Eczema

Eczema Li Xiao-hong Dept. of Dermatology The first affiliated hospital of zhengzhou university

Definition(1) 

The terms 'dermatitis' and 'eczema' are nowadays generally regarded as synonymous.  Some authors still use the term 'dermatitis' to include all types of cutaneous inflammation  All eczema is dermatitis, but not all dermatitis is eczema.

Definition(3) 

The clinical features of eczema may include clustered papulo-vesicles, redness, scaling and itching ；

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Eczema is an inflammatory skin reaction characterized histologically by 

spongiosis with varying degrees of acanthosis,

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a superficial perivascular lympho-histiocytic infiltrate.

Definition(2)

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Spongiosis refers to intercellular edema of the epidermis. Acanthosis refers to increased thickness of the epidermis. superficial perivascular lympho-histiocytic infiltrate.

The condition may be induced by a wide Etiology range of external and internal factors acting singly or in combination. 

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Endogenous factors genetic factor (hereditary background) infection focus (bacteria or virus) neuropsychic factor (anxious, stress, depressed) ▪▪▪ ▪▪▪ Exogenous factors some irritant food (pepper, white wine ▪▪▪) physic factor (sunlight, coldness▪▪▪) chemical factor (cosmetics, soap ▪▪▪) ▪▪▪ ▪▪▪

Pathogenesis  Some

cases of eczema may be related to type Ⅳ hypersensitivity.  However, the pathogenesis of some cases is unknown.  Eczema accounts for a large proportion of skin diseases.

Classification(1)  The

classification of the many clinical forms is difficult, because in many cases the precise cause is unknown, and because two or more forms of eczema may be present in the same patient simultaneously or consecutively.  The classification divides eczema into two groups  

exogenous eczema endogenous eczema.

Classification(2)  Exogenous

eczemas are related to clearly defined external trigger factors in which inherited tendencies play a minor role  Exogenous eczemas include irritant dermatitis, allergic dermatitis, infective dermatitis, et al.

Classification(3) eczema implies that the  endogenous

eczematous condition is not due to exogenous or external environmental factors, but is mediated by processes originating within the body.  Endogenous eczemas include atopic eczema, hand eczema, nummular eczema, asteatotic eczema, stasis eczema, et al.

Three stages of eczema  Acute

eczema

 Subacute  Chronic

eczema

eczema

Clinical Manifestation   

Acute eczema The onset is acute; Erythema, papule, papulovesicle, erosion, exudation are common.

Erythema, grouped papules and papulovesicles on the left arm.

Erosion, exudation on the anterior area of the right ear.

Clinical Manifestation  

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Subacute eczema Subacute eczema is from the relief of acute eczema or the aggravation of chronic eczema; The lesions are little xerotic erythema with small patch of exudation and scattered crusting.

The erythema with small patch of exudation and scattered crusting on the periumblical area.

Clinical Manifestation  

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Chronic eczema The chronic eczema is often from the prolongation of the acute or subacte eczema, occasionaly beginning as the chronic feature; The lesions of chronic eczema include lichenification, pigmentation, scaling and excoriation.

Notable lichenification with excoriation, scaling on the ankle.

Diagnosis  Regardless

of any form, eczema shows some common clinical features as follows:   

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Chronic and recurrent; Symmetrical distribution and ill-defined; The lesions include erythema, papule, papulovesicles, scaling, lichenification, which tend to exudation; Intense and severe pruritus.

Some important eczemas  infective eczema  atopic  hand

eczema

eczema

 nummular

eczema

 asteatotic

eczema

 stasis  ▪▪▪

▪▪▪

eczema

 Infective eczema Infective eczema(1) is eczema which is

caused by microorganisms or their products, and which clears when the organisms are eradicated.  This should be distinguished from infected eczema in which eczema due to some other cause is complicated by secondary bacterial or viral invasion of the broken skin.

Infective eczema(2)

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Infective eczema in a man. Well-demarcated erythema, with some papulovesicles, on the lumbosacral area. Histology of this localized rash showed eczema, and Staphylococcus aureus was repeatedly isolated. There was no response to topical steroid therapy, but the condition cleared rapidly with oral flucloxacillin.

Atopic eczema --definition  Atopic

eczema or dermatitis (AD) is a pruritic disease of unknown origin that starts in early infancy and is typified by pruritus, eczematous lichenified lesions, and xerosis of the skin.  AD is associated with other atopic diseases (asthma, allergic rhinitis, urticaria) and increased immunoglobulin E (IgE) production.

Atopic eczema -- etiology  

Hereditary background A family history is obtained in about 70% of all cases.

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Immunological abnormalities

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The main immunological abnormalities are excessive formation of IgE.

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Bacteriology

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The skin of patients with atopic dermatitis tends to carry more staphylococci, even without clinical evidence of infection.

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Atopic eczema -- three stages  Atopic

eczema or dermatitis can be divided into three stages: 

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Infantile atopic eczema, occurring from 2 month to 2 years of age; Childhood atopic eczema, from 2 to 10 years; The adolescent and adult stage of atopic eczema.

Atopic eczema -- Infantile atopic eczema(1) 

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The disease runs a chronic, fluctuating course, varying with such factors as teething, respiratory infections, et al. The lesions most frequently start on the face. The exposed surfaces, especially the extensor aspect of the knees, are most involved. The lesions consist of erythema and discrete or confluent edematous papules, and may become exudative and crusted as a result of rubbing. The lesions are intensely itchy.

Atopic eczema -- Infantile atopic eczema(2) the erythema and minute erosion on the face

Atopic eczema -- Childhood atopic eczema(1)  The

lesions are often lichenified, slightly scaly, or infiltrated plaques which are apt to less exudative, drier, and more popular than those of infantile atopic eczema.  The classic locations are the antecubital ( 肘 ) and popliteal( 腘 ) fossae, the flexor wrist, eyelids, and face, and around the neck.

Atopic eczema -- Childhood atopic eczema(2)

Marked lichenification on the cubital fossa

Flexural atopic dermatitis of the wrist in a child

Atopic eczema -- Childhood atopic eczema(3)

erythema, papules, excoriations, crusting ， but little lichenification.

Nail involvement in atopic dermatitis in childhood.

Atopic eczema -- the adolescent and adult stage of atopic eczema(1)  The

picture in this stage is essentially similar to that in later childhood, with lichenification, especially of the flexures and hands.  In addition, dryness is prominent.  A brown ring around the neck is typical but not always present.

Atopic eczema -- the adolescent and adult stage of atopic eczema(2)

Adult flexural dermatitis

Dirty neck sign in chronic atopic dermatitis

Atopic eczema --diagnostic criteria(1) 

the UK diagnostic criteria, the child must have  An itchy skin condition (or parental report of scratching or rubbing in a child)  Plus three or more of the following  1 Onset below age 2 years (not used if child is under 4 years)  2 History of skin crease involvement (including cheeks in children under 10 years)  3 History of a generally dry skin  4 Personal history of other atopic disease (or history of any atopic disease in a first degree relative in children under 4 years)  5 Visible flexural dermatitis (or dermatitis of cheeks/forehead and outer limbs in children under 4 years)

Hand eczema(1)  Hand

eczema is a common, often recurrent condition which varies from being acute and vesicular to chronic, hyperkeratotic and fissured.  Hand eczema results from a variety of causes, such as atopic eczema, allergic causes, fungal infection and occupational factors, and often several factors are involved.

Hand eczema(2) 

Hand eczema often present as a chronic eczema( scaling, hyperkeratotic and fissured ), but may appear as a vesicular eruption because of pompholyx, atopic eczema or contact dermatitis.

Hyperkeratotic, fissured eruptions on the palms and fingers

Hand eczema(3)  Hand

eczema---pompholyx(1)  Pompholyx is a form of eczema of the palms and soles.  Pompholyx may occur at any age, but it is more common before the age of 40 years. Onset before 10 years is unusual.  It often occurs in warm weather, and is often recurrent.

Hand eczema(4)  Hand

eczema---pompholyx(2)  In a typical case the vesicles develop symmetrically on the palms and/or soles. In 80% of patients only the hands are involved.  The primary lesions are macroscopic, deepseated vesicles on the sides of the fingers, palms and soles.  The eruption is symmetrical and pruritic, with pruritus often preceding the eruption.

Hand eczema(5)

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Pompholyx, showing macroscopic, deep-seated vesicles on the palm

Nummular eczema(1)  Nummular

(discoid) eczema is an eczema of unknown etiology characterized by coinshaped lesions on the limbs, which typically affects middle-aged women.  The diagnostic lesion of discoid eczema is a coin-shaped plaque of closely set, thin-walled vesicles on an erythematous base. This arises, quite rapidly, from the confluence of tiny papules and papulovesicles.  Pruritus is usually severe.

Nummular eczema(2)

coin-shaped plaque on the dorsum of hand

coin-shaped plaque on the lower leg

Asteatotic eczema(1)  Asteatotic

eczema is also known as xerotic eczema or winter itch.  Asteatotic eczema is a dry eczema with fissuring and cracking of the skin, often affecting limbs in the elderly.  Overwashing of patients in institutions, a dry winter climate, hypothyroidism and use of diuretics can contribute to eczema in elderly atrophic skin.

Asteatotic eczema(2)  This

condition occurs particularly on the legs, arms and hands.  The primary lesion is a round, small patch covered with a skin-colored to red adherent scale.  The lesions resemble crackled porcelain

Asteatotic eczema(3)

The asteatotic skin is dry and slightly scaly. The lesions resemble crackled porcelain

Stasis eczema (dermatitis)(1) 

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Stasis eczema is associated with underlying venous disease ， usually in the lower leg. Incompetence of the deep perforating veins increases the hydrostatic pressure in the dermal capillaries. The eczema is usually accompanied by other manifestations of venous hypertension, including dilatation or varicosity of the superficial veins, edema, purpura, haemosiderosis, ulceration, or small patches of atrophy . Leashes of dilated venules around the dorsum of the foot or the ankle are particularly common.

Stasis eczema(2)

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Stasis eczema: pigmentation, edema, ulceration of the lower legs

Treatment(1)  General

 Topical

advice (therapy)

therapy

 Systemic

therapy

Treatment(2)  General

advice (therapy) (1)  Removing or avoiding the possible causes (irritant food, cosmetic, et al);  Rest should be complete or local according to the severity and extent of the eczema. An affected leg should be elevated or well supported, and affected hands should be used as little as is practicable. Complete bed rest is advisable for severe eczema

Treatment(3)  General

advice (therapy)(2)  Explanation, reassurance and sympathy will help to alleviate anxiety. Patients should be taught current knowledge of the disease, the types of trigger factors, the treatment options and their likely benefits and risks.

Treatment(4)  Topical       

therapy(1)

Topical medicaments include wet dressing, emollients, topical corticosteroid cream or paste, tar, intralesional steroid injection, tacrolimus et al.

Treatment(5)  Topical 

therapy(2)—actue eczema

For the patient with acute eczema, topical applications should be bland. Wet dressings, aqueous cream or zinc cream are soothing and valuable. Topical corticosteroids are generally used to speed resolution. Generally speaking, medium-strength preparations are adequate. When secondary infection is thought likely to occur, combined steroid antibacterial agents may be used.

Treatment(6)  Topical 

therapy(3)—subacute eczema

At the subacute stage, paste bandages are of special value in occluding areas and may help to break the itch-scratch vicious circle. All dressings should be firmly applied but be light and comfortable. Corticosteroids under polythene occlusion may be helpful, if only for a few days, to lessen itching.

Treatment(7)  Topical 

therapy(4)—chronic eczema

At this stage, emollients should be applied thinly, evenly and, above all, frequently. Mild topical corticosteroids are helpful, and are often used in combination with a tar paste. Occlusive dressings may be useful.

Treatment(8)  Systemic

therapy(1)  Antihistamines, such as chlorpheniramine, diphenhydramine, cetirizine, are used to alleviate pruritus.  systemic steroids in severe cases .  Immunomodulators, methotrexate or cyclosporine, can be used for the patients with severe disease in whom conventional therapy is ineffective.