Prof. DOULAT RAI BAJAJ
FCPS, MCPS
Professor & Chairman
Dept. of Dermatology
LUMHS

At the end of presentation you would be able to:
1.
Clinically evaluate a patient with itch or itchy rash
2.
Make a working diagnosis
3.
Manage it at the best

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History:
 I nfant/child :
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
Atopic Dermatitis
Scabies, Pediculosis
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Infantile seb. dermatitis psoriasis
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Mastocytosis
Insect bites (papular urticaria)
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Urticaria

 Specific dermatoses: Atopic Dermatitis, Contact
Dermatitis, Psoriasis, P. Rosea, lichen simplex chronicus, Prurigo,
 Infections: Scabies, body lice, Yeast & fungal infections (tineas, P. versicolor)….
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Hypersensitivity reactions: urticaria, Dermatitis herpetiformis
Miscellaneous: cut. Lymphoma, psychogenic……

History:
Old age:
 Dermatitis Herpetiformis
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
Xerosis psoriasis
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
Aging of skin
Drug reactions,
 Systemic diseases

History:
Acute vs Chronic
 Acute: scabies, pediculosis, drugs, insect bites, urticaria
 Chronic : AD, ACD, Psoriasis, LSC, prurigo, systemic diseases
 Gender : pregnancy associated dermatoses
 Family history: Scabies, pediculosis, psoriasis,
AD,

History:
 Presence of Systemic Disease:
 Renal: CRF, Pt on dialysis
 Endocrine: DM, hypo-and hyperthyroidism,
 Liver Disease
 Malignancies: any internal malignancy
 AIDS:
 Hematological: Polycythmia, anaemia
 Psychogenic

 Type of lesion: macule/patch, papule/plaque, nodule, vesicle/bullae, pustule, erosion/ulcer ..
 Sites and Distribution:
 Shape: annular, discoid, polygonal, arcuate…
 Pattern: discrete, grouped, linear, segmental, dermatomal
 Colour, consistency, margins etc
 Secondary features: crust, scale, excoriation ,


Woods’ light examination
 Scrappings for fungal infections
 Skin Biopsy:

“ATOPY” is a genetically determined tendency to produce increased amounts of reagens (IgE), in response to allergens.
Clinically manifested by :
 ASTHMA
 HAY FEVER
 ATOPIC DERMATITIS

IgG
IgM
IgA
IgD
IgE
Macropha ge
IL-1
T cell IL-4
Antigen
Plasma cell
B cell

Antigen
Macrophage
IL-1
T cell IL-4
IgE
Plasma cell
B cell

 Pruritus
 Early age of onset
 Typical morphology and distribution
 Infants & Children: Face & extensors
 Adults: Flexureal lichenification & linearity
 Chronic course
 Personal or family history of atopy (asthma, rhinoconjuctivitis, dermatitis).

 Dryness of skin
 Ichthyosis , palmar hyperlinearity/keratosis pilaris
 Hand/foot dermatitis
 Lip dermatitis
 Nipple eczema
 Increased cutaneous infections e.g. Staph. aureus &
H.Simplex)

 Itching
 Erythematous Macules, Papules, vesicles
 Eczema with crusting, Lichenification,
Excoriation
 Dry skin
 Secondary infection

Acute AD
 Redness
 Swelling
 Papules
 Vesicles
 Exudation
 Cracking
Chronic AD
 Less vesiculation/ exudation
 More Thickening, pigmentation &
Lichenification (due to rubbing & scratching)
 Fissures
 Scratch marks

Infantile/childhood AD
 Red Itchy scaly lesions on scalp, cheeks, wrists & trunk
 Diaper area spared
 Extensor aspects of limbs
(begins to Crawl)
 Irritable & restlessness
 Crusts
 Pustules
Adult AD
 Lichenified, pigmented papules, plaques scattered all over body
 Bothering itch
 Prominent infra-orbital crease
 General dry skin

Characterized by:
 Erythematous scaly plaques
 Greasy scaling
 yellow crusted patches & plaques
 There is very minimal itch (vs AD)
 Age of onset:
 Below 06 months: infantile SD
 After puberty: adult SD

Infantile SD:
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Scalp (Cradle Cap),
Face & Neck (eye brows, Ears & sides of neck).
Trunk & Flexures, starting in napkin area.
Adult SD :
 Scalp
 Forehead
 Face: Eyebrows, Nasolabial folds, ear canals, behind pinnae,
 Trunk: sternal area, interscapular region & flexures

1.
2.
Irritant Contact Dermatitis
Allergic Contact Dermatitis

 Non-allergic reaction of the skin caused by exposure to irritating substance
 Any person can develop ICD if concentration & duration of contact sufficient
 About 80% of occupational dermatitis is irritant in nature
 C/F: Erythema, Edema, Vesiculation, Weeping

ALLERGIC CONTACT DERMATITIS
 Immunologically-mediated, Delayed (type IV) hypersensitivity
 Occurs in persons already sensitized
 Not dose related, Not restricted to area of contact
 C/F: erythema, edema, papules, papulovesicles
 it is difficult to distinguish C/F of ACD from irritant or constitutional dermatoses(AD, SD)

 Common sensitizer:
1.
2.
3.
4.
5.
Hair dyes
Nickel, Chromate, cobalt
Leather, Rubber
Topical Drugs: neomycin, gentamicin, lignocaine
Plants

Dry scaly dermatitis

ACD due to items in pocket

 Avoid known triggers
 Moisturize, moisturize, moisturize
 Itch Control
 Topical corticosteroids
 Other topical therapies
 Systemic therapy

 Allergen avoidance during pregnancy and or infancy (mild benefit shown from avoiding cow’s milk, eggs, and dust mites)
 Big Five: dryness, dust mites, animal dander, cigarette smoke, wool
 Others include water and chemicals

 Baths and showers not hot and short
 Mild soap (Dove) – best to avoid alkali soaps
 Blot dry and immediately moisturize (skin should still be slightly damp)
 Creams and ointments better than lotions and oils

 Avoid topical antihistamines
 Products containing menthol, camphor & weak conc: of phenol may be helpful
 Cool compresses
 Avoid hot/sweaty conditions

 In children generally sedating AH used. No role of non-sedating AH in children with AD
 A combination of sedating & non-sedating AH indicated in adults with eczema.
 For AD : Zonalon=topical doxepin – qid for maximum of eight days. Never occlude, some systemic absorption, very sedating, risk of ACD

 Steroid
1.
2.
3.
4.
5.
6.
7.
8.
Potency
Vehicle
Amount
Site
Clinical stage of eczema
Weather
Duration of treatment
Disease

Super Potent Potent
Clobetasol propionate 0.05%
(dermovate)
Fluticasone propionate
(cutivate)
Amcinonide
Diflucortolone valerate (volog) Mometasone Furoate
(hivate)
Flucinolone acetonide 0.2% Betamethasone dipropionate (diprolene)
Halcinonide
Betamethasone valerate
0.1% (betnovate )
Triamcinolone acetonide
(kenacomb)
Moderate
Potent
Betamethason valerate
0.025%
Mild
Hydrocortisone
Prednicarbate
Methyl prednisolone acetate 0.25%
Flucinolone acetonide
0.0025%
Desonide (desone)
Methylprednisolone aceponate 0.1% (advantan )




Tar
Salicylic acid
Topical Tacrolimus, pimecrolimus

 Antibiotics for culture proven infections
 Ketoconazole for head and neck based atopic dermatitis (reduce yeast counts)

 UVB
 Narrow Band UVB
 UVA/PUVA
 Sunlight

 Leukotriene Inhibitors do not work
 Oral cromolyn sodium results conflicting
 Interferon gamma daily s/c inj. helps
 Cyclosporine
 Azathioprine
 Hydroxychloroquine

 Circular or oval plaques
 A clearly demarcated edge
 Related to atopy, emotional stress, bacterial infection
 Usually lesions dry.
 Exudative ones always associated with bacterial infections.
 Treatment : Emollients, topical steroids, antibacterials

An eczematous dermatosis characterized by
 Lichenified plaques, usually 1-2 in number
 Typical sites: nape of neck, scrotum, wrists
 skin thickened, pigmented with prominent skin markings
 Associated with atopy, emotional stress
 Tr: Superpotent steroids with keratolytic agents.
I/L steroid injections

 Characterized clinically by chronic, intensely itchy papules & nodules
 lesions range from small papules to hard nodules, 1 –3 cm in diameter, with a raised, warty surface.
 The early lesion is red later becoming pigmented.
 Tr: superpotent steroids, oral steroids, UVB,
PUVA, thalidomide

 Pompholyx is characterized by the
 sudden onset of clear vesicles over hands.
 Symptoms : No erythema, less pruritus but more heat and prickling sensation.
 Sites : sides and dorsa of fingers & hands
 Vesicles may become confluent and present as large bullae, especially on feet.
 Itching may be severe, preceding the eruption of vesicles

 An acute, self-limiting disease, probably infective in origin, affecting mainly children and young adults.
 The first lesion is “ Herald patch ” a large circular, sharply defined eryhematous patch with fine scales on thigh/trunk.
 This is followed by an eruption of discrete oval lesions, dull pink in colour, covered by fine, dry, silvery scales forming a collarette at edges.
 The centre tends to clear and assumes a wrinkled, atrophic appearance.
 The lesions appear in crops.

 The lesions tend occur in ‘chrismas tree’ pattern along the rib cage.
 There are usually no symptoms. Some pts. have mild to moderate pruritus
 Tr: The common asymptomatic, self-limiting cases require no treatment . If itch is severe or the appearance distressing, a topical steroid
(moderate potent) or UVB can be helpful .

 Eczema developing in dry skin
 Seen on legs, arms and hands.
 Tends to be more marked in the winter and in elderly people.
 Skin is dry, scaly showing a criss-cross skin markings. Finger pulps are dry and cracked; retaining a prolonged depression after pressure
(‘parchment pulps’).
 Associated with hypothyroidism, zinc deficiency, diuretic use and cimetidine use

 A mild eczema in which hypopigmentation is the most conspicuous feature. (NO CALCIUM Deficiency
 Predominantly seen in children b/w ages of 3 -16 ys.
 The individual lesion is circular, oval or irregular hypopigmented patch with NOT well defined edges.
 Lesions often slightly erythematous & have fine scale
 Common sites : cheeks & around the mouth & chin
Less commonly on neck, arms, shoulders & trunk.
 D/D: vitiligo, P. versicolor, PIH
 Tr : mild steroids, emollients

Disease
Irritant CD
Typical morphology
Sharply demarcated macular erythema, little vesiculation
Exzematous, scaly edematous plaques with vesiculation
Diagnostic clues
More burning less itch, only at area of contact
Allergic CD
Atopic
Dermatitis
Sebhorroic dermatitis
Eczematous, honey-crusted scaly plaques, lichenified in chronic cases
Greasy scaly papules, minimal itch
Pruritis, primary lesion at area of contact
,
Flexural areas, neck predominance
Hair bearing areas, glabella, nasolabial folds
Xerotic/asteot ic eczema
Crackled parchment like patches, no edema, no vesiculation
Lower legs
Nummular
/discoid eczema
Pompholyx
Coin-shaped, well demarcated, scaly or weepy plaques, bilateral, symetrical, kissing lesions
Arms, legs, dorsal hands
Deep seated papulo-vesicles on palmar plantar surfaces, volar edges
Palms, soles, typical dorsal involvement

 Eczema management rests on three pillars: avoid irritants, moisturize, topical management
 Use steroids to quiet a flare then switch to a nonsteroidal therapy
 Treating hot spots can prolong remissions
 Control itch!

This presentation is available on www.lumhs.edu.pk/DFHC/html