Atopic Dermatitis, Contact Dermatitis, and Eczema

BIO
Atopic Dermatitis, Contact
Dermatitis, and Eczema (Rashes)
D. Kishore Yellumahanthi, MD, MPH
CME073 Wednesday, 9:15-10:15 a.m., Location: 151AB
CME074 Wednesday, 1:45-2:45 p.m., Location: 151AB
ACTIVITY DISCLAIMER
The material presented here is being made available by the American
Academy of Family Physicians for educational purposes only. This material
is not intended to represent the only, nor necessarily best, methods or
procedures appropriate for the medical situations discussed. Rather, it is
intended to present an approach, view, statement, or opinion of the faculty,
which may be helpful to others who face similar situations.
The AAFP disclaims any and all liability for injury or other damages resulting
to any individual using this material and for all claims that might arise out of
the use of the techniques demonstrated therein by such individuals, whether
these claims shall be asserted by a physician or any other person. Every
effort has been made to ensure the accuracy of the data presented here.
Physicians may care to check specific details such as drug doses and
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material might contain recommendations/guidelines developed by other
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• A board certified family physician
• completed residency in dermatology in India and
practiced as consultant dermatologist
• MPH from University of Alabama at Birmingham, AL
• written numerous journal articles
• Lectured on a range of topics including tropical
infectious diseases, HCV and lichen planus, and HIV
infection.
• Currently, I practice family medicine at Huntsville
Hospital, in Huntsville, Alabama, and in a hospitalaffiliated practice in Gurley, Alabama.
Learning Objectives
1. Compare symptomatology of the different types of
eczema and dermatitis.
2. Counsel patients on lifestyle modifications to
control flare-ups and triggers for atopic dermatitis
and contact dermatitis.
3. Recognize when patients require patch testing to
confirm or rule out allergic contact dermatitis.
4. Create a disease management strategy for patients
with eczema and dermatitis based on the type and
severity of the condition.
FACULTY DISCLOSURE
It is the policy of the AAFP that all individuals in a position to control
content disclose any relationships with commercial interests upon
nomination/invitation of participation. Disclosure documents are
reviewed for potential conflict of interest (COI), and if identified,
conflicts are resolved prior to confirmation of participation. Only those
participants who had no conflict of interest or who agreed to an
identified resolution process prior to their participation were involved
in this CME activity.
All faculty in a position to control content for this session have
indicated they have no relevant financial relationships to disclose.
Agenda
•Classification of Eczema
•Atopic Dermatitis
•Contact Dermatitis
The content of my material/presentation in this CME activity will not
include discussion of unapproved or investigational uses of products
or devices.
1
What is Eczema?
• Clinical and histological pattern of inflammation of the
skin seen in a variety of dermatoses wih widely diverse
etiologies.
• Clinically, eczematous dermatoses are characterized by
variable intensity of itching and soreness and in variable
degrees, a range of signs including dryness, erythema,
excoriation, exuation, fissuring, hyperkeratosis,
lichenification, papulation, scaling and vesiculation.
Rook’s Textbook of Dermatology
Learning Objectives/Goals
1. Compare symptomatology of the different types of
eczema and dermatitis.
2. Counsel patients on lifestyle modifications to
control flare-ups and triggers for atopic dermatitis
and contact dermatitis.
3. Recognize when patients require patch testing to
confirm or rule out allergic contact dermatitis.
4. Create a disease management strategy for patients
with eczema and dermatitis based on the type and
severity of the condition.
30 year old female has the following rash since a
month or so. Mild itching. Has similar rash on the face
and in the pubic area.
Common types of Eczema
Common types of Eczema
Endogenous
Exogenous
Atopic dermatitis Contact
dermatitis
Seborrheic
dermatitis
P. alba
Asteotic eczema
Hand eczema
…………………
• A. Seborrheic
dermatitis
• B. Psoriasis
• C. Dermatophytosis
• D. Polymorphic light
eruption (PMLE)
35 year old has been having the following rash for the
last 6 months or so. Similar,lesions are also present
elsewhere on the body predominantly in the areas
covered by clothes.
• A. Seborrheic
dermatitis
• B. Psoriasis
• C. Allergic contact
dermatitis
• D. Polymorphic light
eruption (PMLE)
2
15 year old boy has this rash since 3 months or so. Has
similar rash on the face and flexors of elbow. Lesions
were few initially and has been getting worse. Mom
thinks child had been to his Dad’s place 3 months ago
and thinks he caught it from his step sister
• A. Seborrheic
dermatitis
• B. Atopic dermatitis
• C. Allergic contact
dermatitis
• D. lichen simplex
chronicus
10 year old boy has this rash since more than 6 months
or so. Asymptomatic. Few lesions are also present on
the other forearm, trunk and face. Mom thinks that, of
late they have become more conspicous and in the
past they were little bit pink (erythematous) and scaly
• Contact dermatitis
• Polymorphic light
eruption
• Pityriasis alba
• Pityriasis rosea
40 year old male has the following itchy lesion for
the past one year or so. Has no lesions elsewhere.
D@nderm
• A. Seborrheic
dermatitis
• B. Psoriasis
• C. Lichen Simplex
Chronicus
• D. Polymorphic light
eruption (PMLE)
History and Clinical examination is
the key to diagnosis of eczema.
Diagnosis of Eczema – History taking
• Duration
• Sites of involvement
• Symptom
• Anybody else at home with similar complaint
• Co morbid conditions
• Similar complaints in the past
• If had used any topical medications already for the rash
Diagnosis of Eczema – History taking
• Seborrheic dermatitis - scalp, eyebrows, glabella, post
auricular region, nasolabial folds, front of chest,
interscapular area
• Atopic dermatitis - flexural areas, associated features
• Lichen simplex chronicus - accessible area for scratching.
Usually solitary
• P.alba – often on face
Why is contact dermatitis a difficult diagnosis to make?
3
Seborrheic Dermatitis
Seborrheic Dermatitis
• Malassezia furfur.
• Erythematous, sharply marginated lesions covered with
greasy-looking scales
• Scalp, eyebrows, glabella, post auricular region,
nasolabial folds, front of chest, interscapular area
Seborrheic Dermatitis
Asteotic Eczema
• Seen in elderly
• Associated with very dry skin
• Legs, arms and hands
• Parchment like pattern
Seborrheic Dermatitis
Asteotic eczema
4
Asteotic eczema
Hand Eczema
Pityriasis alba
Hand eczema
• Children 3-16 years
• hypopigmented patch.
• Usually several patches
• Course is variable
P. alba
Hand eczema
5
Lichen Simplex Chronicus
Lichen Simplex Chronicus
Atopic Dermatitis
Learning Objectives/Goals
1. Compare symptomatology of the different types of
eczema and dermatitis.
2. Counsel patients on lifestyle modifications to
control flare-ups and triggers for atopic dermatitis
and contact dermatitis.
3. Recognize when patients require patch testing to
confirm or rule out allergic contact dermatitis.
4. Create a disease management strategy for patients
with eczema and dermatitis based on the type and
severity of the condition.
Lichen Simplex Chronicus
What is Atopic Dermatitis?
• Itchy, Chronic, inflammatory
• Characterized by itchy papules which
become excoriated and lichenified
• Typically have flexural distribution
• Frequent association with other atopic
conditions
6
Atopic Dermatitis – Etiology &
pathogenesis
• Allergies, infections, emotional, climatic
and other environmental influences
• Epithelia have significant impairments of
innate antimicrobial defences
• Colonization of skin by S.aureus exacebates
eczema
• Food allergens and airborne allergens
Atopic Dermatitis – diagnosis..
• Hanifin and Rajka’s diagnostic criteria, the
child must have
• An itchy skin condition (or a parental
report of scratching or rubbing a child)
• Plus 3 or more of the below:
1. Onset below 2years (not used if child is
under 4yrs)
2. History of skin crease involvement
Atopic Dermatitis – clinical features
• Infantile
• Childhood
• Adolescent& adult
Atopic Dermatitis – clinical features
• Infantile – erythema of the face and then as
child starts crawling more exposed parts
are involved
• Onset after 2 months.
• Childhood :18-24 months
• Flexural distribution – elbow, knee, ankle,
wrist, sides of the neck
…Atopic Dermatitis - diagnosis
Atopic Dermatitis – clinical features
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 other limbs in
children under 4 years)
• Adult – lichenification in the flexures
• Lichenified follicular papules
• Localized distribution
• Complications – secondary infection,
psychosocial aspects
• Prognosis – Tendency towards spontaneous
improvement throughout childhood
7
Atopic Dermatitis
Atopic Dermatitis
Atopic Dermatitis
Atopic Dermatitis
Atopic Dermatitis
Atopic Dermatitis – Management
• Initial treatment – patient education,
avoiding or reduction of trigger factors, use
of emolients and topical steroids.
• Patient education – updated knowledge of
the disease, various trigger factors,
therapeutic options and their pros and
cons.
• Trigger factors – several – scratching, wool
clothing, stress, skin infections, food
allergens to name few.
8
Atopic Dermatitis – Management
• Reduction of trigger factors
- dispersible cream can be used as a soap
substitute to cleanse the skin
- Reducing/turning down the central heating
- Not heating the bed room
- Wearing cotton clothing
- Food allergens
Atopic Dermatitis – Management
• For maintenance therapy, low
corticosteroids
• Oral antihistamines, antibiotics
• Topocal calcineurin inhibitors
Learning Objectives/Goals
1. Compare symptomatology of the different types of
eczema and dermatitis.
2. Counsel patients on lifestyle modifications to
control flare-ups and triggers for atopic dermatitis
and contact dermatitis.
3. Recognize when patients require patch testing to
confirm or rule out allergic contact dermatitis.
4. Create a disease management strategy for patients
with eczema and dermatitis based on the type and
severity of the condition.
Contact Dermatitis
IRRITANT
DERMATITIS
Can occur in any
individual
Acids, alkalis, animals..
ALLERGIC CONTACT
DERMATITIS
Occurs only in those who
are previously sensitized
to the allergen
Cell mediated immunity
or hypersensitivity
Allergic Contact Dermatitis
Contact Dermatitis
• Can mimic or be associated with any type
of eczematous eruption
• Careful history & sound knowledge of
common allergens and irritants
Poison ivy, nickel,balsam of peru, neomycin,
fragrance, thimerosal, gold, formaldehyde ,
bacitracin, rubber compounds
9
ACD to paraphenylene diamine
Patch testing
• Small amounts of suspected allergens are placed
onto tape and then applied to the patient’s back
• The tape is removed after 48hrs and a reading is
made to check for reactions (erythematous spot at
the location of particular allergen)
• Pt is made to return again at day 4 or 5
ACD to fragrance in a detergent
THIN-LAYER RAPID USE EPICUTANEOUS
PATCH TEST- T.R.U.E. TEST
• Easy to use patch test
• 3 test panels consisting of 35 different
substances known to cause contact
dermatitis
• If negative and you still suspect contact
dermatitis, requires additional testing
• Positive reactions need to be confirmed by
patient history and symptoms.
ACD to toluene sulfonyl urea in
nail varnish
When do we need patch testing?
10
When do we need patch testing?
Allergic Contact Dermatitis
• The contact allergen avoidance data base
(CARD) provide names of alternative
products.
When do we need patch testing?
Management of Eczema
• Patient education
• Avoid or reduce trigger factors
• Topical steroids – strength depends on
severity of the eczema, site of the lesion
and age of the patient
• Oral steroids short period
When do we need patch testing?
• Doesn’t have to be done in obvious
situations
• Not responding to treatment and where
offending agent is unknown.
• Dermatitis with atypical or unusual
distribution
References
• Rook’s Textbook of Dermatology 8th edition
• Andrews’ diseases of the skin clinical
dermatology 11th edition
• www.truetest.com
• http://www.dandermpdv.is.kkh.dk/atlas/index.html
• Physician Consortium for Performance
Improvement (PCPI)
11
Summary
1. History and Clinical examination is the key to
diagnosis of eczema.
2. The diagnosis of contact dermatitis is based on
a careful history combined with a sound
knowledge of common allergens and irritants
in the environment.
3. Initial treatment of AD consists of education,
reduction of trigger factors, use of bathing
with emolients and topical steroids.
4. Potency of the topical steroid depends on
severity of eczema, site of the lesion and age of
the patient
Contact
D KISHORE YELLUMAHANTHI, MD, MPH
kishore@cchs.ua.edu
Practice Recommendations
1. Initial treatment of AD consists of education,
reduction of trigger factors, use of bathing
with emolients and topical steroids.
2. For maintenance therapy, low corticosteroids
are recommended. Intermediate –high potency
corticosteroids should be used for the treatment
of clinical exacerbations and applied to affected
areas of skin over short periods
3. The diagnosis of allergic contact dermatitis is
made by patch testing
Questions/Poll Everywhere
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