Dermatitis 101:
Diagnosis and Treatment
of Eczema
Adrian Guevara MD
Dermatitis 101
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Atopic
Seborrheic
Contact
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Allergic
Irritant
Nummular
Asteatotic
Stasis
Neurodermatitis/Lichen Simplex Chronicus
Dermatitis 101
Dermatitis=“Eczema”=Spongiosis
Dermatitis 101
Acute Dermatitis
Dermatitis 101
Subacute Dermatitis
Commonly misdiagnosed as tinea
Dermatitis 101
Chronic Dermatitis
Commonly misdiagnosed as psoriasis
24 y/o male 2 year h/o red,
scaly feet
Allergic Contact Dermatitis
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Type 4 Hypersensitivity Response
Classically well demarcated/patterned
Exposure can be infrequent (once a month)
Patch testing is gold standard for diagnosis
Severe reactions need systemic steroids
Forget the dose pack
Allergic Contact Dermatitis
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Poison Ivy/Oak/Sumac
linearity
Allergic Contact Dermatitis
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Potassium Dichromate
in Leather
Allergic Contact Dermatitis
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Latex
Cleaning products
Cosmetics
Occupational
exposures
Check the feet and
nails!!!
Allergic Contact Dermatitis
40 y/o female homemaker with dry,
itchy hands
Irritant Contact Dermatitis
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Most contact dermatitis is irritant in nature
Occupational
morbity
Irritant vs allergic
Prevention is key!
Look at the cuticles
Lip licker dermatitis
Blunting of vermillion
Accentuation of angles
4 y/o boy with chronic, itchy,
bleeding plaques
Atopic Dermatitis
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10-20% of population
Primary symptom:
itch
Location, location,
location
Associated with atopic
background
Periorbital pallor
Look for
keratosis
pilaris
52 y/o male with erythematous, scaly
patches of face and scalp
Seborrheic Dermatitis
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Distribution
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Chronic condition
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Face, scalp, axillae, upper chest
Nonsteroidal adjuvants
Disease associations
45 y/o female with intermittent
“fungus all over”
Nummular Dermatitis
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Coin shaped patches and
plaques
Secondary to xerosis cutis
Primary symptom itch
Notice the surrounding
xerosis
Asteatotic Dermatitis
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Extreme case of xerosis
Riverbed type cracking
52 y/o male with painful, itchy rash
on right leg
Stasis Dermatitis
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Venous hypertension
Full spectrum of timing
Id reaction common
Complicated by ulceration
Pseudokaposi’s
(acroangiodermatitis)
Lipodermatosclerosis
Venous ulceration
Dispigmentation
(chronic)
Superimposed
allegic contact
Do:
1) dry weeping lesions
2) cover for infection
Don’t: 1) apply neosporin
2) just hope steroids
will fix it
Id reaction
Elephantiasis Verrucosa Nostras
14 y/o anxious female who can’t stop
itching
Neurodermatitis/Lichen Simplex
Chronicus
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Paroxysmal pruritus
Habitual excoriating or
rubbing
Skin thickens to defend
Consider underlying
disease
Increased skin markings
Lichen simplex chronicus
No fungus on the scrotum!
Prurigo simplex
Butterfly sign
Prurigo Nodularis
Consider screening
Prevention
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Remove the offending agent
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Edema, allergen, irritant, yeast, long fingernails
Daily cleansing and MOISTURIZING
Dove, Oil of Olay, Neutrogena
 Mild temperatures
 Cream/Ointment based emollients
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Neosporin, antifungals ≠ moisturizers
Treatment
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Topical Steroids
Clobetasol
 Triamcinolone
 Desonide
 Hydrocortisone
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I
IV
VI
VII
Treatment
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TIM
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Light
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Protopic 0.1% oint
Elidel cr
nbUVB
Systemic immunosuppressives
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Prednisone
Cyclosporine
Azathioprine
IVIG
Only on thin skin !!!
Treatment
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Antihistamines
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Mechanism of action: soporific
Indications for Dermatitis ≠ Urticaria
7 m/o infant with itchy skin
75 y/o nursing home patient with
intolerable itchy skin
Common Pitfalls
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Misdiagnosis
Scabies (intensely pruritic, burrows/vesicles, others
itch)
 Psoriasis (elbows/knees/inflammatory arthritis/nail
changes)
 Fungus (central sparing, well marginated, scaly
border)
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Lose the Lindane!
25 y/o male tx’d for eczema in
antecubital fossa with “some cream”
Common Pitfalls
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Mistreatment
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Lose the Lotrisone!
 1)
Commit to a diagnosis
 2) Shotgunners: “Don’t be a wimp”
 Quadriderm: betamethasone, gentamycin,
clotrimazole
 Animax
The End