Eczematous skin disorders

Dr. Ravneet Sekhon, PGY3 Pediatrics

Thanks to Dr. Ramien for her feedback and support in preparation of this presentation!
 Objectives
• Describe the functions of skin
• Description of skin lesions
• Eczema and other dermatides
• Outpatient management of eczema
 Functions of the skin
• Protection
– Protective barrier
– Radiation shield from UV light
– Mechanical, chemical, thermal insults
– Relatively impermeable to water
– Microbes
• Sensation: receptors
• Thermoregulation
– Insulates from heat loss
– Heat loss through evaporation of sweat
• Metabolic function
– Subcutaneous fat stores energy
– Vitamin D synthesized in epidermis in presence of UV light
Normal skin anatomy
• Careful and detailed history should be
gathered regarding onset, inciting factors,
evolution of skin lesions, pruritus,
medications/immunizations, family hx
 Describing skin lesions
• Describe:
– Size
– Shape
– Color
– Texture
– Configuration (relation to each other)
– Distribution (where on the body)
Review of common skin lesions

Macule; flat and <1 cm Patch; flat and >1 cm Papule; raised and <1 cm Plaque; raised and >1 cm

Nodule; raised with more Vesicle: small bubble, fluid Pustule: pus containing
deep component, <1 cm filled, <0.5 cm bubble; can be related to
Tumor is > 1 cm Bulla: >0.5 cm hair follicles
• Great resource with modules -
https://www.aad.org/education/basic-derm-c
urriculum/suggested-order-of-modules/morph
ology
(American Academy of Derm)
 Eczematous disorders
• Erythema, edema, pruritus, weeping
• Chronic: thick, dry, scaly lesions with
lichenification and changed pigmentation
• Includes:
– Eczema or atopic dermatitis
– Seborrheic dermatitis
– Allergic and irritant contact dermatitis
– Nummular eczema
– Acute dyshidrotic eczema
Diagnosis?
 Nickel dermatitis
• A type of allergic contact dermatitis
• Due to prolonged or repetitive exposure
• Improves after removal of stimulus but recurs
quickly on re-exposure
• Temporary treatment with topical or oral
corticosteroids - what steroid, how much, and
for how long?
• Education of parents about cause
 Contact dermatitis
• Irritant contact dermatitis:
– Dry skin dermatitis: from repetitive wet-to-dry like
lip licking, thumb sucking, etc.
– Juvenile plantar dermatosis: red scaly lesions on
weight bearing aspects of foot due to wearing
occlusive footwear
• Diaper dermatitis: irritant, infection (Candida)
• Allergic contact dermatitis: poison ivy, poison
oak, nickel
Diagnosis?
Diagnosis?
Diagnosis?
Diagnosis?
 Pityriasis alba
• Mainly in kids 3-16 yo, M=F
• Hypopigmented, ill defined, round or oval patches
• Can be mildly erythematous and have fine scales
• Location: face, neck, upper trunk, prox arms
• Frequently misdiagnosed: vitiligo, tinea versicolor,
tinea corporis
• Treatment: emollient, low potency topical steroid
or calicineurin inhibitor
Diagnosis?
 Seborrheic dermatitis
• Also called cradle cap in infants
• Greasy scaling of scalp, axillae, groin folds; in adults face,
eyebrows, upper trunk
• Salmon pink patches that can flake or peel
• Not itchy
• Infants<3 mo
• Associated with proliferation of various Malassezia
species
• Treatment: keratolytics, topical antifungals, mild
corticosteroids.
Diagnosis?
 Atopic dermatitis
• 10-30% of kids worldwide
• Most common relapsing-remitting skin
condition
• Occurs with other atopic dz like: asthma,
allergic rhinitis, food allergy
 Etiology
• Genetic mutations in filaggrin in up to 50%
• Defective skin barrier
• Reduced skin innate immune responses
• Exaggerated T cell response to environmental
allergens and microbes
• Chronic skin inflammation
 Toddlers
Infants

School kids
Adults
• Many have Staph aureus colonization at time
of flare and may have altered cellular
immunity
• Higher risk of developing generalized eczema
herpeticum
 Differential diagnosis
Differential diagnosis Differentiating features

Seborrheic dermatitis Salmon pink patches with greasy scale, scalp involved, min itch
Contact dermatitis Location to specific skin area, exposure history
Nummular eczema Coin shaped itchy eczematous plaques on extensors, buttocks, shoulders; face sparing
Psoriasis Koebner phenomenon, red patches with little scale, diaper area affected
Icthyoses Dry thick fish scale ski, acquired or inherited
Scabies Involvement of skin folds, diaper area, vesico-pustules on palms/soles
HIV-associated dermatitis Impetigo and cellulitis (Staph), recurrent herpetic gingivostomatitis, scabies, severe atopic
dermatitis, drug eruptions, leukocystoclastic vasculitis
Insect bites Single large lesions, rust brown spots on bedding, blisters could develop and ooze on
scratching
Cutaneous lymphoma Telangiectasias in early cases, LNs, skin biopsy
LCH Crusted atrophic rash, chronic draining ears, hsm, LNs
Dermatitis herpetiformis Bullous lesions, blisters can erode, serpiginous clusters, can initially present with petechiae;
located on scalp, shoulders, buttocks, elbows and knees
Wiscott-Aldrich Associated thrombocytopenia
SCID
Hyper IgE syndrome Facial, dental, and skeletal abnormalities, fail to lose their primary teeth, specific facial
features; recurrent staphylococcal and candidal infections, pneumonias
Zinc deficiency Stomatitis, oral ulcers, angular cheilitis, disturbed smell/taste, night blindness, resp/GI
infections from impaired immune function, anorexia, cognitive function decline, growth
Vitamin B6 and niacin def Atrophic glossitis with ulcers, conjunctivitis, somnolence, confusion, neuropathy
PKU Seizures, “musty odor”, microcephaly
Tinea corporis Single lesion often, steroids make it worse
 Management
• Prevention
– Bathing: lukewarm baths or showers; mild skin cleanser (unscented); pat
skin dry
– Moisturize: traps water in the skin and improves barrier function. Can be
applied throughout the day PRN. Aveeno, Glaxal base, Cliniderm, Vaseline,
etc.
– Clothing: avoid wool, rough clothes; prefer cotton. Loose, light clothes in
warm weather.
– Bedroom:
• Vacuum bedroom carpet daily
• Use special mattress and pillow covers under cotton liner or mattress cover
• Change furnace filters q3-4 months
• Wash sheets and mattress cover weekly
• Humidifier
– Replace scratching with moisturizing, etc.
– Wet wrap overnight, after moisturizing or
medicated creams are applied (for flares)
WET WRAP VIDEO:
https://www.youtube.com/watch?v=CMX_AEu_Oro
• Treatment
– Topical corticosteroids: what can you apply and
where?
– Treat the itch!: antihistamines orally, also has
sedative effect for sleep
– Antibiotics for superinfections
 What kind of topical preparation to use?
• The various preparations:
– Ointment:
• Less likely to produce burning/stinging (no preservatives)
• More effect with the same active ingredient and concentration bc of their
occlusive effect
• Need only to apply a thin layer to affected areas until they are smooth to
touch
– Cream: more cosmetically acceptable
– Lotion: good for hair-bearing areas
– Oil based: easier to spread (esp useful in large areas of skin are
involved) and are not too strong (useful for mild-mod eczema); Ex.
Dermasmooth
– Foam
 Topical corticosteroids
• Mild: hydrocortisone 1% ointment to red
raised itchy areas on face or folds BID PRN
• Mild-mod: Desonide 0.05% ointment on face
or body BID PRN
• Moderate: Betaderm 0.1% ointment to body
BID PRN
• Severe: Clobetasol propionate 0.05% to palms
and soles BID PRN; not on body usually
• Risks of steroid use:
– Cutaneous atrophy
– Striae
– Telangiectasias
– Systemic absorption -> adrenal suppression
– Around mouth: peri-orificial dermatitis
– Around eyes: intraocular HTN, cataracts
 Common questions
1. Which steroid can be used for daily prevention use (proactive use)?
– None
2. How to manage acute flares?
– Treat red, raised, rough areas with topical steroids for up to 1-2 weeks at a time; if not improving by then seek MD
3. How much steroid is safe to prescribe in the clinic?
– Limit prescribing to low potency steroids for face/neck/skin folds and moderate to trunk/extremities
– If red, raised rough areas not resolved in 1-2 weeks, then reassess and consider other diagnoses. If still convinced pt
has eczema, step up to next level potency steroids and reassess. If eczema, should resolve.
4. If a particular steroid in a particular class doesn’t improve symptoms, is there any evidence that an
alternate steroid from the same class might work better?
– Not usually unless the patient has been using the same one for a LONG time and has tachyphylaxis
5. How frequently can higher potency steroids be used for flares? (ex. in one year)
– 1-2x/month but if they are flaring this often, they might need better baseline or maintenance treatment to avoid
flares ie. 1-2x/week application of BMV/calcineurin inhibitor to recurrent areas.
6. When to consult Dermatology?
– Lack of response to routine treatment
– Features not compatible with eczema
– Needing to use treatment cream every day continuously
– Needing better eczema education/reinforcement of general measures
– If would like a one-time consultation to confirm diagnosis, make it clear on consultation that you would like to
continue following the patient after consultation performed
 Topical calcineurin inhibitors
• Topical immuno-suppressants
• Inhibit T cell activation
• 2 forms:
– Tacrolimus (Protopic) 0.03% and 0.1% ointment; only 0.03% approved for 2-15 yo kids
– Pimecrolimus 1% cream
• Second line therapy for recurrent areas
• Adverse effect profile is different from steroids
• More costly
• Adverse effects:
– Stinging/burning, pruritus – tend to be brief (few days)
– Rare cases of skin malignancy and lymphoma reported; continuous long term use not
recommended and limit application to affected areas only
– Prolonged systemic exposure associated with inc risk of infections
– Unknown if interferes with skin response to UV damage; minimize/avoid sun
• Health Canada recommends if sx do not improve in 6 weeks of BID treatment,
then discontinue and reassess diagnosis
 Treat that itch!
• DAYTIME (all PRN):
– 6-12 mo: Cetirizine 2.5 mg PO daily
– 12 mo – 2 yo: Cetirizine 2.5 mg PO daily, can
increase to 2.5 mg q12h PRN
– 2-5 yo: Cetirizine 2.5 mg PO daily, can increase to
2.5 mg q12h or 5 mg PO daily PRN
– 6+ years: Cetirizine 5-10 mg PO daily
• NIGHT TIME (all PRN)
– Benadryl 0.5 mg/kg/dose PO qhs
– Hydroxyzine (Atarax) 0.5-1 mg/kg/dose PO qhs,
max 25-50 mg single dose
 Antibiotics
• Crusty areas where infection suspected:
– Cephalexin 50 mg/kg/day PO divided TID or QID,
max 1500 mg/day for 7-10 days
– If febrile or suspect systemic illness, may need
admission
 Decolonizing Staph aureus
• Dilute bleach bath once weekly x 3 months
– Mix ½ cup bleach in full tub of water; or ¼ cup in ½
tub of water
– More dilute than chlorine exposure in a swimming
pool
• Topical mupirocin 2% ointment to nares BID x
5-10 days if colonized with MRSA/recurrent
impetigo
Thank-you!
 References
1. Nelson’s textbook of Pediatrics
2. Zitelli’s atlas of pediatric physical diagnoses:
5th edition
3. New Zealand website on Dermatology
http://www.dermnetnz.org/
4. AAP Article on Eczema Nov 2014
http://pediatrics.aappublications.org/content
/pediatrics/early/2014/11/18/peds.2014-281
2.
full.pdf