Eczema

Question 1

What does eczema mean?

Answer 1

Inflammation of the skin, it means the same as dermatitis

Question 2

How can the causes of eczema be divided?

Answer 2

Exogenous causes e.g. Photosensitive, Contact Dermatitis (Allergic or Irritant Dermatitis)
Endogenous causes- Atopic, Seborrhoeic, Venous, Asteatotic, Discoid

Question 3

What are the three atopic diseases?

Answer 3

Atopic eczema
Asthma
Hayfever

Question 4

What are the symptoms of eczema?

Answer 4

Itch- can be very unpleasant
Weeping skin
Crusting when fluid dries out
Scaling/thickening of the skin
Sleep disturbance due to itch
Colour change- especially in pigmented skin due to itch
Bleeding (may become darker or lighter)

Question 5

Describe some of the differences between eczema and psoriasis

Answer 5

Eczema has a tendency to affect the flexor surfaces rather than the extensor surfaces seen in psoriasis ( but this is mostly in white people, less so in ethnic minorities)
Eczema lesions are not well demarcated with clear boundaries like the plaques seen in psoriasis
Eczema is less scaly whereas psoriasis is associated with silvery scales
Eczema is very very itchy and so has associated excoriations

Question 6

What are some complications of eczema? What would indicate this?

Answer 6

Infection- often with Staph Aureus (>90%) or Group A Strep.

Weeping, crusting or pustules

Question 7

What could be a sign of secondary infection in eczema?

Answer 7

Weeping, crusting or pustules

Question 8

What is a concerning infection in children with eczema that can cause multiple punched out lesions?

Answer 8

Herpes Simplex Virus leading to Eczema Herpeticum

HSV infects the skin of patients who are susceptible, such as with atopic eczema due to the breaks in the skin surface.

Question 9

What does eczema herpeticum look like?

Answer 9

Eczema herpeticum is caused by HSV-1

Groups of small blisters initially and then more can form
Blisters contain a clear fluid that then develops into pus
They may weep or blead
Heal which rarely can result in scaring

Multiple punched out lesions

Question 10

How is eczema herpeticum diagnosed?

Answer 10

Clinical diagnosis

Swab the blisters and send for PCR, MC+S if could be bacterial too

Question 11

What is the treatment for eczema herpeticum?

Answer 11

Acyclovir- anti-viral therapy

Question 12

What are the features of seborrhoeic eczema?

Answer 12

Red scaly rash that is itchy and affects the scalp, eyebrows, naso-labial folds, cheeks and flexures

Question 13

What should be tested for in patients with severe seborrhoeic eczema?

Answer 13

HIV- Severe forms of seborrhoeic eczema are associated with being HIV positive

Question 14

What is the cause of seborrhoeic eczema?

Answer 14

Overgrowth of skin yeasts- e.g. Malassezia

Question 15

What is the treatment for seborrhoeic eczema?

Answer 15

Mild topical steroids or anti-fungal preparations

Question 16

What are the two types of contact dermatitis?

Answer 16

Allergic

Irritant

Question 17

What type of hypersensitivity is an allergic contact dermatitis?

Answer 17

Type IV

Question 18

What are some causes of allergic contact dermatitis?

Answer 18

Nickel- jewellery, watches, coins, keys,
Rubber- marigold gloves
Latex
Lanolin- creams, cosmetics
Chromate- leather, cement (builders hand eczema)
Hair-dye allergy (due to PPD)

Dermatitis is seen where the object is in contact with the skin, there is often a sharp cut-off where the contact ends

Question 19

For allergic contact dermatitis do patients develop it the first time they come into contact with the allergen?

Answer 19

No sensitisation must occur first

This is an example of a type IV hypersensitivity reaction

Question 20

How can you test for allergic contact dermatitis?

Answer 20

Patch testing +ve reaction is redness and blistering

Note- This is difficult from Type I which is IgE mediated and occurs instantly. It is done for allergies such as food allergies and the result is urticaria.

Question 21

What is irritant contact dermatitis?

Answer 21

Prolonged exposure to irritants begins to cause dermatitis, everyone is prone to developing this

Common irritants include- hand soap, detergents, washing up liquid, solvents, cleaning solutions

Question 22

What is the management for irritant contact dermatitis?

Answer 22

Avoid exposure to the irritant where possible
Gentler hand washes
Hand care- regular moisturising
Gloves for cleaning
PRN use of topical steroids for acute flares

Question 23

What is venous eczema?

Answer 23

This occurs when there is poor venous drainage and venous hypertension. There is failure of the valves within veins, leading to varicose veins and venous hypertension. Triggers inflammation in the skin.

Question 24

What does venous eczema look like?

Answer 24

Occurs on the lower legs
Redness
Dry flaky skin
Itching
Scaling
Weeping skin
White patches may form- called Atrophie Blanche
Thickening of the skin- Lipodermatosclerosis 
Venous ulcers may also form

Question 25

What is the name given to the thickening of skin seen with venous eczema?

Answer 25

Lipodermatosclerosis

Question 26

What is the name given to pale patches that form with venous eczema?

Answer 26

Atrophie Blanche

Question 27

Describe the features of a venous ulcer

Answer 27

Large shallow irregular border Pain improves on raising the leg, unlike arterial ulcers where this worsens pain Exudative granulating base Sloped edge (arterial ulcers appear punched out) Associated varicosities, atrophie blanche, lipodermatosclerosis Commonly in malleolar area- especially medial (found in gaiter area)

Question 28

How is venous eczema managed?

Answer 28

Must do ABPI before consideration of compression stockings/bandages ``` Raise legs Compression bandages Moisturising creams/Topical emollients Avoid damaging the skin Varicose vein repairs ```

Question 29

What is pompholyx eczema?

Answer 29

Eczema found on the hands and/or feet Intensely itchy Burning sensation Small Bilsters

Question 30

What is the treatment for pompholyx eczema?

Answer 30

Avoid contact with potential irritants Emolients (moisturisers) Steroid creams Anti-histamines to relieve itching Specialist treatments: Phototherapy, Oral steroids, Tacrlimus cream, Ciclosporin tablets, azathioprine, alitretinoin (retinoid)

Question 31

What is asteatotic eczema?

Answer 31

Eczema that occurs with age due to skin drying out | Often settles with moisturisers

Question 32

What are the features of photosensitive eczema?

Answer 32

Eczema (redness, itching, flaking, scaling, exudate) is seen in areas exposed to the sun Note- Phytophoto Eczema can occur when sap from plants comes into contact with the skin and then there is sun exposure. E.g. Giant Hogweed, and Fig Tree

Question 33

What are the diagnostic points for atopic eczema?

Answer 33

A child must have itchy skin and at least three of: Onset for 2 years of age Past flexural involvement History of generally dry skin Personal history of other atopy or atop in 1st degree relative Visible flexural dermatitis (or on cheeks/forehead) and outer side of limbs if less than 4)

Question 34

What should parents be asked to urgently report if their child has eczema?

Answer 34

Any weeping or blistering or punched out lesion that develop over the face. This could be eczema herpeticum and this can be fatal.

Question 35

What are the core treatment modalities of eczema?

Answer 35

``` Emolients (moisturisers) Soap substitutes Topical corticosteroids Topical immunomodulators (Systemic if very severe) ```

Question 36

What is the best emollient?

Answer 36

The one the patient prefers

Question 37

How should emollients be used?

Answer 37

Liberally applied to the skin and the most greasy one tolerated should be used (greasier emollients may be okay to use at nighttime) Massage emollients in the direction of hair growth the avoid blocking hair follicles

Question 38

When should topical steroids be used for the management of eczema?

Answer 38

Topical steroids should be used for exacerbations of eczema, or in severe cases high potent steroids should be used for flares and potency reduced when required- use the weakest steroid that is effective.

Question 39

Give an example of a mild topical steroid

Answer 39

1-2.5% corticosteroid cream

Question 40

Give an example of a moderate topical steroid

Answer 40

Eumovate or Modrasone

Question 41

Give an example of a potent topical steroid

Answer 41

Betnovate, Elocon, Synalar

Question 42

Give an example of a very potent topical steroid

Answer 42

Dermovate

Question 43

How should secondary infections be treated in eczema?

Answer 43

Oral antibiotics Might consider adding in antiseptic creams (e.g. Dermol 500) or antiseptic bath oils (olatum plus)

Question 44

What can be given for the management of itch?

Answer 44

Anti-histamines- but this is often sedating ones that are for the getting to sleep at night. E.g. Hydroxyzine

Question 45

What are some side effects of steroid cream?

Answer 45

SEs depend upon potency ``` Skin thinning Irreversible striae Telangiectasia Worsening of any untreated infections due to local immune suppression Adrenal Suppression (rare) ```

Question 46

Describe the finger tip unit

Answer 46

The amount of cream squeezed from a standard 5mm nozzle along the palmar surface of a distal phalanx in an adult hand. 1 FTU will cover the palmar surface (including fingers) of two adult hands.

Question 47

What might be considered if eczema is not controlled by steroids?

Answer 47

Topical tacrolimus/pimecrolimus | Systemic Treatments- Ciclosporin, Azathioprine, Methotrexate

Question 48

When might systemic therapies be considered for eczema?

Answer 48

For very severe eczema. Oral prednisolone, methotrexate, ciclosporin (nephrotoxic), azathioprine (bone marrow suppression)

Question 49

Where should topical steroids not be used?

Answer 49

Not on the face- Topical immunomodulators such as tacrolimus may be used on the face.