Inflammatory Skin Conditions

Question 1

What is Eczema?

Answer 1

• Eczema (or dermatitis) is a chronic skin condition common in children but also prevalent in adults.
• 20% prevalence in <12 years old in the UK

Question 2

What are the causes of Atopic Eczema?

Answer 2

Not fully understood, but

• Positive family history of atopy (i.e. eczema, asthma, allergic rhinitis) is often present
• Primary genetic defect in skin barrier function (loss of function variants of the protein filaggrin) appears to underlie atopic eczema
• Exacerbating factors such as infections, allergens (e.g. chemicals, food, dust, pet fur), sweating, heat, occupation and severe stress

Question 3

What is the presentation of Atopic Eczema?

Answer 3

• Acute presentation consists of itchy papules and vesicle often weepy (exudative)
• Chronic lesions: dry scaly itchy patches can be erythematous in paler skin or grey/ brown in richly pigmented skin
• More common on the face and extensor aspects of limbs in infants, and the flexor aspects in children and adults
• In richly pigmented skin eczema may present as brown, grey or purple bumps (papular eczema or follicular eczema)
• Chronic scratching/rubbing leads to lichenification
• Across of skin types eczema can lead to pigmentary changes such as hypopigmentation (reduced pigmentation) and hyperpigmentation (increased pigmentation)
• Nail may show pitting and ridging of the nails

Question 4

What is the management of Atopic Eczema?

Answer 4

• General measures: avoid known exacerbating agents, frequent emollients +/- bandages and bath oil/soap substitute
• Topical therapies: topical steroids for active areas; topical immunomodulators (e.g. tacrolimus, pimecrolimus) for maintenance therapy as steroid-sparing agents
• Oral therapies: antihistamines for symptomatic relief, antibiotics (e.g. flucloxacillin) for secondary bacterial infections, and antivirals (e.g. aciclovir) for secondary herpes infection
• Phototherapy and immunosuppressants (e.g. azathioprine, ciclosporin, methotrexate) for severe non-responsive cases, biologic therapy

Question 5

What are complications of Atopic Eczema?

Answer 5

• Secondary bacterial infection (crusted weepy lesions)
• Secondary viral infection - molluscum contagiosum (pearly papules with central umbilication), viral warts and eczema herpeticum

Question 6

What is Acne?

Answer 6

• An inflammatory disease of the pilosebaceous follicle
• Over 80% of teenagers aged 13- 18 years

Question 7

What are the causes of Acne Vulgaris?

Answer 7

• Hormonal (androgen)
• Contributing factors include
  
  • Increased sebum production
  • Abnormal follicular keratinization
  • Bacterial colonization (Propionibacterium acnes)
  • Inflammation

Question 8

What is the presentation of Acne Vulgaris?

Answer 8

• Non-inflammatory lesions (mild acne): open and closed comedones (blackheads and whiteheads)
• Inflammatory lesions (moderate and severe acne): papules, pustules, nodules, and cysts
• In richly pigmented skin:
  
  • Inflammatory lesions’ may not be so apparent, instead hyperpigmented lesions (‘acne hyperpigmented macules’) are seen.
  • Hyperpigmented lesions may also signify ongoing inflammation
  • Non-erythematous nodules may be present and detected by palpation

Commonly affects the face, chest and upper back

Question 9

What is the management of Acne Vulgaris?

Answer 9

• General measures: no specific food has been identified to cause acne, treatment needs to be continued for at least 6 weeks to produce effect
• Topical therapies (for mild acne): benzoyl peroxide and topical antibiotics (antimicrobial properties), and topical retinoids (comedolytic and anti-inflammatory properties)
• Oral therapies (for moderate to severe acne) - oral antibiotics, and anti-androgens (in females)
• Oral retinoids (for severe acne)

Question 10

What are complications of Acne Vulgaris?

Answer 10

• Post-inflammatory hyperpigmentation
• Scarring
• Deformity
• Psychological and social effects

Question 11

What is Psoriasis?

Answer 11

A chronic inflammatory skin disease due to hyperproliferation of keratinocytes and inflammatory cell infiltration

Question 12

What are types of Psoriasis?

Answer 12

• Chronic plaque psoriasis (most common type)
• Guttate (raindrop lesions)
• Seborrhoeic (naso-labial and retro-auricular)
• Flexural (body folds)
• Pustular (palmar-plantar)
• Erythrodermic (total body redness)

Question 13

What is the cause of Psoriasis?

Answer 13

• Complex interaction between genetic, immunological and environmental factors
• Precipitating factors include trauma (which may produce a Köebner phenomenon), infection (e.g. tonsillitis), drugs, stress, and alcohol

Question 14

How does Psoriasis present?

Answer 14

• Well-demarcated erythematous scaly plaques
• In richly pigmented skin psoriasis can present as dark brown, grey or purple patches or plaques
• Lesions can sometimes be itchy, burning or painful
• Common on the extensor surfaces of the body and over scalp
• Auspitz sign (scratch and gentle removal of scales cause capillary
• bleeding)
• 50% have associated nail changes (e.g. pitting, onycholysis)
• 5-8% suffer from associated psoriatic arthropathy - symmetrical polyarthritis, asymmetrical oligomonoarthritis, lone distal interphalangeal disease, psoriatic spondylosis, and arthritis mutilans (flexion deformity of distal interphalangeal joints)

Question 15

What is the management of Psoriasis?

Answer 15

• General measures: avoid known precipitating factors, emollients to reduce scales
• Topical therapies (for localised and mild psoriasis): vitamin D analogues, topical corticosteroids, coal tar preparations, dithranol, topical retinoids, keratolytics and scalp preparations
• Phototherapy (for extensive disease): phototherapy i.e. UVB and photochemotherapy i.e. psoralen+UVA
• Oral therapies (for extensive and severe psoriasis, or psoriasis with systemic involvement): methotrexate, retinoids, ciclosporin, mycophenolate mofetil, fumaric acid esters,and biological agents (e.g. etanercept, adalimumab, ustekinumab)