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  1. 1. Dr. Angelo Smith M.D WHPL
  2. 2.  10-15% children suffer from atopic dermatitis  Asteototic dermatitis is becoming more and more common in the elderly  Hand dermatitis is a major cause of absence from work
  3. 3.  Type  Color  Shape  Arrangement  Duration  Distribution
  4. 4.  Skin symptoms  Constitutional symptoms  Travel/Occupation  Systems review  Self care
  5. 5.  The shape of a lesion frequently gives clues to the etiology of the skin lesion.  Shapes include lesions that are: round, polygonal, polycyclic, annular, iris, serpiginous, umbilicated,and target.  Margination is also important – are the lesions well or ill defined  Arrangement – are the lesions grouped or disseminated
  6. 6.  A significant number of skin diseases are limited to specific regions of the body  Are the lesions isolated, localized, regional, or generalized  Are the lesions symmetrical; limited to exposed areas, sites of pressure, or intertriginous areas
  7. 7. Historically  Endogenous (occurring from within) dermatitis was given the name “eczema”  Exogenous dermatitis (occurring from without) was termed “dermatitis”
  8. 8. Endogenous  Atopic or IgE  Seborrheic  Discoid or nummular  Pompholyx  Venous  Asteatotic  Juvenile plantar  Erythoderma Exogenous  Allergic  Toxic irritant contact  Photosensitive
  9. 9.  Any itching rash  Any red itching rash  Any red itching rash that has scales or is dry  The itch that rashes  Any rash that cannot otherwise be identified
  10. 10.  An acute, subacute but usually chronic pruritic inflammation of the epidermis and the dermis, often occurring in association with a personal family history of hay fever, asthma, allergic rhinitis or atopic dermatitis. 1  1 Color Atlas and Synopsis of Clinical Dermatology
  11. 11.  Well demarcated plaques of erythema and edema on which are superimposed and closely spaced small vesicles filled with clear fluid with punctate erosions and crusting  Distribution may be isolated and localized or general
  12. 12.  Term dyshidrotic is a misnomer as sweat glands are not involved  Also known as pompholyx
  13. 13.  Plaques of mild erythema with small dry scales and or superficial desquamation, sometimes associated with small red, pointed or round papules  Distribution may be isolated and localized or general
  14. 14.  Note erythema, swelling and desquamation
  15. 15. Commonly misdiagnosed as tinea
  16. 16.  Plaques of lichenification with deepening of the skin lines with satellite, small, firm flat or round top papules, excoriations and pigmentations or mild erythema Distribution – isolated and localized or generalized
  17. 17.  Note lichenification, scaling and fissuring
  18. 18. Commonly misdiagnosed as psoriasis
  19. 19. Swelling and erythema Punctate erythema, desquamation Lichenification
  20. 20.  10-20% of population  Primary symptom: itch  Location, location, location  Associated with atopic background Periorbital pallor
  21. 21. Characteristics:  60% have onset in the first year of life  Influenced by genetics and environmental factors  More common in males that females  Ethnicity may be a factor –less common in Asians; more common inWesterners and higher socioeconomic families  Theory is - manifestation of well nourished immune system rarely challenged by infection  Rare to have adult onset  2/3 of patients have family history of asthma, hay fever or allergic rhinitis
  22. 22.  May persist months to years  All patients have dry skin  Exacerbations caused by allergens, stress, hormones, climate, skin dehydration  Physical characteristic may include all phases Distinctive Characteristics:  Lesions are usually bilateral  Located frequently in skin folds/creases and flexor surfaces
  23. 23. Note: •Bilateral •Skin folds and flexor surfaces
  24. 24. Triggers: Irritants  Dry skin; bathing without moisturizing  Harsh/perfumed soaps, detergents  Disinfectants  Contact with wool, occupational chemicals/fumes Allergens  Dust mites  Pet dander (cat more allergenic than dog)  Pollens, seasonal and molds  Foods- strawberries, carrots
  25. 25. Infections Bacterial Viral 1. Cold and other URI viruses 2. GI viruses Fungal Environmental Extremes in temperature and/or humidity Perspiration Stress
  26. 26. Confused with:  Scabies, seborrhea, psoriasis and, contact dermatitis
  27. 27. 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
  28. 28. 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
  29. 29. 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.
  30. 30.  Characteristics: Positive family history is common  Seen in all age groups equally  May occur on presternal area and mid upper back  Stress may increase symptoms  Pityrosporum ovale may be causative factor  Distinctive Characteristics:  Red greasy scaling rash consists of patches and plaques with indistinct margins and an underlying red glazed look to the skin  Most commonly located in the hairy areas, nasolabial folds, retroauriclar folds  Excoriations from scratching are rare
  31. 31.  Redness and flakes appear in the head.  Eruptions on scalp may appear.  Treated with shampoos containing ketokonazole or hydrocortisone
  32. 32. Characteristic:  Delayed, cell mediated hypersensitivity  Strong sensitizer results in reaction soon after exposure  Weak sensitizer my take months or years to develop reaction  Age does not influence capacity for sensitization but more common in adults  Black skin is less susceptible  Important cause of disability in industry  Non seasonal
  33. 33. Characteristics:  usually clears quite rapidly on withdrawal of offending agent  may appear as erythematous papules, vesicles or bullous  more common where epidermis is thinner Distinctive Characteristics:  Initial lesions usually limited to contact area  not bilateral  lesions with sharp borders or angles are pathognomonic
  34. 34.  Metals- nickel, platinum (10% of women)  Detergents  Plants and fibers  Chemicals and dyes  Polyethylene glycol and polysorbate 60  Topical antibiotics and medications  Animal keratin
  35. 35. Note: distribution
  36. 36. Note: Linear distribution with satellite lesions
  37. 37.  Poison Ivy/Oak/Sumac linearity
  38. 38.  Potassium Dichromate in Leather
  39. 39.  Latex  Cleaning products  Cosmetics  Occupational exposures Check the feet and nails!!!
  40. 40.  Contact dermatitis with Nickel.  Reddish marking and itching will occur.
  41. 41.  Prevention is key!
  42. 42.  Coin shaped patches and plaques  Secondary to xerosis cutis  Primary symptom itch Notice the surrounding xerosis
  43. 43.  Characteristics:  usually -personal or family history of allergy, especially asthma, hay fever, and childhood eczema  Distinctive Characteristics - Coin-shaped papulovesicular patches that develop in to scaling and crusting lesions; lesions may be as large as 4-5cm in diameter with distinct margins, initial eruptions on arms and legs; intense itching; tends to be chronic
  44. 44.  Characteristics:  Most severe during winter; may be aggravated by systematic administration of iodine or bromine; secondary bacterial infections are common  Treatment: skin hydration, topical corticosteroids, intralesional injection, coal tar ointments, UVB treatment, treat secondary infection
  45. 45. Note: •Coin shaped lesions • dorsal surface arms •bilateral
  46. 46.  Extreme case of xerosis  Riverbed type cracking
  47. 47. Characteristics:  Seen mainly in elderly  Worse in the winter  Precipitated by excessive washing Treatment:  Avoid excessive washing and use of soap  Emollients  Increase humidity in the environment  Topical steroids for a short periods of time
  48. 48.  Venous hypertension  Full spectrum of timing  Id reaction common  Complicated by ulceration
  49. 49. Venous ulceration Dispigmentation (chronic) Lipodermatosclerosis
  50. 50. Superimposed allegic contact Do: 1) dry weeping lesions 2) cover for infection Don’t: 1) apply neosporin 2) just hope steroids will fix it
  51. 51.  Characterisitcs:  Origin often small patch of dermatitis or insect bite starting the itch –scratch- itch cycle  Condition unrelated to allergies or family history  More common in women  Nonseasonal  aggravated by stress  worse at night  may be secondary to atopic eczema, contact dermatitis, lichen planus, psoriasis, or insect bite
  52. 52. Distinctive Characteristics:  Lesions lichenified or excoriated  usually limited to a single patch at hairline of nape of neck or on wrists, ankles, ears, or anal area  Not bilateral  Llichenification of dark skin develops a “follicular pattern”
  53. 53. Prurigo simplex No fungus on the scrotum!
  54. 54. Butterfly sign Prurigo Nodularis Consider screening
  55. 55.  ConservativeTherapy 1. Education - prevention 2. Use of astringents and emollients/moisturizers 3. OTC products (hydrocortisone, Benadryl, Calamine, etc.)  Low to mid potency steroid creams  High potency steroid creams  CoalTar  PUVA therapy (phototherapy)
  56. 56. Moisturize daily Wear cotton, avoid wool and tight clothes Take lukewarm showers, using mild soap or nonsoap cleansers Pat dry – do not rub Apply moisturizer within 3 min. to “lock in” moisture Avoid extremes of heat / humidity and perspiration Learn triggers and how to avoid them Keep fingernails short Remove carpets and pets from the home
  57. 57. Irritants:  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.
  58. 58.  Cetaphil  Aquanil  Aveeno Daily Mositurizer  Eucerin Gentle Hydrating Cleanser  Lobana Body Shampoo  Moisturel  pHisoderm Indications: For use in those eczema patients who may be sensitive to one or more of the various potential sensitizers in soaps and shampoos. To cleanse, reduce irritation (if sensitive to soaps), and reduce dryness (thereby increase absorption of other topicals).
  59. 59.  Aquaphor  Balmex Daily  AmLactin  Cutemol  DML Forte  Eucerin Original  Hydrisinol  Lanolor  Indication: To soften and soothe rough, dry skin and increase absorbability of topical medications  Directions: Apply as necessary or as prescribed; generally after showering/bathing and pat drying; apply liberally to affected areas  Neutrogena Norwegian Formula  Lac-Hydrin  Aveeno  Pen-Kera  Curel  Lubriderm AdvancedTherapy  Minerin
  60. 60.  Astringents – reduce secretions (by causing contraction of tissues) and are antibacterial  Best used in eczema where vesicular or draining lesions are present  Acetic Acid 5% (white vinegar) – especially useful in Pseudomonas infections  Burow’s Solution (Domeboro and others)  Potassium Permanganate
  61. 61.  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.
  62. 62.  Tegrin cream and lotion  Medotar ointment  PsoriGel gel  Polytar andTegrin soaps  Tegrin,T/Gel, and other shampoos Indication: to relieve and control itching, and flaking skin associated with psoriasis and seborrhea as well as eczema Directions: Depending on product 1-4 times daily
  63. 63. Contraindications:  Hypersensitivity Precautions:  Do not use on broken skin, genital or rectal area except on the advise of your health care provider.  Photosensitivity x 24hr after application  May stain light colored hair Warning:  High concentrations of some chemicals in coal tar may cause cancer. Concentrations of 0.5% to 5% appear to be safe.
  64. 64. Indications: Psoriasis, eczema, pruritic rashes of other causes Consists of psoralen (photosensitizing agent) followed by UVA phototherapy Must avoid sunlight for 24h after psoralen Sessions are 3d/wk, may be from 12-30 sessions, increasing in duration Side effects are redness, burning, occasional nausea