Eczema
Georgia Skin and Cancer Clinic
Cynthia A. Doallas, PA-C
Eczema
(Atopic Dermatitis)
the most common
inflammatory skin condition
 most confusing skin ailment for
both patients and their
nondermatologic health care
providers
Atopic dermatitis is the most common type of eczema. It is a chronic,
inflammatory, itchy skin condition with unpredictable course of flares and
remissions. It effects 5% to 10% of the United States population.
Most cases begin in childhood (often in infancy); however may start any age
The disease frequently remits
spontaneously-reportedly in
40% to 50% of children- but it
may return in adolescence or
adulthood and possibly persist
for a lifetime.
Typically families are advised that children “will grow out of eczema”
.
Atopic dermatitis is an inherited
Type I hypersensitivity
disorder of the skin. It is
usually associated with
personal or family history of
hay fever, asthma, allergic
rhinitis or sinusitis.
M
Grandfather
M.
Grandmother
MOM
P.
Grandfather
P.
Grandmother
DAD
BABY
Normal Skin
Skin of Acute
Eczema
Eczematous epidermis
contains intercellular an
intracellular fluid that
appears in a sponge-like
formation (spongiosis);
Vasodilatation of the
dermis occurs, resulting
in the clinical
manifestation of
ACUTE eczema.
Acute Eczema
Appears as “itchy” erythematous patches, plaques, or papules that may develop
into vesicular lesions, or may continue as a less nonvesicular, erythematous
eruption.
Chronic Eczema
Later, the epidermis will thicken
(acanthosis) and retain
parakeratosis, resulting in an
overabundance of cellular
infiltrate in the dermis.
These changes account for the scale
and lichenification of
CHRONIC eczema.
The epidermis shows hyperkeratosis, acanthosis,
and a prominent granular layer. There is
liquefaction degeneration at the dermal-epidermal
interface.
Chronic Eczema
(aka: Chronic eczematous dermatitis)
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Has a hallmark lichenification (plaque with an exaggeration or hypertrophy
of the normal skin markings).
Scale and hemorrhagic crusts can result from scratched or drying vesicles.
 Older lesions exhibit hypo or hyper pigmentation.
Severity
Atopic dermatitis can present with a
wide spectrum of severity.
 mild, recurrent, localized itchy rash
on “dry” skin or
 more severe, extensive eruption that
can be accompanied by unremitting
pruritus, sleepless nights,
secondary cutaneous bacterial
infections, and/or embarrassing
lichenification.
Effects
Psychosocial problems, such as poor self-image, anger, and frustration
may lead to depression and social isolation.
What to look for….
The character and distribution of the skin rash tends to
vary according to the patient’s age.
Any or all manifestations of atopic dermatitis may exist in
a single patient.
The different phases of atopic dermatitis are not always
clearly distinct.
Infantile Phase
Childhood Phase
Adolescent and Adult Phase
Infantile Phase
(patients 2 months to 2 years of age)
Eruption may become generalized, in most cases it first manifests with severe
“cradle cap” or severe intertriginous rashes (groin, neck, axillae).
As the patient approaches age 2 years, the flexor creases become involved.
Lesions consist of scaly, red, and occasionally oozing plaques that tend to be
symmetric.
Occurs on the
 scalp
 face, particularly cheeks
 neck
 chest
 extensor extremities
Childhood Phase
(patients aged 2 years to 12 years of age)
These patients tend to be less acute and lesions less exudative than those seen in
infancy.
Inflamed lesions become lichenified (especially in Asian and African-American
patients)
secondary to chronic rubbing and scratching.
Lesions tend to occur symmetrically, with characteristic distribution in the flexural
folds.
Occurs on the:
Antecubital and popliteal fossae
Neck, wrists, and ankles
May occur on the eyelids, lips, scalp, and
postauricular areas
Adolescent and Adult Phase
(patients 12 years and older)
Post inflammatory hyper or hypo pigmented changes tend to
be seen.
The appearance of atopic dermatitis may change to a more
poorly defined, itchy, erythematous rash, possibly with
papules and/or plaques.
Lichenified plaques of atopic
dermatitis are typically less well
demarcated than are the plaques
seen in psoriasis. These plaques
tend to blend into surrounding
normal skin.
Clinical Aspects
Clues to diagnosing Atopic Dermatitis:
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Persistent Xerosis, or dry, “sensitive” skin.
“Allergic Shiners”-this refers to the darkened or
tanned coloring in the periorbital areas.
Hyperlinear palmar creases
Follicular eczema (most common in AfricanAmerican patients)
Ichthyosis vulgaris
Keratosis Pilaris
Possible Complications
Pruritus (itching) may interfere with sleep. Pruritis is increased
by repeated scratching and rubbing, which leads to
lichenification, oozing, and secondary bacterial infection.
Secondary infection with Staphylococcus aureus may
trigger relapse of atopic dermatitis.
Differential Diagnosis
Diagnosis of atopic dermatitis is generally not difficult,
especially in patients with atopic history. The following
should be considered or excluded:
Contact Dermatitis
Determine whether the patient was exposed to a substance that could cause contact
dermatitis. The location of the lesions may suggest an external cause.
Differential Diagnosis
Psoriasis
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Lesions are generally in extensor locations (elbows,
knees, and other large joints) rather than the flexor
creases. May be palmar or plantar as seen in this image.
Patients typically have a positive family history of
psoriasis.
Psoriasis is less pruritic than eczema, lesions
tend to be clearly demarcated from normal
surrounding skin, and the scale of psoriasis
tends to be thicker in appearance.
However, psoriasis may at times be clinically
indistinguishable from atopic dermatitis
Differential Diagnosis
Tinea
A positive KOH test or
fungal culture result will
confirm
(remember, an unresolved
eczematous-like rash, worsening
with topical corticosteroids could
be tinea)
Once I diagnosis it, how do I treat it?
Topical Corticosteroid Therapy
General Principles:
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Application of an appropriately chosen topical steroid will usually bring
prompt improvement in a patient with atopic dermatitis.
Topical Steroids should be used only as short-term therapy. (Two weeks
on, two weeks off unless severe flare).
They should not be used for prevention of future lesions or for cosmetic
concerns, such as post inflammatory hyperpigmentation
“Stronger” is often preferable to “Longer” in the use of topical steroids,
because long-term application is more often associated with side effects.
Topical Steroids can be used in conjunction with “Wet wrap Usage”.
When the condition is under control, the frequency of application and the
potency should be reduced.
Low potency steroids should be used to treat the face and body folds.
Wet Wraps and
Moisturizers
Combination Therapies to be used
with Topical Steroid
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Topical Immunomodulator
Therapy (six-week intervals)
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Tacrolimus (Protopic) 0.03% or
0.1% ointment (age-dependent)
Pimecrolimus (Elidel) 1% cream
Other Therapeutic Measures
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Antihistamines prn
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Benadryl
Atarax or Cyproheptadine,
Palgic and other H-1 blockers
Minimal Mild, moisturizing
soaps (i.e. Vani, Dove, Cera Ve
Fragrance-free regimine
Oils/Moisturizers
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Derma-Smoothe FS
Robathol
Olive
Crisco Lard
Vanicream, Cera Ve
Mimyx, Atopiclair, Hylira
Avoidance
Irritants:
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Recommend non-irritant fabric, such as
cotton. Wool may induce itching
Overheating and sweating:
Excess dryness or humidity should be avoided.
An air conditioner or humidifier in a child’s
bedroom may help to avoid the dramatic
changes in climate that may trigger
outbreaks.
Allergens:
 Environmental elimination of
airborne substances may bring lasting
relief.
Severe cases
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In severe patients that failed oral and tropical
corticosteriods consider Cellcept.
Points to Remember
Topical Steroids should be applied only to inflamed skin
(active disease).
 When Topical Steroids are applied immediately after
bathing their penetration and potency are increased.
 Low-potency topical steroids are recommended for use
on the face and in skin folds.
 There are primarily two causes of eczema:
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Outside (contact dermatitis)
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Inside (atopic dermatitis)
Patients and their parents, caregivers, and teachers
should be educated on the manifestations and
management of atopic dermatitis
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The National Eczema Association can be contacted at (503) 228-4430 or
www.eczema-assn.org
Thank you for your attention
Questions?