mycophenolate mofetil
Methotrexate
Biologic 
Dupilumab (IL-4/IL-13 inhibitor)

Question 27

Deep rips in flexure skin - steroid induced?

Answer 27

STEROID INDUCED STRIAE