Eczema and dermatitis Flashcards
T/F
Exogenous eczema means spongiotic dermatoses caused by things contacting the skin
True
mainly treat by removing the trigger
What are the causes of exogenous eczemas?
Irritant contact dermatitis Allergic contact dermatitis Photoallergic contact dermatitis Phototoxic contact dermatitis inc phytophotodermatitis Eczematous PMLE Dermatophytide (Id reaction) Infectious eczema e.g. Discoid Post-traumatic eczema
T/F
phototoxic drug reactions are a type of Exogenous eczema
False
phototoxic drug reactions are sunburn like rather than eczematous if due to systemic drugs
Phototoxic contact dermatitis is an exogenous eczema
T/F
generalized endogenous eczema is a valid diagnosis in elderly people
True
If doesnt fit a recognised type and no exogenous cause found
T/F
All eczematous dermatoses have acute, subacute and chronic lesions
False
eczema does but many other have single charcteristic appearances which are often acute
e.g. pompholyx, phytophotodermatitis
T/F
Autoeczematization means the same as dermatophytide or ‘Id’ reaction
False
Autoeczematization is secondary dissemination of eczema
‘Id reaction’ or ‘dermatophytide’ etc is used if the primary site is infection rather than eczema
Whic type of eczema most commonly causes autoeczematization?
stasis dermatitis
Also, regardless of cause, more likely if primary eczema site is on feet or legs
T/F
Typical for hand eczemas to spread to feet and vice versa
True
autoeczematization
T/F
Autoeczematization only occurs in long established eczemas
False
Eczema may have been present for any duration of time before spread
T/F
Dissemination (autoeczematization) often follows a local flare
True
How does autoeczematization present?
Often the eruption is symmetrical and striking
Starts as oedematous papules or papulovesicles or sometimes macules or wheals – soon become eczematous lesions
Can become generalized, can become erythroderma
T/F
Autoeczematization responds to Rx of the primary site but worsens if primary site worsens
True
What is meant by ‘conditioned hyperirritability’?
Skin away from the eczema site is more prone to flare up from irritants than normal skin
o Can be the cause for high proportion of irritant reactions to patch tests and the ‘angry back’ syndrome
o Unclear if this is the real cause of autoeczematisation reactions
T/F
Eczematous (spongiotic) drug reactions are a type of Exogenous eczema
False
Classified as endogenous as not due to something contacting the skin
What are the clinical appearances of eczematous drug eruptions?
Localized eczema Generalized eczema (AD-like) seb derm-like Erythroderma Pompholyx (esp IVIg) Baboon syndrome subtype of ‘systemic contact-type dermatitis (medicamentosa)’
T/F
SDRIFE is the same thing as Baboon syndrome as a presentation of systemic contact dermatitis
False
Look the same and both called Baboon syndrome but Symmetrical Drug-Related Intertriginous and Flexural Exanthema (SDRIFE) is a clinical pattern of drug reaction caused by a normal oral drug exposure not oral ingestion of a contact allergen
T/F
Phenytoin is a classic cause of a widespread eczematous eruption which can involve flexures resembling atopic dermatitis
False
this is Carbamazepine
T/F
IVIg can cause cheiropompholyx
True
What is systemic contact-type dermatitis (medicamentosa)?
AKA ‘systemically reactivated contact dermatitis’ or ‘systemic contact dermatitis’
whereby a rash is precipitated by ingestion of a drug or compound to which the patient has a contact allergy due to prior physical contact of the same or a related compound
Can present as Baboon syndrome or another clinical pattern
What are the causes of systemic contact dermatitis?
Many
People sensitive to balsam of Peru can get rcns to ingested Cinnamon, vanilla, cloves or inhalation of tincture of benzoin
Pts sensitized to nickel, chromium, parabens, propylene glycol or sorbic acid can get rcns when these are ingested
Which allergens are associated with the Baboon syndrome presentation of systemic conatct dermatitis?
Nickel, chromium, balsam of Peru
T/F
systemic contact dermatitis often first or most severely affects site of prior ACD
True
T/F
systemic contact dermatitis is often symmetrical
True
T/F
Contact sensitization to neomycin can result in systemic contact dermatitis when gentamicin is given
True
also if given systemic neomycin
T/F
Contact sensitization to thiurams can result in systemic contact dermatitis when aminophylline is given
False
when disulfiram is given
T/F
Contact sensitization to ethylenediamine can result in systemic contact dermatitis when aminophylline is given
True
also when cetirizine or hydroxyzine given
T/F
Sorbic acid is found in foods such as strawberries, sweets, margarine and cheeses
True
can cause systemic contact dermatitis if contact allergy to sorbic acid
T/F
marinated fish products, jams and jellies, pickles and preserves contain parabens
True
can cause systemic contact dermatitis if contact allergy to parabens
T/F
Contact sensitization to propylene glycol can result in systemic contact dermatitis when antihypertensives are given
False
antihistamines
What are the top causes of eyelid dermatitis?
Atopic
Seborrhoeic
ACD esp nail varnish/acrylics, fragrance, make up, rubber, eye drops
T/F
Eczema craquele only occurs on the legs
False
Mainly on legs esp shins but can be arms and hands, lower flanks or posterior axillary line
can generalize
What are ‘parchment pulps’
dry and cracked fingertip pulps – maintain a depression after pressing
T/F
Discoid eczema can complicate Eczema craquele
True
T/F
Eczema craquele is not itchy
False
very itchy esp at night
What is the treatment of Eczema craquele?
soap free wash
BD greasy emollient (paraffin, petrolatum, lanolin, ceramide or urea)
may need weak-mod TCS to settle any inflammation
May need to reduce heat and increase humidity at home
Avoid long or hot baths
T/F
Chronic superficial scaly dermatitis is a prelymphomatous eruption
False
Thought to be abortive type of CTCL esp if clonal lymphocytic infiltrate
Whta is the difference if any between Chronic superficial scaly dermatitis and prelymphomatous eruption
Prelymphomatous eruption can look very similar but has finer scale, more angulated patches and is more itchy
Also histo shows spongiosis and minimal infiltrate in benign Chronic superficial scaly dermatitis but is more towards MF in prelymphoma eruption
If develop atrophy or reticulate pigmentation reclassify as ‘prelymphomatous poikiloderma’
T/F
Chronic superficial scaly dermatitis is the same as Small plaque parapsoriasis and digitate dermatosis
True
Digitate dermatosis is a variant which presents as elongated finger-like patches symmetrically distributed on flanks
T/F
Patches of Chronic superficial scaly dermatitis measure less than 5cm in diameter
True
except in digitate dermatosis
What is the natural history of Chronic superficial scaly dermatitis?
what is the treatment?
Persist for years or decades
Resistant to sustained remission
Risk of progression to MF is from zero to
May transform to prelymphomatous eruption with an increased risk of progression to MF
treat with emollients, TCS, UVB
T/F
symmetrical rash on borders of fingers is a characteristic dermatophytide reaction to tinea pedis
True
T/F
dermatophytide persists even when the fungus is treated
False
resolves
T/F
dermatophytide can cause other reactions than eczema at distant sites
True - but v rare Pit rosea EN EAC urticaria erythroderma
T/F
Patients with discoid eczema often have some more typical eczema elsewhere
True
T/F
Patients with discoid eczema always have a history of atopic dermatitis
False
often do but not always
T/F
Discoid eczema is rarely itchy
False
very itchy
T/F
Discoid eczema can look annular
True
T/F
Discoid eczema can resemble HSV
True
can be group of vsicles on erythematous base
T/F
Discoid eczema of the hands affects the palms resembling pompholyx
False
discoid hand eczema affects dorsa and fingers
T/F
Discoid eczema is symmetrical
True
Often unilateral initially and then develop mirror image lesions on other side after some time
T/F
Discoid eczema may be triggered by staph aureus colonization of eczema
True
T/F
Discoid eczema can koebnerize
True
What are some triggers for discoid eczema?
staph aureus colonization of eczema depilating creams aloe vera mercury systemic drugs - methyldopa, gold think of 'Gold coins'
T/F
Discoid eczema affects children or older adults
True
kids often have AD
T/F
Discoid eczema is prone to superinfection and is often resistant to treatment
True
Discoid eczema treatment ladder?
General measures
Rule out drug trigger
BetC or BOZ+C good
Betnovate in coal tar also useful for chronic treatment
Infective flares may need antibiotics – erythro recommended in Rook
Patch test in resistant cases
For resistant cases – oral pred, other immunosuppressents UVB, PUVA
What is Sulzberger-Garbe disease?
= Exudative discoid and lichenoid chronic dermatosis or Oid-Oid disease
Variant of discoid eczema
Widespread eruption
Mainly affects adult jewish men age 40-60
Unknown aetiology
Discoid lesions with both exudative and lichenified (not lichenoid) phases which occur alternately or together
Can be accompanying scattered round urticated lesions
Very itchy
Penile and scrotal lesions are common and pathognomonic; also most persistent
Can blood eosinophilia or gynaecomastia
Treatment resistant
Can use oral pred or AZA
Runs chronic course for months or years then resolves
T/F
Sulzberger-Garbe disease is discoid and lichenoid
False
discoid and lichenified not lichenoid
T/F
Penile and scrotal lesions are common and pathognomonic of Sulzberger-Garbe disease
True
T/F
Blasckitis is a rare, spontaneously reslving eczematous eruption in a blasckoid distribution in adults
True
T/F
Hand dermatitis is twice as common in men
False
twice as common in women
T/F
Hand dermatitis affects 2-5% population at any one time
True
T/F
AI Progesterone dermatitis can present as Hand dermatitis
True
Including pompholyx
T/F
10% of adults with eczema have some component of hand dermatitis
False
60%
T/F
Atopic hand eczema has the worst prognosis of all hand eczema types
True
What are the aetiological types of hand dermatitis?
Usually multifactorial
Endogenous causes;
o Idiopathic
o Dyshidrotic – exacerbated by excess sweating
o Progesterone dermatitis
o Atopic
Exogenous causes
o Irritant contact
Chemical – soaps, detergents, solvents
Physical - friction, minor trauma, cold air, dry
environment
o Allergic contact
Delayed hypersensitivity (type 4) – e.g. chromium,
rubber, epoxy glues
Immediate hypersensitivity (type 1) - latex, seafood
o Ingested allergens - systemic contact dermatitis
o Infection - exacerbates
o Secondary dissemination – autoeczematisation or Id reaction
T/F
Most cases of hand dermatitis have arecognisable morphological type
False
Most hand dermatitis is patchy and vesiculosquamous
1/3 has a recognisable morphological variant
What are the morphological types of hand dermatitis?
Apron eczema Chronic acral dermatitis Discoid eczema Fingertip eczema ‘gut’ eczema Hyperkeratotic palmar eczema Pompholyx Ring eczema Keratolysis exfoliativa (Recurrent focal palmar peeling) Wear & tear dermatitis Contact urticaria Others
T/F
Apron eczema type of hand dermatitis is usually due to ACD
False
Can be irritant, allergic or endogenous
T/F
Chronic acral dermatitis involves High IgE but no Hx of atopy
True
T/F
Chronic acral dermatitis responds well to TCS
False
poor response to TCS
responds to pred
T/F
Chronic acral dermatitis Is a hyperkeratotic papulovesicular eczema of hands and feet
True
T/F
Fingertip eczema involving most fingers on dominant hand is usually due to allergic contact dermatitis
False
this pattern is usually cumulative irritant dermatitis - soaps and trauma
T/F
Fingertip eczema involving first 3 digits on either hand is usually occupational
True
Can be irritant or allergic
Often dominant hand but may be non-dominant if due to foods e.g. onion, garlic
Patch test often positive
T/F
Gut eczema starts in web spaces and spreads down sides of fingers
True
Due to contact with entrails in slaughterhouses esp pigs
T/F
Hyperkeratotic palmar eczema mainly affetcts young men
False
middle aged or older men are main sufferers
T/F
Hyperkeratotic palmar eczema can look alot like psoriasis
True
T/F
Hyperkeratotic palmar eczema is often resistant to treatment
True TCS Crude coal tar Salicylic acid PUVA Grenz rays
T/F
Keratolysis exfoliativa can be precursor of pompholyx
True
T/F
In ring eczema the pt usually patch tests positive to metals in the ring
False
Usually negative
?due to build up of soap etc under ring and microtrauma
T/F
Asteatotic hand eczema is usually due to a genetic defect
False
= wear and tear eczema
Combination irritant dermatitis, asteatosis and microtrauma
Often seen in cleaners and housewives
Can be co-exisiting fingertip or ring eczemas
Skin is dry and red with superficial white cracks criss-crossing surface
T/F
Asteatotic hand eczema is the dame as dyshidrotic hand eczema
False
Asteatotic is very dry, wear and tear eczema
Dyshidrotic eczema is pompholyx
T/F
dyshidrotic hand eczema is due ti abnormality of the eccribe sweat glands
False
although ‘dyshydrotic’ means abnormal sweat there is no proven connection with sweat gland activity
T/F
Pompholyx accounts for 5-20% of hand eczema cases
True
T/F
Pompholyx is an endogenous eczema and is idiopathic
False
Its a clinical pattern of eczema but aetiology can vary
May be endogenous or exogenous
What are the causes of pompholyx?
Atopy 50%
ACD esp to PPD, benzoisothiazolinones, dichromates, perfume/fragrance, balsam of Peru
Autoimmune progesterone dermatitis
Autoecematization of a primary ACD of the feet
Id rcn - dermatophytide or bacteride
Drug eruption – aspirin, OCP, IVIg
Systemic contact-type dermatitis esp to neomycin ingestion in pts with leg ulcers previously treated with topical neomycin
T/F
Cigarette smoking increases risk of Pompholyx
True
T/F
Pompholyx is primarily a bullous disease
False
vesicular but can get bullae as skin is thick allowing vesicles to enlarge
T/F
Pompholyx classically is crops of vesicles on an erythematous base
False
erythema usually not a feature
T/F
In Pompholyx 50% of cases involve hand and feet
False 80% palms only 10% soles only 10% both nearly always symmetrical; if asymmetrical think of contact derm
T/F
Pompholyx classically desquamates then resolves in 2-3 weeks and recurs at varying intervals
True
Some people prefer the term chronic vesicular dermatitis if it continues and doesn’t resolve and recur periodically
T/F
Pompholyx is always confined to the palmar or plantar surfaces
False
can spread to dorsa of hands and fingers and can involve nails;
Dystrophy, transverse pitting and ridging, thickening or discolouration
What is the prognosis of pompholyx?
1/3 don’t recur
1/3 recur
1/3 chronic course
What is the approach to investigation of pompholyx?
Careful Hx for contact allergens, food, medicaments and regularity of flares
Examine feet/legs for tinea and elsewhere for bacterial and dermatophyte infections
Should patch test all cases
T/F
Chronic continuous cases of Pompholyx can become hyperkeratotic
True
coal tar + steroid good
What is the approach to treatment of pompholyx?
General hand dermatitis measures In acute phase; o Rest hands and/or feet from use o Soak 3-4x per day in Condys crystals o Aspirate large bullae o Zinc cream Then start potent TCS in subacute phase Consider need for oral pred Low dose MTX or XRT for refractory cases antibiotics if infected coal tar + TCS if hyperkeratotic
T/F
Dermatophyte, Psoriasis and autoimmune blistering disease should be considered in the differentials for Pompholyx
True
BP, linear IgA disease, Pemph gestationis, paraneoplastic pemphigus, anti-p200 pemphigoid
T/F
Smokers have worse occupational hand eczema than non-smokers
True
T/F
Smokers hand eczema readily responds to treatment
False
more likely to be resistant
T/F
Smokers miss more work time due to hand dermatitis and are more likely to become unemployed
True
T/F
Men are more likely to suffer occupational consequences of hand eczema than women
False
women more likely
Which factors predict poor prognosis in hand dermatitis
atopic dermatitis
widespread eczema
severe disease at presentation
frequnt flares
T/F
acrylates and epoxy resins can penetrate vinyl and rubber gloves
True
What is Rx ladder for hand dermatitis?
Full exam and work up - exclude DDs Usually patch test Rest hands stop smoking Avoid soap and irritants and friction Condys soaks Emollient++ Gloves for hand work potent TCS +/- occlusion Topical tacrolimus Resistant patches may need ILCS Tar on non responding chronic cases e.g. 5% crude coal tar Sal acid if hyperkeratotic PUVA – systemic or topical UVB Superficial Xrays – pt can safely have 3 course of 3Gy of superficial Xrays in their lifetime Alitretinoin - not in Aus Acitretin sometimes useful CsA Can use Zinc paste or Friars balsam to seal fissures Treat infected flares with antibiotics For resistant cases consider metal in diet causing systemic contact dermatitis – can use oral chelating agent
T/F
In hairdressers, localized interdigital dermatitis is a precursor for hand dermatitis
True
T/F
hand dermatitis can resolve quickly if an avoidable causative contact allergen is identified
True
T/F
Infective eczema clears when the triggering infection is treated
True
T/F
Raised CRP can help differentiate infected from colonized eczema
True
T/F
neuts, microvesicles and subcorneal pustules can be a feature of infective eczema
True
T/F
Infective eczema caused by staph or strep is associated with HTLV-1
True
this is a particualr type mainly seen in afro-caribean kids
T/F
Juvenile plantar dermatosis affects girls more than boys
False
boys more
esp age 3-13
T/F
Juvenile plantar dermatosis is more common in kids with atopy
False
but in atopic kids the hands may be affected
T/F
Juvenile plantar dermatosis affects the weigh beairng parts of the feet
True
T/F
Histo of Juvenile plantar dermatosis shows a severe spongiotic dermatitis
False
usually mild
may show blocked sweat ducts
What are the main DDs of Juvenile plantar dermatosis?
ACD
moccasin tinea pedis
What are the treatments for Juvenile plantar dermatosis?
Usually clears spontaneously
Wear cotton socks and leather shoes, avoid non-porous footwear
WSP, tar, urea, Lassar’s paste (sal acid in zinc paste)
T/F
Juvenile plantar dermatosis can persist into adulthood
True
but rare
What is dermatogenic enteropathy?
malabsorption due to severe eczematous inflammatory skin disease
What are the causes of photosensitive eczemas?
Hot (sun) CHIP Carcinoid syndrome Hartnup disease Isoniazid Pellagra
What is Meyerson’s naevus / Meyerson’s phenomenon
Halo of dermatitis around a naevus or other benign lesion
• Resolves spontaneously in few months
• Naevus remains
T/F
Pityriasis alba always presents with other features of atopic dermatitis
False
T/F
Pityriasis alba clears in 3-4 months
False
Often last many months, on face often over a year
T/F
Erythema and scale may be features of Pityriasis alba
True
often precede hypopigmentation and may persist
What are the associations of Seborrhoeic dermatitis?
Parkinsons
HIV (1/3 of HIV pts)
mood disorders
NB Can improve with levadopa Rx in Parkinson’s
T/F
Sebum excretion is increased in seb derm
False
normal in males and reduced in females
T/F
Seborrhoeic dermatitis can extend beyond scalp margins onto forehead
True
= ‘corona seborrhoeica’
T/F
Seborrhoeic dermatitis Can cause otitis externa or blepharitis
True
T/F
Seborrhoeic dermatitis can form annular lesions
True
Petaloid seb derm - small annular areas close to each other
T/F
Severe persistant scalp seb derm can cause non-scarring alopecia
True
T/F
Seborrhoeic dermatitis cannot generalise
False
Some get a generalised erythrosquamous eruption which is typically pityriasiform but more extensive than pit rosea
can cause erythroderma
T/F
Seborrhoeic dermatitis at genital sites can be same as elsewhere, red with minimal scale or more psoriasiform
True
T/F
Seborrhoeic dermatitis always worsens in sun
False
often flares it initially then later sun may help
T/F
Seborrhoeic dermatitis and rosacea together is common
True
T/F
Seborrhoeic dermatitis in HIV has more follicular involvement and more plasma cells + more malassezia
True
T/F
What are main histo features of Seborrhoeic dermatitis?
SNP - sullivan Nics pathology
Spongiosis - mild
may be Neuts in horn
Parakeratosis ‘lipping’ the edges of follicles
Little or no parakeratosis in between follicles
T/F
Washing with soap is recommended in seb derm
True
malassezia live on sebum (lipids) - soap best to get rid of this
What is treatment ladder for seb derm?
Pt education - chronicity Wash BD with soap and water Azole antifungals +/- weak-mod TCS weak tar or sulphur can help; - 2% LPC cream - 3% sulphur +/- 3% salacid cream TCNI if requiring frequent TCS oral terbinafine or itraconazole if resistant Pred low dose if severe/generalized Scalp; Azole (ketoconazole 2%), selenium sulphide, zinc pyrithione or tar shampoos 5% sal acid for severe scalp involvement
What organism is responsible for Pityrosporum folliculitis?
malassezia Spp.
In yeast form only - no hyphae
Usually M. furfur but also globosa
In whom is Pityrosporum folliculitis most common?
What are risk factors?
women slightly more than men Down's syndrome Immunosuppressed, diabtes after antobiotics esp doxy pts with acne pregnancy, OCP stress
T/F
Pityrosporum folliculitis affects the upper trunk with itchy follicular papules and pustules which look like acne except no comedones, cysts or scars
True
What are DDs of Pityrosporum folliculitis?
steroid folliculitis
acne
T/F
Pityrosporum folliculitis usually responds to azole creams
True - but often recurs
apply twice a week for 4 wks. Wash off after 15 mins
rare cases need oral itraconazole 200mg/day for 1 week
Nb Dont use terbinafine or griseo - not effective
regular azole cream, shampoo etc may allow longer remission
T/F
Venous eczema only occurs if there is increased venous pressure
True
T/F
Lateral malleolus is the classic starting point of Venous eczema
False
medial malleolus
T/F
Venous eczema can have a sudden onset
True
T/F
Venous eczema only affects the legs
False
can occur in fatty pannus of obese abdomen or around AV fistula site
Other leg can develop autoeczematisation even if not involved primarily
Can be generalized eczematisation, can be erythroderma
T/F
Venous eczema has highe rate of secondary infection and medicament ACD
True
T/F
For infected stasis eczema topical antiseptics +/- systemic antibitoics are preferred to topical antibiotics
True
What are the features of post thrombotic limb/ deep venous insufficiency ?
varicose veins, dilated superficial veins, (woody) oedema, purpura, haemosiderin, ulceration, telys, atrophie blanche, lipodermatosclerosis
What is Prurigo Pigmentosa?
Rare eruption of Itchy red papules on trunk and neck, can be vesicles
Affects adult females in spring and summer esp in japan; rare in western world
Lesions coalesce and turn into reticular erythema and then hyperpigmentation
Unknown cause. Pts may have diabetes or anorexia
Can have blood eosinophilia
Treat with minocycline 200mg/day or erythromycin
T/F
The incidence of atopic dermatitis in the western world is about 2%
False
10%
T/F
Elevated IgE is found in nearly all cases of atopic dermatitis
F
80% of atopics have high IgE, 20% normal
50% of infants with eczema have normal IgE but only 5% of adults
15% of normal people have high IgE
T/F
Sensitvity to M furfur may play a role in atopic dermatitis restricted to the face
True
Look for Malassezia specific IgE on RAST/positive skin prick to Malasseza components – if so, try oral anti-fungal (itraconazole)
T/F
Spongiosis is an important feature of chrinic atopic dermatitis
False
spong more in acute
Psoriasiform hyperplasia is most important finding in subacute and chronic eczema
T/F
The dirty neck seen in atopics is due to melanin incontinence
True
reticulate pigmentation due to longstanding eczema
What is Hertoghe sign?
thin/absent lateral eyebrows in stopic dermatitis
T/F
Most cases of infantile atopic dermatitis are present at birth
False
onset is rarely prior to age 2 months
T/F
Involvement of the napkin area is common in atopic dermatitis
False
rare
T/F
In infants the face is often first site involved in atopic dermatitis
True
T/F
Follicular lichenified papules can be seen as a feature of atopic dermatitis in asian and dark skinned children
True
T/F
In adults genital and nipple pruritus can be a feature of atopic dermatitis
True
T/F
Hand involvement is rare in children with atopic dermatitis
False
A patchy, vesicular and somewhat licheniifed eczema of the hands is a common manifestation of atopic dermatitis in childhood
T/F
In atopics the risk of anaphylactic drug reactions is increased
True
T/F
In atopics the risk of non-type 1 drug reactions is increased
False
T/F
Dennie-Morgan infraorbital folds are specific for atopic dermatitis
False
non specific
T/F
The incidence of cataracts is increased in atopic dermatitis
True
Uncommon overall but up to 10% of severe AD pts
T/F
In up to 80-90% of individuals the onset of atopic dermatitis is prior to 5 years of age
True
T/F
Atopic dermatitis shows little tendency to improve during childhood
False
improves during childhood but may relapse at adolesence
50-80% clearance within 20 years
T/F
The recommended concentration of topical tacrolimus for children is 0.1%
False
0.03% for children if over age 2 years
Use 0.1% for adults
Pimecrolimus (1%) for children over 3 months
T/F
Breast feeding reduces the risk of atopic dermatitis
True
Or possibly true - evidence that it may do
Also;
Early avoidance (first 6 mths) of food (milk, soy, peanuts, wheat, fish) and aero allergens may prevent developing allergy
Extensively hydrolysed cows milk formula rather than cows milk or soy formulas
Pro or pre -biotics for preg mum or child up to age 4 may also help reduce AD development
T/F
Non atopics make IgG to housedustmite but atopics make IgE
True
T/F
If pt has eczema alone IgE may not be that high but usually very high if asthma and/or hayfever
True
Raised IgE is a marker of atopy
T/F
Many AD pts have IgE mediated allergy to components of their own sweat
True
What are intrinsic and extrinsic eczema?
Eczema with raised serum IgE has been called extrinsic atopic dermatitis whereas eczema with normal IgE sometimes called intrinsic eczema/AD
not recommended terminology
T/F
The skin of pts with eczema has reduced defense against staph, malasezzia and herpes virus
True
may be due to imbalance in favour of Th2 T-helper profile
alos at increased risk of; HPV warts, vaccinia, coxsackie A, molluscum and fungal infection
T/F
eczema pts are prone to vasoconstriction of small skin vesssels resulting in cold extremeties and white dermatographism
True
T/F
Sedating anthistamines mainly help eczema by reducing pruritus
False
mainly by sedation
But mast cells and histamine do play a role in eczema
T/F
The itch of atopic derm responds quickly to cyclosporin
True
T/F
Targeting the histamine HR4 receptor in addition to the HR1 receptor and targeting IL-31 may be future strategies to reduce histamine-related itch in AD
True
T/F
Low but not high vitamin D increases suceptibility to eczema
False
both low and high vitamin D increases suceptibility to eczema
T/F
Normal skin has a slightly basic pH
False
slightly acidic (pH 5) due to natural moisturizing factor
eczema skin is more basic than normal skin - pH 6
T/F
Both soap and bleach are alkali and hence can worsen eczema
True
avoid soap and keep bleach baths short
T/F
AD skin has reduced ceramides
True
esp ceramides 1 and 3
What are the patho-aetiological factors in eczema?
B-SIMVA (BJD paper 2014) Barrier dysfunction Staph colonization Immune dysregulation Mast cell histamine release Vitamin D derangement Abnormal vascular responses
What is the sequence of the atopic march?
Eczema - peaks age 1-2
Asthma - peaks age 5-6
Hayfever - peaks early in second decade
NB food alergy peaks age 1-2 and often resolves before age 5
T/F
There is evidence that aggressive control of eczema may somewhat mitigate the progress of the atopic march
True
T/F
anaphylactic drug reactions are more common in atopics
True
T/F
Protein contact urticaria is rare in atopic dermatitis pts
False
quite common
T/F
one quarter of infants with seb derm go on to develop eczema
True
T/F
Hand dermatitis affects >50% of adults with AD
True
60%
T/F
AIDS can trigger eczema ‘recall’ in soemone who previously outgrew their AD
True
T/F
50% of eczema pts have icthyosis vulgaris and 15% of icthyosis vulgaris pts have eczema
False
other way around
T/F
Adult AD pts are at increased risk of fractures
True
T/F
AD causes increased skin cancer risk
False
no increase in skin or internal cancers
What are the associations of atopic dermatitis?
Atopy - asthma, food allergy, hayfever Alopecia areata Hand dermatitis (inc w/ age) Icthyosis vulgaris Keratosis Pilaris Eye problems - cataract, keratoconus Fractures (adults only) Contact urticaria In kids - depression, anxiety, ADHD
T/F
atopic derm pts ofetn get keratosis pilaris in the absence of icthyosis vulgaris
True
40% of AD pts get KP
kids get it on cheeks
What are the diagnostic criteria for atopic dermatitis?
Modified UK criteria;
‘Itch Only Involves His Visibly Dry Areas’
Itchy rash + at least 3 out of 5 of;
Onset before age 2
Involves skin flexures or cheeks if under 10 yrs on History
Visible involvement of flexures or cheeks/forehead/extensors if under 4
Dry skin in last year
Asthma or hayfever or atopy in Pt or 1st degree relative before age 4
T/F
AD typically starts after 2 months and before one year
True
60% in first one year, 90% before age 5
What are triggers of eczema flare ups?
Infection stress/habitual scratching Sweating (thermal or emotional) Wool (and sometimes other) fabrics Water/ chlorinated water Dry weather Sand Can flare pre-menstrually In pregnancy – 50% flare, 25% no change, 25% improve
T/F
AD often flares in pregnancy
True
50% flare, 25% no change, 25% improve
T/F
Thick scaly scalp/cradle cap after 2 months of age is AD rather than seb derm
True
T/F
Infantile AD often involves nappy area
False
usually spared
T/F
Asian and black infants may retain extensor distribution eczema until older than caucasian kids
True
In addition to eczema kids often have pit alba, lip-licking eczema /upper lip cheilitis, hand dermatitis and juvenile plantar dermatosis
True
AD pts may have Icthyosis, KP and hyperlinear palms but not necessarily have icthyosis vulgaris
True
can all occur in AD alone
Asian and black kids often get micropapular eczema variant with hypo or hyper pigmentation – lesions are often folliculocentric – look like goosebumps
True
AKA Patchy pityriasiform lichenoid eruption or follicular atopic dermatitis
What is ‘atopic red face’?
Adult AD pts with primary facial dermatitis often severe around eyelids
What is Hertoghe sign?
thin/absent lateral eyebrows in eczema
What is dirty neck?
reticulate pigmentation due to longstanding eczema
How may eyes/eye region be affected in eczema?
Conjunctivitis, keratoconus
‘atopic red face’
eyelid only eczema - ichenification is characteristic
Orbital darkening/Panda eyes – grey-brown-violet skin around eyes. Often pale elsewhere
Dennie-Morgan infraorbital folds
Blepharitis
What are Dennie-Morgan infraorbital folds?
Start at or near inner canthus, extend ½ to 2/3 width of eye
single or double
T/F
nails are usually spared in adult hand dermatitis
True
kids more vesicular and more likely nail involvement – coarse pits and ridges
T/F
Half of pts with atopic hand eczema also have foot involvement
True
How do your test an eczematous child for potential immunodeficiency?
Immunoglobulin levels and subclasses, total IgE level, FBC, complement profile & function, Tcell, Bcell and phagocyte cell numbers and function tests. Consider also HIV and/or HTLV-1 testing
T/F
both RAST and skin prick tests have low specificity and positive predictive value (about 50%) but high sensitivty/negative predictive value (>95%)
True
good rule out tests
T/F
severity scoring systems are useful in rotione eczema practice
False JAAD says not useful NICE says classify as mild/mod/severe e.g. Diepgen SCORAD – Scoring atopic dermatitis EASI – Eczema area scoring index Rajka & Langeland score Nottingham score
T/F
Children with eczema often clear by teens
True 50% clear by teens many clear by school age Overall; 50% clear in about 10 years and 85% clear in up to 20 years
What are the features of Atopic keratoconjunctivitis?
JAAD paper on this 2014
Chronic (not seasonal) itching, watering, burning pain, blurred vision
Most severe ocular complication – can cause blindness
Suspect esp if eyelid/periorbital eczema, look for red eyes
Urgent ophthal referral - see within days
What are the eye complications of eczema?
Blepharitis - common if eyelid AD
Cataracts
Atopic keratoconjunctivitis
Vernal keratoconjunctivitis (cobblestone papillae on upper palpebral conjunctivae)
Keratoconus (conical cornea) – rare, can be assoc w/ AD
Retinal detachment (rare)
T/F
stress-responders are pts whose eczema flares when they are stressed
True
‘no-stress responders’ have no association between stress and disease course
What are the complications of eczema?
Psychological - family dysfunction, school/work problems, relationship problems, social stigma, mental health problesm
Financial - v costly
QoL - impaired for pt and caregivers
Skin - infection, lichenification, prurigo nods, dyspigmentation, erythroderma, hand dermatitis, topical or systemic steroid AEs
Eyes - several
Systemic - sleep disturbance, irritability, poor concentration, growth delay
Other drug AEs including those from alternative medicines
T/F
Psychoneuroimmunology is the interaction between nervous and immune systems by hormones, neuropeptides and neurotransmitters
True
a brain-skin connection underlies many inflammatory dermatosis
T/F
Stress responses can stimulate mast cell activation
True
T/F
AD patients may have a blunted production of cortisol so that CRH release is not switched off by negative feedback
True
T/F
Stress causes increase endogenous glucocorticoids and reduced lipid synthesis and impairs skin barrier function leading to flares of AD or other skin disease
True
T/F
high perceived stress levels have no effect on barrier recovery rates
False
cause delayed barrier recovery rates
T/F
>90% of AD pts experienced itch at least once a day
True
70% do 5x per day
may experience their itch as heat or pain
T/F
In AD levels of depression, anxiety and suicidal ideation correlate with disease severity
False
levels are higher than normal but dont corelate with severity
T/F
The impact of AD on health related QoL is same as arthritis, diabetes, heart disease, depression or if severe the same as CF or renal disease
True
T/F
adults with AD have lower libido
True
T/F
It is important to to assess pts mental state and QoL during the consultation for AD
True
What info is important to provide at first diagnosis of atopic dermatitis?
Explain diagnosis - written info
Must explain chronicity - need to manage; cant cure
Prognosis - tends to improve
Associations esp atopic march
Usually not diet related but may have food allergies also
advise on triggers and irritants
Establish short and long term goals of treatment
provide written management plan inc managing flares
info on dose and frequency of Rx, how to step up or down
advise on recognistion of infection
where to find further info/ get support
What is Therapeutic Patient Education (TPE)?
Educational strategy for pts/carers
Delivered by MDT
For pts with little social support or failed treatment
Tailored to pts educational and cultural background
4 steps;
- Understand pts current knowledge, beliefs etc
- Determine educational objectives with the pt
- Help pt/carer to acquire knowledge and skills – wide range of tools/resources used
- Assess the TPE process
Good evidence for improved disease control and QoL esp for interventions lasting >30 mins
T/F
Demonstrating how to apply topicals and wet wraps improves compliance and disease control
True
How do you do ‘soak and smear’?
AJD, 2015
Apply compress of lukewarm tap or bathwater to area for 10-20 mins then apply TCS
T/F
‘soak and smear’ is a useful alternative to wet dressings
True
T/F
In eczema pts after a bath topical steroid or emollient should be applied within 10 minutes of drying
False
within 30 minutes max but ideal is within 3-5 minutes
T/F
using TCS in evening with emollient in morning can as effective as BD steroid
True
Which steroids are more suitable for children under age 1?
Usually moderate and/or mild potency but may need potent
Elocon and advantan/AFO have increased cutaneous metabolism so less systemic bioavailability so better for kids (as have high rates of systemic absorption)
T/F
cling film occlusion is a useful technique in eczema
False
use wet dressings for occlusion NOT cling film
T/F
can leave wet wraps on for 24 hrs
True
Fine if tolerated
Usually used for up to 12 hrs
often left on overnight
What are the side effects of topical steroids?
Irritation and stinging (esp creams & gels or if contain alcohol or propylene glycol)
Skin atrophy, with striae, visible veins and easy bruising
Erythema and telangiectasia
Periorificial dermatitis/ steroid acne
Masking of infection esp tinea
If applied to eyelids; glaucoma, cataracts
Systemic steroid effects and HPA axis suppression
What is TCS withdrawal?
JAAD Hajar et al 2015
Skin eruption which can occur after using TCS daily. Usually mod or strong potency, rare in mild TCS
Occurs on ceasing TCS or during TCS use and required increase use/strength to prevent it
Well demarcated erythema with burning/stinging
Half of pts get papules/nodules/pustules
2 broad subtypes - about half of all pts in each subtype;
- Papulopustular subtype – erythema, papules, pustules – often TCS used for cosmetic reason or acneiform disorder
- Erythematoedematous subtype – burning erythema and oedema – often TCS used for eczema or seb derm
May be itch, pain, hot flushes and exacerbations with sunlight or heat
T/F
Most pts with steroid addiction/withdrawal have positive patch tests to a topical they are using
False
15% do
may be the TCS or another topical
How do you manage TCS withdrawal?
stop steroids
supportive cares – cold compresses, consider antibiotics if papular
Consider APT
consider a weaker TCS which the pt has not had a positive patch test to in order to wean off
T/F
topical calcineurin inhibitors increase risk of skin cancer
False
No proven risk of lymphoma or skin cancer
How do you prepare a bleach bath?
White King bleach 4%, 12mls in 10L warm water (not hot)
- fill bath with 10L bucket first time and mark level
bath for up to 15 mins
Can add 100g pool salt per 10L and/or 1-2 capfuls of oil per bath
RCH Melbourne advise; daily for one month; 3x/wk for 1 month; weekly for 1 month
Are topical antimicorbials useful in eczema?
Fucidic acid and bactroban not of use except nasal bactroban for eradication (Rook)
Mupirocin can be used alone in localized infections (BJD, 2014)
Clioquinol useful - can use with TCS; Hydroform or compounded
T/F
You should rinse off the bleach after a bleach bath
False
do not rinse
What are some trigers to avoid in eczema?
Mechanical – rough textiles, wood
Physical – car exhaust, tobacco smoke
Biological – pets, HDM, pollen, microbes
Chemical – acids, alcohol, solvents, bleaches, some foods/additives, vasoactive amines
T/F
emollients alone can settle acute eczema
False
Emollients can irritate acutely inflamed skin and increase risk of infections - settle acute flare before suing emollient
T/F
Potent or superpotent TCS cream is mainstay for (wet) acute eczema flares
True
Some pts w/ very acutely inflamed lesions will not tolerate TCS alone and need wet wrap therapy with potent TCS cream for several days
What is ‘proactive’ or ‘hot spot’ Rx? why is it used?
Apply TCS or TCI twice a week to previously affected areas and emollient only to non-affected areas
– results in reduced flare incidence and duration and improved QoL
T/F
tachyphylaxis occurs with antihistamines
True
take a break every 2 weeks
T/F
CsA is better tolerated in kids than adults
True
‘Drug of choice for refractory AD’ (BJD)
In kids kids check BP and U&E every 2 weeks for first 3/12 then monthly
T/F
A 3-6 month course of CsA is often sufficient to gain control in kids with eczema
True
Start at 3-5mg/kg/day (often 5) and wean down to lowest effective dose if acute, otherwise can start low and work dose up
T/F
CsA is 1st line for long term systemic in AD
False
AZA 1st line if long term systemic needed
Usually in kids about 2.5 mg/kg/day but up to 4 (higher than adults)
T/F
AZA causes photosensitivty
False
but increases risk of skin cancer so avoid sun
T/F
nbUVB in eczema uses same protocol as in psoriasis
True
Eczema is a stronger risk factor for food allergy than asthma
False
other way around
T/F
Food can aggravate eczema in 10-35% of young children
True
Food allergy may result from and aggravate eczema rather than ‘causing’ it
Which 6 foods account for >90% of childhood food allergies which can aggravate eczema?
Eggs (most often reported to flare AD) Milk Peanuts Soy Wheat Fish
T/F
Milk and soy allergies tend to persist
False
(tree) nuts, fish and shellfish allergies tend to persist
other resolve in childhood
When to test for food allergy in AD?
US JAAD guidelines – can consider limited food allergy testing to 6 highest risk foods if pt is under 5 and has mod-severe eczema and
o Fails to clear despite optimized topical therapy; Or;
o Reliable Hx of immediate allergic reaction after ingesting a specific food; Or;
o Both of above
T/F
In AD with food allergies if cows milk an issue try extensively hydrolysed formula or amino acid formula rather than soy as can also be allergic to soy
True
T/F
Strong evidence that breast feeding prevents eczema
False
What is the most important inhaled allergen for eczema?
Housedustmite antigen
T/F
TCS are the most common contact allergens in atopic dermatitis allergic contact dermatitis
False
Most common are;
Nickel, neomycin, fragrance, formaldehyde and other preservatives, lanolin and rubber chemicals
What is protein contact dermatitis?
what are the causes?
= contact urticaria
Allergy to contact with plant or animal proteins
causes initial urticaria within 30mins then a dermatitis like eczema which can be acute or chronic
E.g. fruit/veg, grain, latex, meats, fish, mites, insects, nuts, spices/herbs, animal dander/hair/saliva/urine
T/F
probiotics help restore a normal skin microbiome in eczema
False
no evidence of benefit
It is unclear if gut microbiome impacts on skin microbiome
T/F
Evening primrose oil helps reduce itch in eczema
False
no evidence of benefit
T/F
consultations with dermo for eczema usually meet patients expectations
False
data from UK;
Only 19% of initial eczema consultations w/ dermatologist met pt expectations in UK
Only 50% of pts satisfied with the treatment given
Why do eczema pts get por outcomes/ treatment failure?
AJD review paper Sokolova, 2015 (NSW);
- Treatment regimes too complex and time consuming
- Lack of understanding of what different topical are and when and how to use them
- Health related QoL is impaired for both eczema kids and caregivers – negatively impacts on adherence
- Patient/carer dissatisfaction – less likely to adhere if not involved in decision making
- White coat compliance
- Long follow up results in lower rates of compliance
- Corticosteroid phobia – >80% of parents worried about effects of steroids
- Use of complementary and alternative medicines
What steps should you take if eczema pt fails to respond?
Take Hx of triggers/ change in behaviours
Check compliance and assess for steroid phobia
assess for infection (and infestation)
Consider an alternative or additional diagnosis;
Irritant CD
ACD
Protein contact dermatitis
Photo allergic contact, phytophoto, photo-drug etc
Other – lupus, DH, MF, nutritional deficiency, immune deficiency
Drug eruption
Consider investigation - food diary, APT, RAST, skin prick
Finally consider escalating Rx
What is ‘white coat compliance’ ?
medications (esp TCS) are used most around the time of clinic visits but rapidly drop off after opd until shortly before
T/F
Fibulin is the major gene mutation in eczema
False
FLG gene which codes for fillagrin
Different populations display different mutations at different frequencies = ‘ethnospecific profiles’
T/F
Bathing without subsequent emollient leads to dry skin
True
T/F
HPA axis suppression is highly unlikely in kids with eczema even with long use of TCS
False
HPA axis suppression can occur quickly in children even with low or moderate strength TCS
Try to keep courses to under 3 weeks
acute flares need Rx for 1-2 weeks
What methods can be used to improve treatment adherence in AD?
Optimize relationship between Dr and patient/caregiver
Education – can’t have too much! E.g. handouts, demonstration, nurse-led training sessions, videos, workshops
Particular education about TCSs
Written eczema action plan
Encouragement strategies – sticker charts for kids, texts for teens etc
Early and frequent follow up
Emphasize improved QoL for whole family if better disease control is gained
What are the 5 Pillars of AD management?
Eczema is a ‘Cycle RACE’
- Tackling itch-scratch cycle
- Rebuilding and maintaining optimal barrier function
- Avoidance/modification of environmental triggers
- Clearance of inflammatory skin disorders
- Education and empowerment of Pt/caregiver
T/F
Moisturizers act as topical steroid sparers reducing need for TCS
True
T/F
Moisturizer and emollient mean the same thing
False Moisturizers have varyng amounts of these properties; Occlusive (prevent water loss) Humectant (trap moisture in SC) Emollient (lubricate)
How much moisturizer should be used in AD?
100-200g/wk in kids
200-300g/wk in adults
T/F
prescription emollient devices (PEDs) containing ceramides or filaggrin breakdown products are more effective than other moisturizers
False
no evidence for this
What is a fingertip unit?
‘amount of topical expressed from tube with a 5mm diameter nozzle from distal skin crease to tip of index finger of an adult’
covers the surface area of a hand (2 palms)
is about 0.5g
How many FTUs are needed for the bosy in adults?
Entire body: about 40 units (20g)
One hand: apply one fingertip unit
One arm: apply three fingertip units
One foot: apply two fingertip units
One leg: apply six fingertip units
Face and neck: apply 2.5 fingertip units
Trunk, front & back: 14 fingertip units
T/F
Infected skin is a contraindication to TCS
False
No contraindication to TCS in infection but must treat infection
When are wet dressings most useful?
when are they not advisable?
Should be used during acute flares in mod-severe eczema with or without TCS
Avoid or use with caution if any infection present
T/F
50% of adult pts with eczema carry staph
False
90% carry staph
In 90% of affected areas and 75% of uninvolved areas
T/F
there is controversy about the use of topical antibiotics and antimicrobials in eczema
True
AsiaPacific committee doesn’t support topical antiseptics (bleach baths, triclosan, benzalkonium chloride, chlorhex) due to risk of irritation and removal of normal skin commensals
JAAD supports bleach bath w/ intrnasal bactroban as eradication for pts with recurrent clinical staph infections
Rook says never use bactroban except nasally
BJD paper says bactroban can be used alone in localized infections
T/F
Phototherapy can be used in children over 12 years
True
not for kids under 12
T/F
Oral steroids are never useful in AD
False
Short term oral steroids may be useful – up to 6 wks for acute flares
Don’t use IV or IM steroids
What strategies may help Primary prevention of eczema in a baby?
early avoidance of food and aero allergens may prevent developing allergy ie) in first 6 months of life
Early life exposure to endotoxins, farm animals and dogs may be protective
Breast feeding recommended and may reduce AD, also extensively hydrolysed cows milk formula rather than cows milk or soy formulas
Weak evidence that maternal avoidance of milk, eggs and other dietary allergens in pregnancy and lactation can reduce risk of eczema
Pro or pre -biotics for preg mum or child up to age 4 may also help reduce AD development
Early use of emollient can be protective
T/F Eczema herpeticum (Kaposi’s varicelliform eruption) is a more widespread skin involvement than would be seen on normal skin infected with same virus (usually HSV1)
True
Most Herpes infections in eczema pts are localized and not more severe than in normal pts so should not be called KVE but often still called ‘eczema herpeticum’
T/F
Eczema herpeticum can be caused by primary or recurrent herpes infection
True
Primary infection more likely to cause malaise, fever and low lymphocyte count
What are the risk factors for Eczema herpeticum?
Age – most common in teens and 20s Early age of onset of AD High IgE Severe eczema and asthma Not linked to TCS or topical calcineurin inhibitors
T/F
Eczema herpeticum causes scarring
False
What are complications of Eczema herpeticum?
Rare progression to systemic infection – can be fatal
herpes keratitis - must get ophthal consult if close to eyes
meningoencephalitis
T/F
In Eczema herpeticum early initiation of antivirals reduces length of hospital admission
True
T/F
In Eczema herpeticum should use antivirals early and for at least 7 days
True
IV if severe
also swab for baceria
most dermos give course of Abs empirically
T/F
should stop TCS in cases of Eczema herpeticum
False
can continue if on Rx for HSV and also for bacteria
Whats the incubation period for HSV/Eczema herpeticum?
about 10 days (5-20)
T/F
Immiquimod should be avoided in eczema pts with molluscum
False
can use all treatments
some may be iritating so try to keep off eczema skin
T/F
Malasezzia hypersensitivity can be a cause of treatment failure esp in pts with severe facial AD
True
Test w/ skin prick to malasezzia extracts
Rx w/ 2 weeks of oral itraconazole
Treatment ladder for atopic dermatitis
General measures - trigger avoidance, education, soap free wash
Emollient - TDS, cream if acute, ung if subacute/chronic
Anti-infectives as required
TCS - BD or OD, up to 3 weeks; stenght depends on pt age and body site; formulation on acuteness; advantan and mometasone safer for infants
soak and smear
wet dressings (both emollient or TCS)
TCNI - short course or as proactive Rx; esp if steroid AEs
+/- sedating antihistamines prn short course
Phototherapy - 2nd line if >12 years
Systemics;
pred - for up to 6 wks to gain control
CsA - for up to 3-6 months
AZA - 1st line for long term Rx - 1-2 yrs. 2.5-4mg/kg
MMF - 2nd line; 25-50mg/kg/day in kids >2yrs
MTX - 3rd line; 7.5-25mg weekly
Rarely needed;
monteleukas
oral/topical sodium cromoglycate
PDE4 inhibitors (Apremilast)
IVIg; 0.5g/kg daily for 4 days each month for min 3/12
IFN gamma - last line
Also consider and treat;
ACD, food allergy, protein contact dermatitis, inhlaed aeroallergens esp HDM
Rx associated depression, anxiety, ADHD
Education and engagement of caregivers is paramount
