Eczema & Acne

Question 1

What are the important history taking and physical examinations to consider when looking at acne?

Answer 1

Sex
Age
Motivation
Occupation 
Previous treatment
Cosmetic usage 
Menstrual history 
Medications
Skin type, colour
Scarring
Pigmentation

Question 2

What would we see in mild acne?

Answer 2

Non-Inflammatory

Open (blackheads) and Closed comedones (whiteheads)

Question 3

What would we see in moderate acne?

Answer 3

Inflammatory lesions, papules, pustules, nodules and cysts.

Question 4

What would we see in severe acne?

Answer 4

> 5 pseudocysts
50 total inflammatory count
Permanent scar and post inflammatory pigmentation.

Question 5

What is Acne fulminans?

Answer 5

Most severe form of cystic acne
characterised by abrupt onset of nodular and supportive acne with systemic manifestations
(fever, myalgia)

Question 6

What is Drug induced acne?

Answer 6

Can be seen as a side effect of numerous medications (anabolic steroids, corticosteroids)

Question 7

What is Acne excoriee?

Answer 7

Papules and comedones are neurotically excoriated leaving crusted lesions that may scar.

Question 8

Treatment for Acne

Answer 8

Topical retinoids 
Benzoyl peroxide 
Topical antibiotics 
Azelaic acid 
antibiotic tablets 
Combined pill 
Isotretinoin tablets

Question 9

What is Rosacea?

Answer 9

Common skin disease in adults with a variety of clinical manifestations.
- not associated with seborrhoea
Most common in fair-skinned.

Question 10

Clinical features of Rosacea

Answer 10

Polymorphic disease with several variants
Affects central convex areas of the face (nose, forehead, cheeks, chin)
Development of facial pustules
Onset marked by vascular change - notably episodic flushes no sweating.
Erythema with burning sensation.
Tissue thickening.

Question 11

Treatment of Rosacea

Answer 11

Avoidance of obvious irritants
Oral antibiotics
Metronidazole cream or gel is a major topical therapy
Azelaic acid cream or gel

Question 12

What is eczema?

Answer 12

Atopic dermatitis - a common inflammatory skin condition that commonly affects flexural areas.
(barrier dysfunction and inflammation)

Question 13

What is the definition of atopic eczema?

Answer 13

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

Question 14

Pathogenesis of Eczema

Answer 14

Genetics - many genes implicated
Key role for Filaggrin gene 
Atopic family history - eczema, asthma, hay fever. 
Epidermal barrier dysfunction
Environmental factors

Question 15

What are the clinical features of Eczema?

Answer 15

Itch
Disturbance - flexures, neck, eyelids, face, hands and feet
Acute changes - pruritus, erythema, scale, papule, vesicle, exudate, crusting, excoriation
Chronic changes - Plaques, fissures

Question 16

What is Exogenous (external) Eczema

Answer 16

Contact dermatitis 
- irritant 
- allergic 
Lichen simplex
Photo allergic or photoaggravated

Question 17

What is Endogenous (internal) eczema?

Answer 17

Atopic
Discoid
Venous
Seborrhoeic dermatitis 
Pompholyx
Juvenile plantar dermatitis 
Asteatotic

Question 18

What type of hypersensitivity is allergic contact dermatitis?

Answer 18

Type 4 hypersensitivity

- contact of materials (necklace, belt, jeans) with the skin reacting in a red rash - an allergic reaction.

Question 19

What is irritant contact dermatitis?

Answer 19

Skin injured by

1. Friction - micro-trauma, cumulative
2. Environmental factors - cold, over-exposure to water, chemicals such as acids, alkalis, detergents and solvents
   * certain occupations are more susceptible such as hairdressers, NHS staff, Cleaners…

Question 20

What is patch testing?

When is it used?

Answer 20

Potential allergens applied (no needles involved)
Baseline/standard sereis - applies to all patients
- applied Monday, remove wednesday
Re-asses Friday
– used in allergic contact dermatitis

Question 21

What is Seborrhoeic dermatitis?

Answer 21

Infants:
- Distinctive pattern
- Predilection for scalp, proximal flexures
- <6 months age usually
- often clears within weeks of treatment.
(less itchy and child normally well)

Question 22

1. What is Seborrhoeic eczema in adults?
2. How does it present?
3. How is it treated?

Answer 22

1. Chronic dermatitis
   Malassezia yeast increased in the scaly epidermis of dandruff and seborrehoic dermatitis.
2. Red, sharply marginated lesions covered with greasy looking scales. Distinctive distribution - areas rich in supply of sebaceous glands (scalp, face, upper trunk)
3. Topical anti-yeast (ketoconazole)

Question 23

What is Discoid eczema?

Answer 23

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

Question 24

What is Pompholyx/vesicular eczema?

Answer 24

Palms and soles
Intensely itchy
More common under 40 years
Sudden onset of crops of vesicles

Question 25

What is Asteatotic eczema?

Answer 25

Very dry skin 
Cracked scaly appearance 
Most commonly shins affected
Climate - heat 
Excessive washing/soap

Question 26

What is Venous eczema?

Answer 26

Stasis eczema or varicose eczema 
Increased venous pressure 
Oedema 
Ankle and lower leg involved 
- compression stockings.

Question 27

1. What is eczema herpeticum?

2. What treatment can be used?

Answer 27

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

Question 28

What treatment is used for eczema?

Answer 28

Patient education 
Avoid causative/exacerbating factors 
Emollients (moisturisers) 
- ointments - greasy but effective 
- creams - lighter 
- lotions - more watery 
Soap substitutes. 
Intermittent topical steroids - different potency 
Antihistamines or antimicrobials 
Calcineurin inhibitors

Question 29

Treatment for severe eczema?

Answer 29

UV light

Immunosuppression