Dermatitis 101:Dermatitis 101:Diagnosis and Diagnosis and Treatment of Treatment of
EczemaEczema
Adrian Guevara MDAdrian Guevara MD
Dermatitis 101Dermatitis 101
AtopicAtopic SeborrheicSeborrheic ContactContact
AllergicAllergic IrritantIrritant
NummularNummular AsteatoticAsteatotic StasisStasis Neurodermatitis/Lichen Simplex ChronicusNeurodermatitis/Lichen Simplex Chronicus
Dermatitis 101Dermatitis 101
Dermatitis=“Eczema”=SpongiosisDermatitis=“Eczema”=Spongiosis
Acute DermatitisAcute Dermatitis
Dermatitis 101Dermatitis 101
Dermatitis 101Dermatitis 101 Subacute DermatitisSubacute Dermatitis
Commonly misdiagnosed as tinea
Dermatitis 101Dermatitis 101 Chronic DermatitisChronic Dermatitis
Commonly misdiagnosed as psoriasisCommonly misdiagnosed as psoriasis
24 y/o male 2 year h/o 24 y/o male 2 year h/o red, scaly feetred, scaly feet
Allergic Contact Allergic Contact DermatitisDermatitis
Type 4 Hypersensitivity ResponseType 4 Hypersensitivity Response Classically well demarcated/patternedClassically well demarcated/patterned Exposure can be infrequent (once a Exposure can be infrequent (once a
month)month) Patch testing is gold standard for Patch testing is gold standard for
diagnosisdiagnosis Severe reactions need systemic Severe reactions need systemic
steroidssteroidsForget the dose pack
Allergic Contact Allergic Contact DermatitisDermatitis
Poison Ivy/Oak/SumacPoison Ivy/Oak/Sumac
linearity
Allergic Contact Allergic Contact DermatitisDermatitis
Potassium DichromatePotassium Dichromate
in Leatherin Leather
Allergic Contact Allergic Contact DermatitisDermatitis
LatexLatex Cleaning productsCleaning products CosmeticsCosmetics OccupationalOccupational
exposuresexposures
Check the feet and nails!!!
Allergic Contact Allergic Contact DermatitisDermatitis
40 y/o female homemaker 40 y/o female homemaker with dry, itchy handswith dry, itchy hands
Irritant Contact Irritant Contact DermatitisDermatitis
Most contact dermatitis is irritant in Most contact dermatitis is irritant in naturenature
OccupationalOccupational morbitymorbity
Irritant vs allergicIrritant vs allergic Prevention is key!Prevention is key!
Look at the cuticles
Lip licker dermatitisLip licker dermatitis
Blunting of vermillionAccentuation of angles
4 y/o boy with chronic, 4 y/o boy with chronic, itchy, bleeding plaquesitchy, bleeding plaques
Atopic DermatitisAtopic Dermatitis
10-20% of 10-20% of populationpopulation
Primary Primary symptom:symptom: itch itch
Location, Location, location, locationlocation, location
Associated with Associated with atopic atopic backgroundbackground
Periorbital pallor
Look for keratosis pilaris
52 y/o male with 52 y/o male with erythematous, scaly patches erythematous, scaly patches
of face and scalpof face and scalp
Seborrheic DermatitisSeborrheic Dermatitis DistributionDistribution
Face, scalp, axillae, upper chestFace, scalp, axillae, upper chest Chronic conditionChronic condition
Nonsteroidal adjuvantsNonsteroidal adjuvants Disease associationsDisease associations
45 y/o female with 45 y/o female with intermittent “fungus all intermittent “fungus all
over”over”
Nummular DermatitisNummular Dermatitis
Coin shaped patches Coin shaped patches and plaquesand plaques
Secondary to xerosis Secondary to xerosis cutiscutis
Primary symptom itchPrimary symptom itch
Notice the surrounding xerosis
Asteatotic DermatitisAsteatotic Dermatitis
Extreme case of Extreme case of xerosisxerosis
Riverbed type Riverbed type crackingcracking
52 y/o male with painful, 52 y/o male with painful, itchy rash on right legitchy rash on right leg
Stasis DermatitisStasis Dermatitis
Venous hypertensionVenous hypertension Full spectrum of timingFull spectrum of timing Id reaction commonId reaction common Complicated by ulcerationComplicated by ulceration
Pseudokaposi’s Pseudokaposi’s (acroangiodermati(acroangiodermati
tis)tis)
Venous ulceration
Dispigmentation (chronic)
Lipodermatosclerosis
Id reactionId reaction
Superimposed allegic contact
Do: 1) dry weeping lesions 2) cover for infection
Don’t: 1) apply neosporin
2) just hope steroids will fix it
Elephantiasis Verrucosa Elephantiasis Verrucosa NostrasNostras
14 y/o anxious female who 14 y/o anxious female who can’t stop itchingcan’t stop itching
Neurodermatitis/Lichen Neurodermatitis/Lichen Simplex ChronicusSimplex Chronicus
Paroxysmal pruritusParoxysmal pruritus Habitual excoriating Habitual excoriating
or rubbingor rubbing Skin thickens to Skin thickens to
defenddefend Consider underlying Consider underlying
diseasedisease
Increased skin markings
Lichen simplex Lichen simplex chronicuschronicus
Prurigo simplex
No fungus on the scrotum!
Butterfly sign
Prurigo Nodularis
Consider screening
PreventionPrevention
Remove the offending agentRemove the offending agent Edema, allergen, irritant, yeast, long Edema, allergen, irritant, yeast, long
fingernailsfingernails Daily cleansing and Daily cleansing and
MOISTURIZINGMOISTURIZING Dove, Oil of Olay, NeutrogenaDove, Oil of Olay, Neutrogena Mild temperaturesMild temperatures Cream/Ointment based emollientsCream/Ointment based emollients
Neosporin, antifungals ≠ moisturizers
TreatmentTreatment
Topical SteroidsTopical Steroids Clobetasol Clobetasol II TriamcinoloneTriamcinolone IVIV DesonideDesonide VIVI HydrocortisoneHydrocortisone VIIVII
TreatmentTreatment TIMTIM
Protopic 0.1% ointProtopic 0.1% oint Elidel crElidel cr
LightLight nbUVBnbUVB
Systemic Systemic immunosuppressivesimmunosuppressives PrednisonePrednisone CyclosporineCyclosporine AzathioprineAzathioprine IVIGIVIG
Only on thin skin !!!
TreatmentTreatment
AntihistaminesAntihistamines Mechanism of action: Mechanism of action: soporificsoporific
Indications for Dermatitis ≠ Urticaria
7 m/o infant with itchy 7 m/o infant with itchy skinskin
75 y/o nursing home patient 75 y/o nursing home patient with intolerable itchy skinwith intolerable itchy skin
Common PitfallsCommon Pitfalls
MisdiagnosisMisdiagnosis Scabies (intensely pruritic, Scabies (intensely pruritic,
burrows/vesicles, others itch)burrows/vesicles, others itch) Psoriasis (elbows/knees/inflammatory Psoriasis (elbows/knees/inflammatory
arthritis/nail changes)arthritis/nail changes) Fungus (central sparing, well Fungus (central sparing, well
marginated, scaly border)marginated, scaly border)
Lose the Lindane!
25 y/o male tx’d for eczema 25 y/o male tx’d for eczema in antecubital fossa with in antecubital fossa with
“some cream”“some cream”
Common PitfallsCommon Pitfalls
MistreatmentMistreatment Lose the Lotrisone!Lose the Lotrisone!
1) Commit to a diagnosis1) Commit to a diagnosis 2) Shotgunners: “Don’t be a wimp”2) Shotgunners: “Don’t be a wimp”
Quadriderm: betamethasone, Quadriderm: betamethasone, gentamycin, clotrimazolegentamycin, clotrimazole
AnimaxAnimax
The EndThe End