Pharmacotherapeutics-II

1. ECZEMA
Dr. Anusha Joel
Assistant professor
Set’s college of pharmacy
Dharwad, Karnataka, India.

2. DEFINITION
• Eczema: Come from the Greek name for boiling, a reference to the tiny vesicles (bubbles)
that are commonly seen in the early acute stage of the disease
• Dermatitis: means inflammation of epidermal layer of the skin.
• Eczema is a non-contagious skin condition that causes severe itching inflammation, and
sometimes pain at the site of a breakout.
• Complications associated with eczema include infection ( Staphylococcus aureus , herpes
simplex, fungal infections) and psychosocial problems (behavioral problems, impaired
performance due to lack of sleep, poor self confidence)
• Currently a cure for eczema is unavailable; however, many types of effective eczema
treatment do exist.
• Treatments are usually based on the type of eczema that is present, the severity of the
condition, a patient's medical history, and the outcome of any previously tried treatments.

3. TYPES
Clinical Types
• Acute Eczema : Erythema, swelling, vesicles & oozing C rusting.
• Chronic Eczema : Lichenification, excoriations & hyper-or hypopigmentation.
• Subacute Eczema : Features of both
Main Types Of Eczema :
I) Contact Dermatitis.
a. Primary Irritant Dermatitis.
b. Allergic Contact Dermatitis.
II) Atopic Eczema.
III) Seborrheic Dermatitis
IV) Napkin Dermatitis.

4. Clinical appearance
• The absence of a sharp margin is a particularly important feature that separates eczema from most
papulosquamous eruptions.
Acute eczema
Acute eczema is recognized by its:
• weeping and crusting
• blistering – usually with vesicles but, in fierce cases, with large blisters
• redness, papules and swelling
• ill-defined border and scaling
Chronic eczema
Chronic eczema may show all of the above changes but in general is:
• less vesicular and exudative
• more scaly, pigmented and thickened;
• more likely to show Lichenification– a dry leathery thickened state, with increased skin markings, secondary to
repeated scratching or rubbing; and more likely to fissure

5. Complications
1. Heavy bacterial colonization is common in all types of eczema , overt infection is most
troublesome in the seborrhoeic, nummular and atopic types.
2. Local superimposed allergic reactions to medicaments can provoke dissemination,
especially in gravitational eczema.
3. a huge effect on the quality of life.
4. An itchy sleepless child can wreck family life.
5. Eczema can interfere with work, sporting activities and sex lives. Jobs can be lost through
it.

6. Differential diagnosis
• Papulosquamous dermatoses, such as psoriasis or lichen planus, are sharply defined and show no
signs of epidermal disruption
• Always remember that eczemas are scaly, with poorly defined margins.
• eczemas exhibit features of epidermal disruption such as weeping, crust, excoriation, fissures and
yellow scale (because of plasma coating the scale).
• Once the diagnosis of eczema becomes solid, look for clinical pointers towards an external cause.
This determines both the need for investigations and the best line of treatment.
• A contact element is likely if:
1. there is obvious contact with known irritants or allergens
2. the eruption clears when the patient goes on holiday, or at the weekend
3. the eczema is asymmetrical, or has a linear or rectilinear configuration
4. the rash picks out the eyelids, external ear canals, hands and feet, the skin around stasis ulcers, or the
perianal skin.

7. Investigations
• Exogenous eczema
Patch testing
 To confirm allergic contact dermatitis and to identify the allergens responsible for it
 In patch testing, standardized non-irritating concentrations of common allergens are applied
to the normal skin of the back. If the patient is allergic to the allergen, eczema will develop at
the site of contact after 48–96 h.
 Patch testing with irritants is of no value in any type of eczema
Photopatch testing
 A chemical is applied to the skin for 24 h and then the site is irradiated with a suberythemal
dose of ultraviolet irradiation; the patches are inspected for an eczematous reaction 48 h later.

8. Other types of eczema
• The only indication for patch testing here is when an added contact allergic element is
suspected. This is most common in gravitational eczema
• Prick testing in atopic eczema
• Total and specific IgE antibodies are measured by a radio-allergosorbent test RAST test as
it carries no risk of anaphylaxis, is easier to perform and is less time consuming
• Cultures for bacteria and Candida if the eczema is worsening despite treatment, or if there is
much crusting

9. Pathophysiology
▪ There are two phases
Acute phase
▪ In acute stage, fluid escapes from dialated dermal blood vessels to produce edema in
epidermis
▪ This collects into tiny vesicles or blisters, particularly where the skin is thick, as on the palms
and soles. These vesicles coleasce into larger blisters.
▪ Where the skin is thinner they lead to rupture onto the skin surface, causing exudation, and
crusting.
Chronic phase
The chronic stage shows less edema and vesiculation and more thickening of the epidermis
and horny layers, produced by prolonged rubbing and scratching by the sufferer.
▪ Both stages are accompanied by a heavy inflammatory cell infilteration of dermis and
epidermis

10. Acute eczema
It is characterized by progression through number of diseases
 Red, hot, swollen and itchy skin
 Papules and tiny blisters
 Exudation and crusting
 scaling blistering
Chronic eczema
In addition to features listed in acute eczema, chronic eczema may show
 Drier skin, becoming more scaly
 Lichenification
 Painful fissures

11. I) Contact Dermatitis
a. Primary Irritant Dermatitis
Any individual; previous contact is not required.
Soon after exposure.
Direct damage by strong acids or alkalis or cumulative damage by
mild irritants.
Soaps, detergents, vegetables or solvents.
housewives, dishwashers, nurses & surgeons.

12. b. Allergic Contact Dermatitis
 Immunological reaction that develops in genetically susceptible individuals
after exposure to allergen.
 Presentation of allergen by LCs to T-cells ͢ Re- exposure to same antigen ͢
Lesions develop in ͢ sensitized individuals at sites of contact
 Nickel, chromate, rubber, resins, glues, cleansers, cosmetics & medications
(sulfa powder, penicillin ointment & local antihistamines).

13. II) Atopic Eczema
 Genetic hereditary predisposition to develop hay fever, bronchial asthma, allergic rhinitis or
atopic dermatitis.
AD is a common chronic relapsing inflammatory skin disease characterized by:
 Intense itching.
 Dry skin.
 Inflammation.
 Exudation.
 Physical & emotional distress for pts. and their families.

14. Phases :
a. Infantile Phase : Infantile Eczema
 2 months-2 years.
 Acute eczema of cheeks & dorsa of hands or may involve whole body.
b. Childhood Phase :
 4-12 years.
 Groups of itchy papules involve the flexures particularly the antecubital & popliteal fossae
& sides of the neck.
c. Adult Phase :
 Over 12 years.
 Similar to childhood type + hyperpigmentation & lichenification.

15. Treatment of Eczema
• a) Acute Eczema :
I) Local Therapy :
 Drying antiseptic lotions (aluminum acetate, KMnO 4 1/8000 or normal saline).
 Corticosteroid creams.
II) Systemic Therapy :
 Antihistamines.
 Corticosteroids.
• b) Chronic Eczema :
Local : Corticosteroid ointments.
Systemic : Corticosteroids.

16. Treatment:
• There are many different ways to treat eczema. The ways to treat eczema are a combination of
treatment and preventive measures. The methods for eczema remediation are:
• Moisturizing
• Itch relief
• Corticosteroids
• Immuno-modulators
• Antibiotics
• Managing mental and emotional state
• Light therapy • Diet
• Traditional remedies
• Oral Retinoid
• Anti-Fungal agents
• Immunosuppressants

17. Moisturizers-
 Moisturizers or emollients including bath oils, soap substitutes can be applied to the
dermatitis as frequently as required to relieve itching, scaling and dryness.
 Emollients should also be used on the unaffected skin to reduce dryness. Emollient therapy
helps to restore one of the skin's most important functions, which is to form a barrier to
prevent bacteria and viruses getting into the body and therefore help to prevent a rash
becoming infected.
 Emollients are safe and rarely cause an allergic reaction. Occasionally, products with lanolin
may cause a reaction.
 Ideally, moisturizers should be applied three to four times a day.
 Apply in a gentle downward motion in the direction of hair growth to prevent accumulation
of cream around the hair follicle (this can cause infection of the follicle).e.g. Vaseline

18. Topical Immunomodulators(calcineurin ihibitors)-
 Topical immunomodulators (TIMs) are a new type of non-steroidal anti-inflammatory drug for the
treatment of eczema. Mild burning sensations have been reported when applying TIMs.
 In general, however, TIMs have fewer side effects than corticosteroids. TIMs are topical drugs that
modulate the immune response (alter the reactivity of cell-surface immunologic responsiveness).
 Studies have shown that this class of drugs will improve or completely clear eczema in more than 80
percent of treated patients, with a side-effect profile comparable with topical steroids.e.g.
 Tacrolimus ointment ( 0.03% & 0.1%). & Pimecrolimus cream ( 1%).
 Apply a thin layer of tacrolimus ointment to affected skin areas twice daily rub in gently and
completely.
 Treatment should be continued for one week after clearing sign and symptoms.
 Should not be used with occlusive dressing.

19. Corticosteroids-
 According to their duration of action are classified into: Short to medium acting: e.g.
Hydrocortisone butyrate 0.1% cream apply thinly 1-2 times daily.
 Intermediate acting: e.g. Triamcinolone 0.1% ointment apply thinly 1-2 times daily.
 Long acting : e.g. Betamethasone (as valerate) 0.1% cream apply thinly 1-2 times daily.
 Severe cases may be treated with oral corticosteroids.
 The dose is higher than with hydrocortisone cream, and the chance of having side effects is
greater.
 Corticosteroids have a long list of side effects. They should not be used for extended periods of
time.
 clobetasol propionate 0.05 cream: is a super high potency corticosteroids. has anti-
inflammatory, antipruritic and vasoconstriction properties.
 It is very effective and widely used. Dose: treatment should be limited to 2 consecutive weeks

20. Oral corticosteroids
Side effects of oral corticosteroids that are used on a short-term basis include:
 an increase in appetite,
 weight gain,
 insomnia,
 fluid retention
 mood changes, such as feeling irritable, or anxious.
Side effects of oral corticosteroids used on a long-term basis (longer than three months) include:
 osteoporosis (fragile bones),
 hypertension (high blood pressure),
 diabetes,
 weight gain,
 increased vulnerability to infection,
 cataracts and glaucoma (eye disorders),
 thinning of the skin,
 bruising easily muscle weakness.

21. Antibiotics-
• Damaged skin is susceptible to bacterial infection. People living with eczema tend to develop more
skin infections than others.
• Antibiotics, topical or oral, may be required to treat eczema. Oral eczema treatments are not used as
frequently as topical therapies.
• However, oral medication may be required to treat complications, or especially severe cases of
eczema.
• Many different types of antibiotics are available.
• Consult your medical professional to find out about the side effects of antibiotics prescribed to you.
• Oral or topical antibiotics reduce the surface bacterial infections that may accompany flares of
Atopic dermatitis.
• In the treatment of stasis dermatitis, oral antibiotics are useful when cellulitis is present; topical
antibiotics are useless and often cause contact dermatitis.e.g. clindamycin topical solution ,
gentamicin – topical ointment .

22. • Clindamycin Topical solution(50ml) Each ml contains : 10 mg of clindamycin
Squeeze few drops of the solution on a small piece of cotton or face pad and
apply to affected area twice daily after cleaning the skin with soap and rinsing
well with water.
• Gentamicin Sulfate Cream Each gram contains: 3mg of gentamicin supplied in
30 gram tubes, a small amount of gentamicin sulfate cream should be applied
gently to the lesions three or four times daily . If necessary this may be
covered with a dressing.

23. • Antifungal agents - Indicated for suspected candidiasis or proven candidal
infection by a medical practitioner.
• Commonly used topical antifungal agents are nystatin cream or ointment and
econazole nitrate cream .
• Dosage and Administration: Nystatin cream-ointment. Each gram contain:
100,000 units Nystatin.
• Supply in a tube of 15 gm Apply 2-4 times daily .

24. • Antihistamines are occasionally prescribed to control itching and help the
eczema sufferer sleep.
• Their effectiveness as anti-itch medication is limited, however, as histamines
are not important components of eczema-associated itching.
• Antihistamines can make you very drowsy. Driving while on antihistamines is
not recommended.
• sedating antihistamines such as promethazine (Phenergan) diphenhydramine
(Benadryl) are more effective at relieving itch than the newer, nonsedating
antihistamines.
• Dosage and Administration: Diphenhydramine 25-50 mg Two times daily or
at night.

25.  Phototherapy- involves the use of light to treat a medical condition. Ultraviolet
light therapy improves eczema symptoms in some people.
 Phototherapy may only use ultraviolet light, or may combine the use of
ultraviolet light with psoralen , a drug that increases light sensitivity. While
ultraviolet rays occur naturally in sunlight, excessive sun exposure causes
sunburn, which can make symptoms worsen.
 Phototherapy uses carefully measured amounts of ultraviolet light; a safety
measure that cannot be duplicated by simple exposure to the sun.
 A side effect of this is photo damage or increased risk of skin cancers.

26.  Coal tar- has been used to treat the itching and inflammation caused by skin conditions for
hundreds of years. The tar contains chemicals that soothe the skin.
 Coal tar is very sticky and messy. It can cause sun sensitivity, and may irritate acute dermatitis.
 Retinoid- is licensed for the treatment of sever chronic hand eczema refractory to potent topical
corticosteroids, patient with hyperkeratotic features are more respond to Oral Alitretinoin .
 This drug only prescribed by or under the supervision of dermatologist .
 Alitretinoin is teratogenic and must not given to pregnant women.
 Dosage and Administration: Alitretinoin10 mg 3 times daily orally, then reduced to once daily if
not tolerated.
 In Patient with CVD and Diabetes should be used once daily initially. Duration of treatment:12-24
weeks discontinue if no response after 12 weeks.
 Isotretinoin gel 0.05% Apply topically 1-2 times daily.

27. • Immunosuppressant- When eczema is severe and does not respond to other forms of
treatment, immunosuppressant drugs are sometimes prescribed.
• These dampen the immune system and can result in dramatic improvements to the patient's
eczema.
• However, immunosuppressant can cause side effects on the body. As such, patients must
undergo regular blood tests and be closely monitored by a doctor.
• the most commonly used immunosuppressant for eczema are cyclosporine , azathioprine
and methotrexate .
• These drugs were generally designed for other medical conditions but have been found to
be effective against eczema.

28. Dosage and Administration:
• Methotrexate 2.5mg tablet. Should be taken 1 hr before or 1-2 hrs after meal.
• Generally 7.5-16 mg in a week not exceed 20 mg.
• If not effective after 8 weeks with the maximum dose should discontinued.
Side effects: Bone marrow depression Hepatotoxic Hair loss Skin rash Mouth sore