ECZEMASECZEMASCecilia T. Roxas-Rosete, FPDSCecilia T. Roxas-Rosete, FPDS

Consultant, Section of DermatologyConsultant, Section of DermatologyThe Medical City HospitalThe Medical City Hospital

ECZEMAECZEMA

-Inflammatory Skin DisorderInflammatory Skin Disorder

-Greek word ek – zeo “to boil Greek word ek – zeo “to boil or bubble over”or bubble over”

Erythema

Papules

Vesicles

Pustules

Oozing

Crusts

Scales

Chronic eczemaHealing

ProgressionRegression

Series 2007Series 2007 A PEODG and SP Dermatology ExclusiveA PEODG and SP Dermatology Exclusive

Acute EczemaAcute Eczema

Series 2007Series 2007 A PEODG and SP Dermatology ExclusiveA PEODG and SP Dermatology Exclusive

Chronic EczemaChronic Eczema

EPIDEMIOLOGYEPIDEMIOLOGY

Atopic dermatitis (AD) is a chronically Atopic dermatitis (AD) is a chronically relapsing skin disorder that arises relapsing skin disorder that arises most commonly during early infancy, most commonly during early infancy, childhood or adolescencechildhood or adolescence

Usually begins before age 6 monthsUsually begins before age 6 months Remits spontaneously in 65% of Remits spontaneously in 65% of

affected children before age 10 yearsaffected children before age 10 years

EPIDEMIOLOGY:EPIDEMIOLOGY:

STAGESSTAGES

1)1) Infantile – 2 months to Infantile – 2 months to 2 yrs.2 yrs.

2)2) Childhood – 2 to 10 yrs.Childhood – 2 to 10 yrs.

3)3) Adulthood Adulthood

ETIOLOGY & ETIOLOGY & PATHOGENESISPATHOGENESIS UnknownUnknown

Triggered by an interplay of Triggered by an interplay of factorsfactors

1.1. GeneticGenetic

2.2. ImmunologicImmunologic

3.3. EnvironmentalEnvironmental

Hanifin &Rajka’s Diagnostic Hanifin &Rajka’s Diagnostic Criteria for Atopic DermatitisCriteria for Atopic DermatitisMust have > 3 major criteria & > 3 Must have > 3 major criteria & > 3 minor criteriaminor criteria

Major Criteria:Major Criteria: PruritusPruritus Personal or family history of atopic Personal or family history of atopic

disorders (asthma, atopic eczema, allergic disorders (asthma, atopic eczema, allergic rhinitis)rhinitis)

Chronic or chronically relapsing courseChronic or chronically relapsing course Typical distribution and morphologyTypical distribution and morphology

> infants: facial and extensor involvement> infants: facial and extensor involvement> children & adults: flexural lichenification > children & adults: flexural lichenification and linearityand linearity

Hanifin & Rajka’s Diagnostic Hanifin & Rajka’s Diagnostic Criteria for Atopic DermatitisCriteria for Atopic Dermatitis

Minor Criteria:Minor Criteria: XerosisXerosis Icthyosis/keratosis pilaris/palmar Icthyosis/keratosis pilaris/palmar

hyperlinearityhyperlinearity Type I skin test reactivityType I skin test reactivity Elevated serum IgEElevated serum IgE Early age at onsetEarly age at onset Tendency to skin infection (Staph aureus & HS Tendency to skin infection (Staph aureus & HS

I)I) Hand / foot dermatitisHand / foot dermatitis

Hanifin & Rajka’s Diagnostic Hanifin & Rajka’s Diagnostic Criteria for Atopic DermatitisCriteria for Atopic Dermatitis

Minor Criteria:Minor Criteria: Nipple eczemaNipple eczema Cheilitis / conjunctivitis / keratoconus / Cheilitis / conjunctivitis / keratoconus /

ant. subscapular cataractsant. subscapular cataracts Dennie-Morgan foldDennie-Morgan fold Orbital darkeningOrbital darkening Pityriasis albaPityriasis alba

Hanifin & Rajka’s Diagnostic Hanifin & Rajka’s Diagnostic Criteria for Atopic DermatitisCriteria for Atopic Dermatitis

Minor Criteria:Minor Criteria: Itch when sweatingItch when sweating Intolerance to wool and lipid solventsIntolerance to wool and lipid solvents Food intoleranceFood intolerance Perifollicular accentuationPerifollicular accentuation White dermographism / delayed White dermographism / delayed

blanchingblanching Course influenced by Course influenced by

environmental/emotional factorsenvironmental/emotional factors

Triggering Factors in Atopic Triggering Factors in Atopic DermatitisDermatitis

Contact irritants and allergensContact irritants and allergens Aeroallergens – house dust mites,pollens Aeroallergens – house dust mites,pollens

and moldsand molds Foods – egg, milk, peanuts, fish, wheat Foods – egg, milk, peanuts, fish, wheat

and shellfishand shellfish Microbial organisms – Staph. aureus, Microbial organisms – Staph. aureus,

URTI, CandidaURTI, Candida HormonesHormones StressStress ClimateClimate

SEBORRHEIC SEBORRHEIC DERMATITISDERMATITIS common chronic skin disordercommon chronic skin disorder infants / adultsinfants / adults often assoc with increased sebum often assoc with increased sebum

production (seborrhea) of face & production (seborrhea) of face & scalpscalp

2-5% of the population2-5% of the population affects males > femalesaffects males > females often assoc with HIV (85%), often assoc with HIV (85%),

parkinsonismparkinsonism

Etiology – Inflammatory Rx to yeast Etiology – Inflammatory Rx to yeast (Pityrosporum Ovale)(Pityrosporum Ovale)

Sites: Face, ears, scalp, upper trunkSites: Face, ears, scalp, upper trunk

Infants – Cradle CapInfants – Cradle CapAdults – Dandruff (scalp, eyebrows)Adults – Dandruff (scalp, eyebrows)

Skin: “greasy” yellowish scales on a Skin: “greasy” yellowish scales on a red basered base

Seborrheic Seborrheic DermatitisDermatitis

Nummular EczemaNummular Eczema

discrete coin-shaped pruritic discrete coin-shaped pruritic lesionlesion

erythematous, vesicular, crusted erythematous, vesicular, crusted patchespatches

assoc with emotional stressassoc with emotional stress sites – legs, arms, dorsum of sites – legs, arms, dorsum of

handshands

Dyshidrotic Dyshidrotic eczemaeczema

Lichen simplex Lichen simplex chronicuschronicus

CONTACT DERMATITISCONTACT DERMATITIS

Any pruritic skin disorder that results Any pruritic skin disorder that results when a particular substance comes in when a particular substance comes in contact with the skincontact with the skin

Inflammation of the skin with Inflammation of the skin with spongiosis or intercellular edema of the spongiosis or intercellular edema of the epidermisepidermis

A common cause of occupational A common cause of occupational disabilitydisability

A form of extrinsic eczemaA form of extrinsic eczema

Contact Dermatitis: Contact Dermatitis: PrevalencePrevalence

General population: 1.5% - 5.4%General population: 1.5% - 5.4% Important cause of disability in Important cause of disability in

occupational and personal lifeoccupational and personal life Accounts for about 20% of all Accounts for about 20% of all

dermatological consultationsdermatological consultations Accounts for majority of all Accounts for majority of all

occupational skin diseasesoccupational skin diseases

2 Types (Contact 2 Types (Contact Dermatitis)Dermatitis)

1.1. Irritant CD – Skin reaction resulting Irritant CD – Skin reaction resulting from exposure to an offending agent.from exposure to an offending agent.

- immediate Rx- immediate Rx- Acids, alkali, detergents- Acids, alkali, detergents

2. Allergic CD – results from repeated 2. Allergic CD – results from repeated exposure to an allergen or compound exposure to an allergen or compound due to DELAYED hypersensitivity RXdue to DELAYED hypersensitivity RX

- 7-10 days- 7-10 days

IRRITANT CONTACT IRRITANT CONTACT DERMATITISDERMATITIS

Severity of the reaction is related to the Severity of the reaction is related to the amount and duration of exposure to the amount and duration of exposure to the irritant.irritant.

Most cases are acute in onset - Most cases are acute in onset - symptoms develop within seconds of symptoms develop within seconds of exposure.exposure.

Prolonged exposure to a low-level irritant Prolonged exposure to a low-level irritant (soap, water) can lead to chronic ICD.(soap, water) can lead to chronic ICD.

Most common site: hand.Most common site: hand.

Irritant Contact Irritant Contact Dermatitis: Mild Irritant Dermatitis: Mild Irritant

(Acute)(Acute)

Irritant Contact Irritant Contact Dermatitis: Mild Irritant Dermatitis: Mild Irritant

(Chronic) (Chronic)

Irritant Contact Irritant Contact Dermatitis: Dermatitis:

Strong irritantStrong irritant

ALLERGIC CONTACT ALLERGIC CONTACT DERMATITIS (ACD)DERMATITIS (ACD)Due to repeated exposure to a Due to repeated exposure to a

substance to which the substance to which the individual is sensitizedindividual is sensitized

A cell-mediated type IV A cell-mediated type IV delayed hypersensitivity delayed hypersensitivity reactionreaction

Series 2007Series 2007 A PEODG and SP Dermatology ExclusiveA PEODG and SP Dermatology Exclusive

Application of contact allergens Application of contact allergens (Ag) (Ag)

Release of cytokines by Release of cytokines by keratinocytes, Langerhans cells keratinocytes, Langerhans cells and other cells within the skinand other cells within the skin

Cytokines activate Langerhans Cytokines activate Langerhans cells which uptake the antigen cells which uptake the antigen and emigrate into the regional and emigrate into the regional lymph nodeslymph nodes

During this process, the During this process, the Langerhans cells mature into Langerhans cells mature into dendritic cells; the antigen is dendritic cells; the antigen is processed, re-expressed on the processed, re-expressed on the surface and finally presented to surface and finally presented to naïve T cells in the regional lymph naïve T cells in the regional lymph nodenode

Upon appropriate antigen Upon appropriate antigen presentation, T cells bearing the presentation, T cells bearing the appropriate T cell receptor appropriate T cell receptor clonally expand and become clonally expand and become effector T cells. effector T cells.

Effector T cells recirculate into the Effector T cells recirculate into the periphery where they may later periphery where they may later meet the antigen again. meet the antigen again.

Common Allergens In Common Allergens In the General Populationthe General Population

NACDG 1998NACDG 1998

1.1. NickelNickel

2.2. FragrancesFragrances

3.3. NeomycinNeomycin

4.4. Balsam of PeruBalsam of Peru

5.5. ThimerosalThimerosal

PCDSG 2000PCDSG 2000

1.1. NickelNickel

2.2. Potassium Potassium DichromateDichromate

3.3. Fragrance MixFragrance Mix

4.4. CobaltCobalt

5.5. Paraben MixParaben Mix

ACD: NickelACD: Nickel

ACD: NickelACD: Nickel

ACD: NickelACD: Nickel

ACD: FragranceACD: Fragrance

ACD: Colorant in ACD: Colorant in ToothpasteToothpaste

ACD: Fragrance in ACD: Fragrance in DeodorantDeodorant

Common Occupational Common Occupational AllergensAllergens Rubber accelerating chemicals Rubber accelerating chemicals

(thiuram)(thiuram) Biocides (formaldehydes)Biocides (formaldehydes) Hairdressing chemicalsHairdressing chemicals Resin – acrylatesResin – acrylates ChromatesChromates Plant allergensPlant allergens LatexLatex

ACD: RubberACD: Rubber

Series 2007Series 2007 A PEODG and SP Dermatology ExclusiveA PEODG and SP Dermatology Exclusive

ACD due to contact with ACD due to contact with acrylatesacrylates

ACD: ChromateACD: Chromate

Patch TestPatch Test

Only objective diagnostic tool for Only objective diagnostic tool for the definitive diagnosis of allergic the definitive diagnosis of allergic contact dermatitiscontact dermatitis

May aid in differentiating ACD May aid in differentiating ACD from ICDfrom ICD

Patch Test: TechniquePatch Test: Technique

1.1. Test substances Test substances appropriately diluted. appropriately diluted. Standardized kits Standardized kits available. available.

Some Common Allergens Some Common Allergens Used in Patch TestingUsed in Patch Testing

Nickel - JewelryNickel - Jewelry Balsam of Peru - Perfumes, citrus fruitsBalsam of Peru - Perfumes, citrus fruits Dichromate - Cement, leather, matchesDichromate - Cement, leather, matches Paraphenylenediamine - Hair dyes, Paraphenylenediamine - Hair dyes,

clothingclothing Rubber chemicals - Shoes, clothing, Rubber chemicals - Shoes, clothing,

glovesgloves Colophony - Sticking plastersColophony - Sticking plasters

Some Common Allergens Some Common Allergens Used in Patch TestingUsed in Patch Testing

Benzocaine - Topical anaestheticsBenzocaine - Topical anaesthetics Neomycin - Topical medicamentsNeomycin - Topical medicaments Parabens - Preservatives in cosmetics, Parabens - Preservatives in cosmetics,

creamscreams Epoxy resins - GluesEpoxy resins - Glues Formaldehyde - Clothing, cosmetics, Formaldehyde - Clothing, cosmetics,

paperpaper Wool alcohol - Lanolin, cosmetics, Wool alcohol - Lanolin, cosmetics,

creamscreams

Patch Test: TechniquePatch Test: Technique

2. Apply the patch to the upper or mid 2. Apply the patch to the upper or mid back. back.

Leave the patch in place and keep dry Leave the patch in place and keep dry for for

2 days before removing.2 days before removing.

Patch Test: TechniquePatch Test: Technique

3. Read tests: 3. Read tests: – a) The same day that patches are a) The same day that patches are

removedremoved– b) One additional reading 3, 4, or 7 b) One additional reading 3, 4, or 7

days after test initially applieddays after test initially applied

Patch Test: TechniquePatch Test: Technique

4.4. Grade test reactions according to Grade test reactions according to intensity: intensity:

0 = no reaction 0 = no reaction

doubtful = minimal doubtful = minimal erythemaerythema

(+) = erythema w/ papules(+) = erythema w/ papules

(++) = (++) = erythema,papules,vesicleserythema,papules,vesicles

(+++) = erythema, bullae(+++) = erythema, bullae

(++) REACTION

(+++) REACTION

Patch Test: TechniquePatch Test: Technique

5. Relate relevance of positive 5. Relate relevance of positive reactions to clinical dermatitis reactions to clinical dermatitis cautiously. Careful history and cautiously. Careful history and review of skin exposures must review of skin exposures must establish significanceestablish significance

Photocontact eczemaPhotocontact eczema

Require exposure to sunlight following Require exposure to sunlight following topical application of certain chemicalstopical application of certain chemicals

Long wave UVA – action spectrumLong wave UVA – action spectrum Topical photosensitizers – PPD in hair Topical photosensitizers – PPD in hair

dyes, PABA esters in sunscreening dyes, PABA esters in sunscreening agents, halogenated salicylates in soaps agents, halogenated salicylates in soaps and cosmetics & topical sulfonamidesand cosmetics & topical sulfonamides

Topical photoirritants – psoralens in Topical photoirritants – psoralens in perfumesperfumes

PSORIASISPSORIASIS

Cecilia Roxas-Rosete, MD, FPDSCecilia Roxas-Rosete, MD, FPDS

Consultant, Section of Consultant, Section of DermatologyDermatology

The Medical City HospitalThe Medical City Hospital

PsoriasisPsoriasis

EPIDEMIOLOGYEPIDEMIOLOGY Age of onset: 20 to 50 y/oAge of onset: 20 to 50 y/o Sex: M=FSex: M=F Heredity: PolygenicHeredity: Polygenic Pathogenesis: Alteration of the Pathogenesis: Alteration of the

cell kinetics of keratinocytescell kinetics of keratinocytes

PsoriasisPsoriasis

PHYSICAL FINDINGSPHYSICAL FINDINGS

Psoriasis VulgarisPsoriasis Vulgaris Most commonMost common Erythematous well-Erythematous well-

defined papules & defined papules & plaques with large plaques with large amounts of silvery amounts of silvery white scaleswhite scales

Sites: scalp, Sites: scalp, elbows,knees, lumbar elbows,knees, lumbar area area

PsoriasisPsoriasis

PsoriasisPsoriasis

Auspitz SignAuspitz Sign

PsoriasisPsoriasis

PsoriasisPsoriasis

PsoriasisPsoriasis

PsoriasisPsoriasis

PsoriasisPsoriasis

PsoriasisPsoriasis

Physical FindingsPhysical Findings

Eruptive (Guttate) Eruptive (Guttate) PsoriasisPsoriasis

0.5cm-1.0cm 0.5cm-1.0cm lesionslesions

Young adultsYoung adults Streptococcal Streptococcal

throat infectionthroat infection

PsoriasisPsoriasis

PHYSICAL FINDINGSPHYSICAL FINDINGS

Psoriasis Psoriasis geographicageographica

‘‘land map”land map”

PsoriasisPsoriasis

PHYSICAL FINDINGSPHYSICAL FINDINGS

Annular PsoriasisAnnular Psoriasis Partial central Partial central

clearing resulting clearing resulting in ring-like lesionsin ring-like lesions

PsoriasisPsoriasis

PHYSICAL FINDINGSPHYSICAL FINDINGS

Psoriasis inversaPsoriasis inversa Flexural psoriasisFlexural psoriasis Localized in skin Localized in skin

foldsfolds

PsoriasisPsoriasis

PHYSICAL FINDINGSPHYSICAL FINDINGS

Psoriatic ErythrodermaPsoriatic Erythroderma

(Exfoliative Dermatitis)(Exfoliative Dermatitis) All body sitesAll body sites Prominent erythemaProminent erythema May represent May represent

generalized Koebner’s generalized Koebner’s phenomenonphenomenon

PsoriasisPsoriasis

PHYSICAL FINDINGSPHYSICAL FINDINGS

Pustular PsoriasisPustular Psoriasis Pustular psoriasis Pustular psoriasis

of von Zumbuschof von Zumbusch Pus are sterilePus are sterile

PsoriasisPsoriasis

TRIGGER FACTORSTRIGGER FACTORS

A. Physical trauma: Koebner’s A. Physical trauma: Koebner’s PhenomenonPhenomenon

various traumatic insult to skinvarious traumatic insult to skin 30%-50% of psoriasis patients 30%-50% of psoriasis patients

give history of koebner’sgive history of koebner’s

PsoriasisPsoriasis

Koebner’s PhenomenonKoebner’s Phenomenon

PsoriasisPsoriasis

TRIGGER FACTORSTRIGGER FACTORS

B. InfectionB. Infection 15%-76% report history of infection15%-76% report history of infection E.g. Streptococcal throat infectionE.g. Streptococcal throat infection

- guttate psoriasis- guttate psoriasis

HIVHIV

- 2.5% develop psoriasis- 2.5% develop psoriasis

PsoriasisPsoriasis

TRIGGER FACTORSTRIGGER FACTORS

C. StressC. Stress 30%-40% adult cases30%-40% adult cases 90% in children90% in children

PsoriasisPsoriasis

TRIGGER FACTORSTRIGGER FACTORS

D. DrugsD. Drugs Corticosteroids – may cause flare-upsCorticosteroids – may cause flare-ups LithiumLithium Beta-Adrenergic blockers, ACE Beta-Adrenergic blockers, ACE

inhibitorsinhibitors AnitmalarialsAnitmalarials AspirinAspirin

PsoriasisPsoriasis

SYSTEMIC ASSOCIATIONSSYSTEMIC ASSOCIATIONS

Psoriatic arthropathy is the only Psoriatic arthropathy is the only recognized non-cutaneous recognized non-cutaneous manifestationmanifestation

Classified as one of the Classified as one of the seronegative seronegative spondyloarthropathiesspondyloarthropathies

PsoriasisPsoriasis

SYSTEMIC ASSOCIATIONSSYSTEMIC ASSOCIATIONS Psoriatic ArthritisPsoriatic Arthritis

PsoriasisPsoriasis

SYSTEMIC ASSOCIATIONSSYSTEMIC ASSOCIATIONS Arthritis mutilans – 5%Arthritis mutilans – 5%

PsoriasisPsoriasis

SYSTEMIC ASSOCIATIONSSYSTEMIC ASSOCIATIONS

Genetically determined Genetically determined autoimmune disease – 5%-8%autoimmune disease – 5%-8%

(+) HLA-B27 linkage in 20% of (+) HLA-B27 linkage in 20% of psoriatic arthropathiespsoriatic arthropathies

frequency of ulcerative colitis frequency of ulcerative colitis in psoriasis patientsin psoriasis patients

PsoriasisPsoriasisSYSTEMIC ASSOCIATIONSSYSTEMIC ASSOCIATIONS Metabolic syndrome:Metabolic syndrome: > heart disease (high blood > heart disease (high blood

pressure)pressure) > stroke> stroke > diabetes (insulin resistance)> diabetes (insulin resistance) > excessive body fat around waist > excessive body fat around waist

(obesity)(obesity) > dyslipidemia ( low HDL, > dyslipidemia ( low HDL,

high triglyceride)high triglyceride)

THANK YOUTHANK YOU