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Hello cohort, today discussion will emphasizes in the most common dermatologic conditions related to eczemas and how to differentiate them for proper diagnosis and treatment.
The term eczema encompasses a heterogeneous group of inflammatory skin disorders that share similar hallmarks of epidermal inflammation. It includes such entities as atopic dermatitis, contact dermatitis, stasis dermatitis, dyshidrotic eczema, seborrheic dermatitis, and asteatotic eczema.
Eczema can present acutely, characterized by red, weeping, draining skin with blisters, or it can present chronically, with dry, thickened, scaly skin with alteration of pigment, appearing either at times hyperpigmented or depigmented. Frequent etiologies include extrinsic causes, such as irritant dermatitis or allergic contact dermatitis, or intrinsic causes, such as atopic or dyshidrotic eczema. Common morphologic types include hand eczema, nummular eczema (coin-shaped lesions), stasis dermatitis (often affecting the lower extremities in the setting of vascular insufficiency), and atopic dermatitis, which often begins in infancy as part of the “atopic” diathesis.
Atopic dermatitis is one of the more common inflammatory skin conditions. In children, it is characterized by involvement of the cheeks, scalp, and extensor aspects of the extremities. Initially, it appears as weeping, erythematous papules and plaques, sometimes accompanied by vesicles and crusting. Over time, lesions become chronic with thickened, lichenified plaques; later in adults, it presents as chronic hand or face dermatitis. Pruritus is a constant complaint regardless of the patient’s age.
Asteatotic eczema, or “winter’s itch,” which commonly occurs in the elderly, presents with dry, rough, scaly patches and plaques with superficial cracking of the skin that appears like a “dried riverbed.” Areas usually involved are the shins, lower flanks, and posterior axillary line. Elimination of aggravating factors, such as frequent bathing, and application of emollients help significantly.
Stasis dermatitis, another form of eczema, often is associated with other signs of venous hypertension, as evidenced by pitting edema and hemosiderin deposition in the skin. Eventually, patients may develop erythema and scaling around the medial malleoli with intense pruritus and subsequent excoriations; later stages may show cutaneous ulcerations.
For the various types of eczema, therapeutic principles are similar; the dictum, “If it is wet, dry it; if it is dry, wet it,” applies. Drying agents include water and aluminum acetate, and “wetting” agents comprise emollients, such as ointments and creams. Topical therapies for various forms of eczema encompass corticosteroids as well as immunosuppressives such as the calcineurin inhibitors (tacrolimus ointment and pimecrolimus cream). Systemic therapy is rarely necessary; however, in refractory or generalized cases, prescribed treatments include oral prednisone, phototherapy, or other immunosuppressives such as cyclosporine, azathioprine, methotrexate, or mycophenolate mofetil. In cases of superinfection, evidenced by weeping, purulent, or honey-crusted plaques overlying areas of eczema, antibiotics may help.
The most significant component of any treatment, however, is educating the patient about the chronic, relapsing nature of eczema. Patients must understand that treatments are tools, not cures. Several proactive measures can help prevent flares: Patients should avoid triggers, modify wet work or handwashing, and liberally use emollients such as ointments and creams, especially after contact with water. Bathing should be brief; showers should be taken with lukewarm to cooler water; moisturizing soaps should be applied primarily to body folds and soiled areas; and within several minutes of bathing, patients should freely administer creams or ointments.
References:
Lowell BA, Froelich CW, Federman DG, Kirsner RS. Dermatology in primary care: prevalence and patient disposition. J Am Acad Dermatol. 2001;45(2):250-255.
Pedrosa AF, Lisboa C, Gonçalves-Rodrigues A. Malassezia infections: a medical conundrum. J Am Acad Dermatol. 2014;71(1):170-176.
