Dinesh Thekke, MD
08/26/2008
Atopic dermatitis (Eczema)
3 phases on the basis of the age of the patient
 Infantile phase
 Begins at 1-6 mo, and lasts for
2-3 yrs
 Red, itchy papules and
plaques
 Oozing and crusting
 Cheeks, forehead, scalp,
trunks
 Extensor surfaces
Childhood eczema
•Between ages 4-10 yrs
•Dry, papular
•Intensely pruritic
•Wrists, ankles,
cubital/ popliteal
fossae (flexor)
•Secondary infections
•75% improve between
10 – 14 yrs
Eczema (Adult phase)
 Begins around age 12; continues indefinitely
 Flexural areas of arms, neck and legs
 Marked lichenification may be present
Associated findings in Eczema
 Xerosis
 Ichthyosis vulgaris (Fish like scales, AD inheritance)
 Keratosis pilaris
 Dennie- Morgan lines
 Dyspigmentation (hypo- or hyper-)
 Altered cellular immunity?
 Infections: Staph. aureus, HSV (eczema herpeticum),
Molluscum contagiosum
Atopic dermatitis: treatment
 Hydration/ lubrication of skin using emollients
 Avoidance of predisposing factors
 Antipruritic agent (Antihistaminics)
 Topical steroids (mild- to moderate potency)
 Topical Pimecrolimus (immunomodulators; ≥ 2 yrs)
 Treatment of infections (topical/ PO anti-Staph. Abx)
Dyshidrotic eczema
•Chronic, recurrent, pruritic,
vesicular eruption
•Palms, soles, fingers, toes
•Hyperhidrosis, water
exposure
Nummular eczema
•Acute, papulovesicular
•Coin shaped, circumscribed
•Extensor thighs, abdomen
•Lack of central clearing
•Resistant to therapy
Irritant dermatides, may be
associated with eczema
Lip licking eczema
Thumb sucking eczema
Diaper dermatitis
Irritant
Candidal
Staphylococcal
Seborrheic
Psoriatic
Tinea
Irritant diaper dermatitis
 Failure to change diapers frequently
 Fecal bacteria split urea (in urine) to form ammonia
 Harsh soaps, detergents, diarrhea
 Convex surfaces of perineum, abdomen, thighs, buttocks
 Spares intertriginous areas
 Tx: frequent diaper changes, barrier pastes, topical steroid
Candidal diaper dermatitis
 Bright red, sharp borders, and satellite lesions
 Intertriginous areas are involved
 KOH prep: budding yeast and pseudohyphae
 Associations: Oral thrush, abx therapy
 Tx: Topical antifungal
Staphylococcal diaper dermatitis
 20 to irritant DD or as 10 lesions
 Thin walled pustules on an erythematous base
 Ruptured pustules  collarette of scaling
 Diagnosis: Gram stain
 Tx: Topical/ PO abx
Seborrheic diaper dermatitis
•Salmon colored lesions,
with yellowish scale
•Prominent in
intertriginous areas
•Satellite lesions absent
•Seborrheic dermatitis
commonly seen
Psoriatic diaper dermatitis
 May be the initial presentation of psoriasis
 Erythematous scaling eruption , clinically
indistinguishable from seborrheic DD
 Scales not as prominent as other forms of psoriasis
 Suspect if seborrheic DD does not respond to Tx
Tinea diaper dermatitis
 Less common
 Scaly perineal rash, with active border
 Diagnosis: KOH preparation
 Tx: Topical antifungals
Contact dermatitis
 Irritant CD
 Caustic agents (acids, alkalis)
 Anyone exposed will develop irritant CD
 Acute well demarcated erythema, crusting, blisters
 Allergic CD
 Type 4 delayed HS reaction; T-lymphocyte mediated
 Only in susceptible individuals
 Poison ivy – Rhus dermatitis
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Most common allergic CD in US
Linear streaks of erythematous vesicles
Direct contact with sap (leaves, stem, roots)
 Other allergens: Nickel, dyes, neomycin, etc.
Contact dermatitis: Treatment
•Localized disease may
respond to topical steroids
•Systemic steroidsIndications
•Widespread reaction
•Involvement of eyelids,
face, genitals, hands
•2 week tapering course
of steroids
•Nickel CD:
•Avoidance
•Painting watch buckle
with clear nail polish!
Psoriasis
 Red well-demarcated plaques covered with dry, thick
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silvery scales
Extensor surfaces, scalp, buttocks
Guttate psoriasis associated with GAS (β-hemolytic)
Infants: persistent diaper dermatitis
Nail changes: plaques in nail bed, pitting, hyperkeratosis
Auspitz sign (bleeding points upon scale removal)
Koebner phenomenon: lesions at sites of injury
Remissions and exacerbations, except in Guttate psoriasis,
which is self limited
Tinea Corporis (Dermatophyte)
 Superficial infection of non-hairy (glabrous) skin
 “Ring worm:” Annular lesion with central clearing and
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active border made of microvesicles
Pruritic red papules papulosquamous lesions
Autoinfection common due to scratching
Trichophyton tonsurans
Confirmed by KOH prep. (loose scales from margin):
True hyphae (long, branching, septate rods)
Tx: Topical antifungal creams
Erythema multiforme (EM)
 Acute hypersensitivity syndrome (drugs, viruses,
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bacteria, food, immunizations, CT disorders)
HSV is most common cause for recurrent EM
Symmetrical; any part of body (dorsum of hands/ feet,
extensor aspect of arms & legs, palms and soles)
Dusky red macule/ wheal  iris/ target shaped lesion
Less pruritus than pain and tenderness (cf. urticaria)
Crops that persist for 2-3 weeks
Sparing of mucous membranes; systemic
manifestations mild (cf. SJS)
Self limited course
Stevens Johnson Syndrome & TEN
 Widespread epidermal and mucous membrane necrosis
 ? HS to drugs, viruses, CT disorder, malignancy, etc.
 Plane of cleavage below the basement membrane full
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thickness vesicles/ bullae (cf. SSSS: thin walled bullae)
SJS: 10-30%; TEN: 30-100% of BSA affected
Prodrome (fever, sore throat) diffuse erythroderma
necrosis 24-48 hrs later hemorrhagic blistering
Nikolsky’s sign
Mucous membrane involvement (eyes-corneal scars,
ectropion, oral, urethral) scarring
Prominent constitutional symptoms
Supportive management; ?IVIG. No steroids
Thank you