Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Dermatology PPT 7 Endogenous Eczema Lecture Notes
ENDOGENOUS ECZEMA
FEW MCQS
? This secondary lesion develops when serum, blood or purulent exudate dries on the skin surface.
a)
Crusts
b) Excoriation
c)
Ulcer
d) Scale
? The best maintenance therapy in atopic dermatitis is
a)
Emol ients.
b) Topical tacrolimus
c)
Topical glucocorticoids
d) Oral and topical antibiotics
? Infantile atopic dermatitis present as red skin topped by tiny vesicles over face
a)
At birth
b) After 1 week of age
c)
After 3 months of age
d) After 1 year of age
? A 15 year old child presented with sudden onset of many deep-seated pruritic, clear "sago grain-
like"vesicles in both hands associated with severe itching. The probable diagnosis is
a)
Scabies
b) Pompholyx
c)
Herpes zoster
d) Irritant dermatitis
? A 29 year old female presents with dandruff and a rash on her face. On examination there is evidence
of areas of erythema with fine greasy scaling over her nasal bridge, around her nasolabial fold and
eyebrows and ears and on scalp. What is the most likely diagnosis?
a)
Psoriasis
b) Contact dermatitis
c)
Seborrheic dermatitis
d) Pityriasis versicolor
? A patient presents with papules which are greasy and brown over her chest. She also complains of
greasy scales on scalp. She is otherwise wel . What is the most likely diagnosis?
a)
Seborrheic dermatitis
b) Atopic dermatitis
c)
Pityriasis rosea
d) Guttate psoriasis
FEW BASIC CONCEPT
? The terms `eczema' and `dermatitis' used interchangeably
? Denotes a polymorphic inflammatory reaction pattern involving the
epidermis and dermis.
? Wide range of etiologies of `Eczema'. Distribution of lesions differ acc. to
the etiology
? Basic morphology of lesions in all etiologies remain same
ACUTE ECZEMA
? Erythema
? Edema
? Oozing
? Papulovesicular eruptions
SUB ACUTE ECZEMA
? Erythema
? Edema
? Oozing
? Scaling and crusting
CHRONIC ECZEMA
? Xerosis,
? Lichenification,
? Hyperkeratosis/Scaling,
? ?Fissuring.
HISTOPATHOLOGY
? SPONGIOSIS : an intercellular epidermal oedema that leads to stretching
and eventual rupture of the intercellular attachments, with the formation of
vesicles
? ACANTHOSIS: increase in thickness of epidermis ? regular/ irregular
? HYPERKERATOSIS: increase in thickness of Stratum corneum
? PARAKERATOSIS : retention of nucleated cells in Stratum corneum
HISTOPATHOLOGY
ACUTE ECZEMA
? The epidermis shows distinct vesicle
formation due to " spongiosis"
? Vesicle contains serum, and a moderate
number of inflammatory cells.
SUBACUTE ECZEMA
? Irregular acanthosis
? Patchy spongiosis with the formation
of incipient microvesicles.
? Few lymphocytes are migrating up
from the dermis into the epidermis
CHRONIC ECZEMA
? Compact hyperkeratosis,
? Patchy parakeratosis
? Irregular acanthosis.
? Mild spongiosis is seen
throughout
? Lymphocytic infiltrate in the
upper dermis
CLASSIFICATION
(acc. to etiology)
ENDOGENEOUS
EXOGENEOUS
1. Atopic dermatitis
1. Irritant dermatitis
2. Seborrhoeic dermatitis
2. Allergic dermatitis
3. Nummular eczema
3. Photodermatitis
4. Stasis dermatitis
4. Infective dermatitis
5. Asteatotic dermatitis
5. Post traumatic dermatitis
6. Pityriasis Alba
7. Dyshidrotic eczema
8. Lichen Simplex Chronicus
ATOPIC DERMATITIS
? Itchy, chronic, relapsing inflammatory skin condition, often
starts in early childhood (< 2 years)
? Characterized by erythema, itchy papules and / or
papulovesicles, may become excoriated and lichenified,
? Typically has a flexural distribution
HANIFIN AND RAJKA'S Diagnostic
Criteria Of Atopic Dermatitis
UK refinement
?Itchy skin condition (parental report of scratching /rubbing in a child)
?Plus three or more of the following:
? Onset below age of 2 years
? History of skin crease involvement (including cheeks in children under 10
years)
? History of a generally dry skin
? Personal history of other atopic disease (or history of any atopic disease in
a firstdegree relative)
? Visible flexural dermatitis (or dermatitis of cheeks/forehead and outer
limbs in children under 4 years
AETIOLOGY & PATHOGENESIS
?Genetic susceptibility
?Immunological changes
1. Familial - ATOPY
1. Abnormalities in lymphocytes
2. Precise mode of inheritance
Acute ? Th2 cytokines
unknown
Chronic ? Th1 cytokines
?Defective Skin Barrier
?Abnormalities of IgE
1. Increased TEWL
1. Elevated levels
2. Easy entry of allergen,
antigens from environment
INFANTILE PHASE
(2 MONTHS- 2 YEARS)
? Frequently start on the face
? Erythema and edematous papules, intensely
itchy, ? exudative and crusted
? As the child begins to crawl, the extensor
aspect of the knees & elbows are most
involved.
? Secondary infection, lymphadenopathy
common
CHILDHOOD PHASE
(2-12 YEARS)
? Sites- elbow, knee flexures,
? sides of the neck,
? wrists and ankles.
? Erythema, crusting, excoriation, hyper and
hypopigmentation, and lichenification
? sides of the neck may show a striking reticulate
pigmentation: 'atopic dirty neck'
? Itching intense.
ADULT PHASE
(12 YEARS AND MORE)
? similar to that in later childhood, with predominant lichenification, especially the
flexures and hands.
COMPLICATIONS AND COMORBIDITIES
?Psychosocial aspect: Itching, scratching and sleep disturbance cause
impairment in quality of life
?Growth delay
?Secondary bacterial infection , viral infection
?Ocular changes: Dennie- Morgan fold
Keratoconjunctivitis
Keratoconus
?Urticaria
?Food allergy
?Alopecia areata
?Lip licking cheilitis
KAPOSI VARICELLIFORM ERUPTION
ECZEMA HERPETICUM
? HSV infection superadded
? Characteristic viral papulovesicles over
existing patches of eczema
? Rapid evolution to a state of extensive
purulent exudate
? To be suspected in case of rapid
deterioration of the eczema.
TREATMENT
General measures
1. Counselling : disease, chronicity, course
2. Avoid scratching
3. Hot water bath
4. Avoid triggers : wool, synthetic clothes, strong soaps,
housedust mite etc
5. Liberal use of emmolients: MAINSTAY of THERAPY
TREATMENT
SEBORRHEIC DERMATITIS
? Chronic dermatitis
? Red, sharply marginated lesions covered with greasy scales
? Scalp, face, central chest, anogenital areas, flexures and submammary
areas
? Symmetrical distribution.
? Males commonly
? 30 years men and 40-50 yrs women
ROLE OF MALASSEZIA
? The commensal lipophilic yeasts of the genus Malassezia
are generally considered pathogenic through indirect and
possibly immunological mechanisms
? exist as skin commensals in a state of symbiosis
CLINICAL FEATURES
? Dandruff/ pityriasis capitis : isolated to the scalp with little
or no overt inflammation, mildest forms of SD
? Seborrheic dermatitis: starts as dull or yellowish red pruritic
lesions covered with greasy scales.
? Erythroderma
Facial SD
? nasolabial area, ear creases, eyelids and
glabellar area, medial eyebrows
? eyelid margin involvement(anterior
blepharitis): flaky debris on the
eyelashes, typically near the base.
SCALP INVOLVEMENT
? Mild flaking without underlying
erythema to a more inflammatory
? Eruption with thicker, yellow, greasy
scales and crusts;
? Similar changes can occur in the
beard
Truncal involvement
? presternal area :petaloid (petalshaped)
lesion
? `pityriasiform': generalized
erythematosquamous eruption
? Flexural lesion
INFANTILE SEBORRHEIC DERMATITIS
? Appears by 3 months and disappears spontaneously by 8
months of age
? presents primarily with cradle cap
? and/or napkin dermatitis.
TREATMENT
DISCOID / NUMMULAR ECZEMA
? Coin shaped plaque of closely set, thin-walled
vesicles on an erythematous base.
? Itching severe.
? Middle aged men
? Sites- lower legs, dorsa of hands, extensor
surfaces of the arms.
? Secondary lesions appear as mirror images
? Dormant patches may become active again
TREATMENT DISCOID ECZEMA
First line
? Emollient, topical corticosteroid, topical or oral antibiotic
Second line
? Topical calcineurin inhibitor
Third line
? Phototherapy (narrowband UVB/PUVA)
? oral immunosuppressants: methotrexate or oral steroids
ASTEATOTIC ECZEMA
ECZEMA CRAQUELE
? Elderly ; legs, arms and hands
? Winter: reduction in humidity
? The asteatotic skin is dry and slightly scaly
? Backs of the hands : crisscross lines.
? Finger pulps: dry, cracked, producing distorted
prints. retain prolonged depression after pressure
`parchment pulps'.
? Legs marked superficial markings:
`crazypaving' pattern (eczema craquele)
TREATMENT ASTEATOTIC ECZEMA
First line
? Humidify environment
Second line
? Emollients, with or without urea, bath oil and soap
substitute
Third line
? Mild topical corticosteroids
? tacrolimus
PITYRIASIS ALBA
? Age : 3 and 16 years
? Confined to the face: cheeks, around
mouth and chin
? Start as slightly erythematous with fine
scaling
? Later: rounded, oval or irregular
hypopigmented patch, not well
marginated
? D/D - Nevus depigmentosus, early
vitiligo, PMLE
TREATMENT PITYRIASIS ALBA
? Response to treatment is often disappointing
First line
? Emollient
Second line
? Mild topical corticosteroids
Third line
? Topical tacrolimus or pimecrolimus
GRAVITATIONAL/VENOUS/STASIS
/VARICOSE ECZEMA
? Secondary to dysfunctional venous drainage of the lower legs.
? middle-aged elderly females.
? Predisposition: previous DVT , presence of venous stasis:
prolonged standing, obesity, immobility,and previous cellulitis
? around the ankle and lower legs
? High ambulatory venous pressure within the calf muscle pump
? Transmitted to the capillary circulation
? Distends the local capillary bed
? Widens the endothelial pores
? Fibrinogen molecules escape into the interstitial fluid, form a fibrin sheath around
the capillaries - pericapillary barrier
? Prevents diffusion of oxygen and other nutrients essential for the normal vitality
of the skin
? Also, increased sequestration of white cells in the venules,
? Consequent release of proteolytic enzymes and free radicals which produce
tissue damage
? first sign - pitting edema - medial aspects of shin; proximal
to the ankle
? Edema more pronounced in evening; resolves overnight.
? Skin in area- dry and itchy.
? Over years, the skin, subcutaneous adipose tissue and deep
fascia indurated and mutually adherent
("lipodermatosclerosis")
? Erythema and scaling most pronounced around the inner
malleoli
? Episodes of vesiculation , oozing and erosive occur
? Repeated episodes of acute eczema gives way to venous
ulcers
TREATMENT VENOUS ECZEMA
First line
? Any underlying venous hypertension and/or pedal oedema controlled.
? Obese patients to lose weight.
? Skin care, including leg elevation
? Emollients, topical corticosteroids, tacrolimus
? Antibiotics for sec. Bacterial inf
TREATMENT VENOUS ECZEMA
Second line
? Compression hosiery (Ankle brachial pressure index, ABPI >.08, in
absence of calcified vessels)
Third line
? Referral to vascular surgeon: surgical intervention
DYSHIDROTIC ECZEMA
? Acute and recurrent
? Firm, pruritic "sago grain-like"vesicles
? Site- palms, soles, lateral and medial
aspects of the fingers and toes
? No disturbance of sweat gland function-
`dyshidrotic' misnomer
? Treatment - Topical and systemic
corticosteroids
? Topical calcineurin inhibitors , PUVA
may be helpful.
FEW MCQS
? This secondary lesion develops when serum, blood or purulent exudate dries on the skin surface.
a)
Crusts
b) Excoriation
c)
Ulcer
d) Scale
? The best maintenance therapy in atopic dermatitis is
a)
Emol ients.
b) Topical tacrolimus
c)
Topical glucocorticoids
d) Oral and topical antibiotics
? Infantile atopic dermatitis present as red skin topped by tiny vesicles over face
a)
At birth
b) After 1 week of age
c)
After 3 months of age
d) After 1 year of age
? A 15 year old child presented with sudden onset of many deep-seated pruritic, clear "sago grain-
like"vesicles in both hands associated with severe itching. The probable diagnosis is
a)
Scabies
b) Pompholyx
c)
Herpes zoster
d) Irritant dermatitis
? A 29 year old female presents with dandruff and a rash on her face. On examination there is evidence
of areas of erythema with fine greasy scaling over her nasal bridge, around her nasolabial fold and
eyebrows and ears and on scalp. What is the most likely diagnosis?
a)
Psoriasis
b) Contact dermatitis
c)
Seborrheic dermatitis
d) Pityriasis versicolor
? A patient presents with papules which are greasy and brown over her chest. She also complains of
greasy scales on scalp. She is otherwise wel . What is the most likely diagnosis?
a)
Seborrheic dermatitis
b) Atopic dermatitis
c)
Pityriasis rosea
d) Guttate psoriasis
THANK YOU
This post was last modified on 07 April 2022