DERMATITIS

dr. Ambar Rialita SpKK

DERMATITIS -Eczema

A common type of inflamation of skin

( epidermo- dermatitis ) which is not caused by microorganism. Itching is the most symptom

Some types appear to be due to as yet unidentified

constitutional abnormalities, while others are more
obviously the result of some external set of circumstance

Constitutional : eg Atopic dermatitis

External : eg Contact dermatitis

Eflorescense of Dermatitis-Eczema
Erythem
Papule

Vesicle
Pustule
Oozing
Crust

Squama

Several types of Derm- ecz

Atopic dermatitis
Contact dermatitis
Seborrhoic dermatitis
Statis dermatitis
Neurodermatitis
Nummular eczema
Dishidrosis
Asteatotic eczema
Infective Eczematoid Dermatitis

Atopic dermatitis /Eczema

A.D may divided into three stages, namely :

Infantile ( 2 months 2 years)

Childhood ( 2 years 10 years)

Adult

Infantile

Usually begins as an itchy erythema of cheeks followed

by development of vesicle, rupture and produce moist
crusted areas

The eruptions may rapidly extend to other parts of the

body, chiefly the scalp, the neck, the forehead, the wrist
and the extremities

The buttocks and diaper area are often involved

The eruption may become generalized with erythroderma

Infantil AD

Childhood AD

The lesion to be less exudative, drier, and more papular

The classic locations are the antecubital, and the popliteal

spaces, the wrist, eyelids, and the face and in collarette about
the neck

The other area, however, are frequently affected

Itching

There is a decrease in the frequency of sensitization to egg,

wheat and milk, but an increase in sensitization to nonigested
substances, particulary wool, cat hair, dog hair, and pollens

Childhood AD

Adolescent and adult AD

Usually the eruption involves the antecubital and popliteal

fossae, the front and sides of the neck, the forehead and
the are about the eyes
Hands dermatitis occurs more frequently in atopic
individuals, and eczematous lessions of the dorsum are
usual
Pruritus : paroxysm, nocturnal, triggered by acute emotional
stress
Trigger factors : rough clothing, wool irritation, foods or
tension.

Adolescent and Adult AD

Associated features

Cutaneous stigmata : Dennie-Morgan fold, Keratosis pilaris,

and Hertoghes sign
Vascular stigmata : White dermographism
Personality traits : Nervous tension
Ophthamologic abnormalities : cataracts, keratoconus.

Susceptibility to infection
:
S.aureus, generalized Herpes simplex or vaccinia virus
infections to produce Kaposis varicelliform eruption

Immunology : elevated serum IgE, decreased T-supressor

cells, decreased chemotaxis and activations of PMN
leucocyte.

Diagnosis
Hanifin & Rajka , Svenson, SCORAD criterias
Hanifin & Rajka criteria :
Major criteria
1.
Pruritus
2.
Typical morphology and distribution
3.
Tendency toward chronics or chronically relapsing dermatitis
4.
Personal or family history of atopic diseases (asthma, allergic
rhinitis, AD)

Minor criteria :
1. Xerosis / ichthyosis/ hyperlinear palms
2. Pityriasis alba
3. Keratosis pilaris
4. Facial pallor / infraorbital darkening
5. Elevated serum IgE
6. Keratoconus
7. Tendency to non spesific hand eczema
8. Tendency to repeat cutaneous infections

Differential diagnosis
Nummular Dermatitis
Seborrhoic Dermatitis
Contact Dermatitis
Psoriasis
Scabies

General management
1.

In infancy and childhood

a. It should be avoided :
External irritation
Sudden change of temperature, excessive
bathing, insufficient cleanless especially in the
diaper region, local infections
b.

Food elimination ( with special attention)

b.

Antihistamin systemically

c.

Olive oil on absorbent cotton may used with

gentle patting for cleansing to avoide rubbing the
affected patrs. Particular attention should be given
the genitals and buttocks and the diapers should
be changed

d.

Weak topical corticosteroid.

2.

In adults :
a. The emosional stress should be controlled
b. Avoid extremes cold and heat
c. Hydrated xerotic skin
d. Antihistamin
e. Topical steroid ( be ware of the potentiallity)
f. Antiobiotics ( if nedded)

Contact Dermatitis (CD)

An exogenous dermatitis which develops as a reaction

of the skin to contact with a foreign substance / an
environmental agent, either a primary irritant ( Irritant
CD) or an allergen (allergic CD)
It may be affected by exposure to UV-light, resulting
into two variant reaction : Photoallergic & Phototoxic
CD

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Allergic Contact Dermatitis (ACD)

Occur in predisposed individual

Sensitization occurs within a week after contact with a
substance (allergen), but there are no visible skin changes
Subsequent contact with allergen, even in small amounts,
causes an dermatitis
Once established, sensitivity may persists for months,
years, or even a lifetime

Irritant Contact Dermatitis

Occure in any individual provided the chemical irritant

is applied in a potent enough concentration for a
sufficient length of time

Inflamation of the skin develops at the site of contact

There is non allergic mechanism involved, the damage

result from direct chemical action

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Irritants:
strong irritant severe inflamation at the first
contact
Weak irritants: less toxic substances which require
repeated or prolinged conatact to
cause inflamation (detergent,
organic solvents, excessive
exposure to water)

Incidence:
The incidence of cases of ICD (each type)
depending mainly on the degree of exposure and
the causative agent
In patients with atopic dermatitis there is a
relatively high incidence of ICD

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Sign
Allergic dermatitis
Based on erythematous skin there are : edema,
papules, vesicles and occasionally bullae. Patches are
single / multiple, and of various size and shape. Strong
irritant burns, ulcer and necrosis

Patch Test

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Treatment

Preventive :
Once the causative agent has been identified, further
contact should be avoided
Topical therapy :
in acute state : wet dressing : Burowi solution 1/20 1/40,
Permanganate 1/10.000, followed by topical steroid.
in chronic state : moderate topical steroid
Systemic therapy :
Antihistamin (severe pruritus) and steroid (severe /
ex tensive eruption

Contact Dermatitis

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Seborrhoic dermatitis
Two distinct subset of patients :

* The Infantile form *

Characterized by large yellowish scale mainly on the scalp,
face, axilla and napkin rash
May cause confusion with Infantile Atopic Dermatitis
No link between the infantile and adult form
No pruritus eat & sleep well

Infantil form Seborrhoeic Dermatitis

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Cradle Cap

* The adult form *

Affect

the face, scalp, anterior chest, axilla, sub

mammary fold, groins, external ear
Facial lesion, particularly in the nasolabial fold, in
men, maybe very persistent
the scalp is frequently involved presenting
complaint, esp severe and persistent dandruff
Eyebrow/ eyelid stickness of the eyelid in
early morning

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Differential diagnosis :
Contact dermatitis, psoriasis and Pityriasis versicolor
Treatment :
Tends to recure whatever treatment is chosen
Topical : imidazol antifungal ketokonazol
(cream/shampoo) , weak potency topical steroid

Adult form Seborrhoeic Dermatitis

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Stasis dermatitis

dermatitis on the lower legs, commonly seen in association

with venous insufficiency
many cases seen in obese, female patients have a degree of
venous insufficiency
inner aspects of boths lower legs above and around the medial
malleous are chiefly involved
the skin is shinny, atrophic and large numbers of small blood
vessels clearly visible, purpura, pigmentation (due to
haemosiderin)
pruritus may be severe and cause scratch marks which are
slow to heal

Treatment :
treatment of underlying varicose veins, topical steroid (weak)
be ware of side effects atrophy

Stasis Dermatitis

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Neurodermatitis
(liken simplex chronicus)

a well demarcated are of chronic lichenified dermatitis which is

not due to either external irritants or identified allergens
In predisposed persons, the lesions are induced by continual
scratching or rubbing of a localized area of itching skin
stress / emotional disturbance pruritic stimulus scratch
itch-scratch-itch cycle stimulate a reactive hyperplasia,
recognized clinically as lichenification
clinically, neurodermatitis are seen as a well-circumscribe,
lichenified, slightly elevated plaque, seen on the nape of neck,
forearm, or the legs

Treatment :
Reduce pruritus, topical steroid (ointment/ intra lesion)

Neurodermatitis

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Asteatotic aczema
(eczema craquele)

The dry irritable skin seen mainly on the limbs of

elderly patients.

The skin is dry and has large scale with a crazypaving appearance.

Treatment : - lubrication
- steroid topical should be avoided
(skin is already thin and fragile)

Asteatotic Eczema

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Dishydrotic
(eczema dishydrosticum)

a very characteristic pattern of intensely itchy vesicles

of the skin of the hands and occasionally the feet and
also the side of finger
Deep-seated vesicle ; often easier to feel than to see
The cause is not understood ( contact dermatitis /
stress? )
Treatment ; systemic antihistamins ( control the need
to scratch) prevent secondary infection, potent
topical steroid ( a short time) ; for the moist lesion
calamine lot.

Dishydrotic

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Nummular or Discoid dermatitis

a chronic, recurrent pattern of dermatitis with discrete

coin-shape lesions tending to to involve the limbs
Usually affects adults (many of whom will have a past
history of AD) ; The aetiology is unknown
Clinically : subacute with erythema, edema,
vesiculation; the surface may be moist and appear
infected bacterial eczema
Pruritus is variable
Treatment : topical steroid + antibiotic

Nummular or Discoid Dermatitis

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INFECTIVE ECZEMATOID DERMATITIS

IED is exogen in nature, can be defined as fluid/ exudate

which originates from inflammation or disorders such as:
OMP, sinusitis, chronic ulcers, etc
IED is thought as autosensitisation dermatitis which occurs
from skins sensitivity toward chemical substances
originating from tissues/ bacteria in the bodys own exudate

Clinical appearances :
Erythema & exudation
In a dry state, there is crust. If crust is peeled, we would
see erythema & often pustules on the edges
Examples :
The earlobes of children suffering from OMP.
The area around the nose of maxilaris sinusitis sufferers

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Therapy :
Rivanol 1/1000, Betadine dressing
When cleared Hidrocortisone 1 % or combination with
antibiotic

Infective Eczematoid Dermatitis

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