What is eczema? Eczema (Dermatitis)- A particular type of inflammatory reaction of the skin in which there is erythema (reddening), edema (swelling), papules (bumps), and crusting of the skin followed, finally, by lichenification (thickening) and scaling of the skin.  Eczema characteristically causes itching and burning of the skin. What Causes eczema? Allergy- One of the commonest cause of Eczema. Triggers include Dust, detergents, rubber, nickel plated jewelry etc. Environment- More likely in urban areas due to high pollution levels. Extremely dry or cold weather tends to make skin scratchy, resulting in eczema. Obesity- Obese children are 3 times more likely to get eczema. Obesity results in inflammation of fat tissues that spills into other parts of the body. Excess fat also results in poor circulation and skin ailments. Smoking- One of the leading causes, especially on the fingers that hold the cigarettes, as well as lips. Stress- Physical or emotional stress has been known to cause enhanced sensitivity and inflammatory skin changes. Diaper rash- In babies eczema occurs because of chemical effect of urine/faeces on sensitive skin. Genetic influence- More likely in individuals with a family history of Eczema or other allergic conditions like Asthma, Hay fever, etc.

1. ECZEMATHE ANNOYING ITCH!

2. WHAT IS ECZEMA?
Eczema (Dermatitis)-
A particular type of inflammatory reaction of the skin in which there
is erythema (reddening), edema (swelling), papules (bumps), and crusting of the skin
followed, finally, by lichenification (thickening) and scaling of the skin.
Eczema characteristically causes itching and burning of the skin.
Erythema Oedema Papular
eczema
Crusting of
skin
Lichenification
and scaling

4. WHAT CAUSES ECZEMA?
 Allergy- One of the commonest cause
of Eczema. Triggers include Dust,
detergents, rubber, nickel plated
jewelry etc.
 Environment- More likely in urban
areas due to high pollution levels.
Extremely dry or cold weather tends
to make skin scratchy, resulting in
eczema.
 Obesity- Obese children are 3 times
more likely to get eczema. Obesity
results in inflammation of fat tissues
that spills into other parts of the body.
Excess fat also results in poor
circulation and skin ailments.
 Smoking- One of the leading causes,
especially on the fingers that hold the
cigarettes, as well as lips.
 Stress- Physical or emotional stress
has been known to cause enhanced
sensitivity and inflammatory skin
changes.
 Diaper rash- In babies eczema occurs
because of chemical effect of
urine/faeces on sensitive skin.
 Genetic influence- More likely in
individuals with a family history of
Eczema or other allergic conditions
like Asthma, Hay fever, etc.

5. TRIGGERS

6. CLINICAL SIGNS AND SYMPTOMS
 Dry, sensitive skin
 Intense itching
 Red inflamed skin
 Recurring rash
 Scaly areas
 Rough, leathery patches
 Oozing or crusting
 Areas of swelling
 Dark coloured patches of skin

7. CLINICAL TYPES
 Acute Eczema- Erythema and edema are seen
with papules, vesicles and sometimes large
blisters. Exudation and crust formation follow.
The eruption is painful and pruritic.
 Subacute Eczema- Edema and vesiculation are
less apparent while papules, erythema and some
scales are predominant.
 Chronic Eczema- It is less vesicular and
exudative, more scaly, pigmented and thickened,
more likely to develop painful fissures and to be
lichenified.

8. OTHER TYPES

11. Lichen Simplex Chronicus (LSC)

12. Dyshidrotic
Eczema
Dyshidrotic eczema is a skin condition in which blisters develop on
the soles of your feet, sides of the fingers or toes and palms of your
hands. The blisters are itchy and usually filled with fluid. Blisters
normally last for about two to four weeks and may be related to
seasonal allergies or stress. So blisters may breakout more frequently
during the spring allergy season. The blisters are often very itchy.
Affected skin areas can scale, crack, and flake.
 Itching on the affected area.
 Redness
 Flakes or dryness
 Cracked skin
 Pain
 Blisters on
fingers/toes/palms/soles of feet.
 high stress levels
 seasonal allergies
 staying in water for too long
 excessive sweating of the hands or feet
 The blisters can also be caused by an allergic
reaction to certain metals, including nickel and
cobalt. These metals are found in everyday objects,
such as jewelry and mobile phones, and also in

13. Discoid Eczema
Discoid eczema or Nummular eczema is inflammation of
skin.
A rash appears that looks like red coin-shaped discs, or
plaques of eczema. It is extremely itchy and
uncomfortable.
The plaques affect different parts of the body, but mostly
the lower legs, hands, and forearms, and sometimes the
trunk. The face and scalp are not affected.
 Unknown
 dry skin
 skin injuries, such as
friction or burns
 insect bites
 poor blood flow
 cold climate
 bacterial skin infections
 certain medications
 sensitivity to metals
and formaldehyde
 atopic dermatitis
 Dryness
 Flakiness
 Rashes
 Redness
 coin shaped rashes, or darkening of the
skin
 lesion or itching

14. Stasis
Dermatitis
Stasis dermatitis is a skin
inflammation that develops in
people with poor blood circulation.
It most often occurs in the lower
legs because that's where blood
typically collects. When blood
collects or pools in the veins of the
lower legs, the pressure on the veins
increases. Legs can swell up and
varicose veins can form.
Asteatotic eczema, also called xerotic eczema generally only affects
people over 60 years of age. This may be due to the skin becoming
drier as a person ages.
Asteatotic eczema typically occurs on the lower legs, but it can also
appear on other parts of the body. Symptoms include:
 cracked, dry skin with a characteristic appearance that people
describe as crazy paving
 pink or red cracks or grooves
 Scaling
 itching and soreness
the causes of asteatotic eczema are unknown, but triggers can
include:
 dry, cold weather
 hot baths
 soaps and other detergents
 excessive cleaning or scrubbing of the skin
 rough towel drying
Xerotic
Dermatitis
Seborrheic
Dermatitis
It produces rash on the scalp,
face, ears and occasionally the
mid-chest in the adults. In
infants, it can produce and
weepy, oozy rash behind the
ears and can be quite extensive,
involving the entire body.

15. DIAGNOSIS
 Patient age and hormonal status in women should be
considered in the initial evaluation of patients with
skin disorders.
 Menopausal women tend to develop brown
hyperpigmentation or melasma. Pregnant women
may develop hyperpigmentation of the areola and
genetelia as well as melasma.
 Patients presenting with a rash or skin lesion should
be evaluated for potential anaphylaxis or angioedema
(e.g. symptoms of difficulty in breathing, fever,
nausea and vomiting).

16.  The area involved and the number of lesions present is important
considerations. A rash involving only the arms and legs suggests a non-
systemic cause, whereas involvement of the trunk as well as the arms and
legs indicates a systemic cause.
 Lesions should be inspected for colour, texture, size, and temperature.
Areas that are oozing, erythematous and warm to the touch may be
infected.
 The duration of the skin condition should be determined, and the temporal
relationship with any new medication should be established.
 Assessment for potential drug-induced skin disorders begins with a
comprehensive medication history, including episodes of previous drug
allergies.
 Diagnostic criteria for atopic dermatitis include the presence of pruritus
with three or more of the following:
1) History of flexural dermatitis of the face in children younger than 10
years of age
2) History of asthma or allergic rhinitis in the child or a first-degree
relative
3) History of generalized xerosis(dry skin) within the past year
4) Visible flexural eczema
5) Onset of rash before 2 years of age

17. TREATMENT
Goals of treatment:
 Relieve bothersome symptoms
 Remove precipitating factors
 Prevent recurrences
 Avoid adverse treatment effects
 Improve quality of life

18. Non-pharmacologic measures to treat eczema include-
 Apply moisturizers frequently throughout the day
 Give lukewarm baths
 Apply lubricants/moisturizers immediately after
bathing
 Use non-soap cleanser(which are neutral to low pH,
hypoallergenic, fragrance free)
 Use wet-wrap therapy (with or without topical
corticosteroids) during flare-ups for patients with
moderate to severe disease. Wet wrap involves
applying damp tubular elasticized bandages and
occlusive dressing to the limbs to promote skin
hydration and absorption of emollients and topical
corticosteroids
 Keep finger nails filed short
 Select clothing made of soft cotton fabrics
 Consider sedating oral antihistamines to reduce
scratching at night
 Learn to recognize skin infections and seek
treatment promptly
 Identify and remove irritants and allergens.

19. First-line treatment of eczema should include an emollient and soap substitute for washing. Topical steroids are
used for anti-inflammatory effect. Systemic treatments for adult atopic eczema include oral prednisolone,
ciclosporin and azathioprine. If there is a secondary bacterial infection, then this should be treated with oral
antibiotics. The antibiotic(s) should be chosen based on sensitivity determined by wound swab.
Emollients
Emollients, topical hydrating agents consisting of fat or oil to soften the skin, are the mainstay of eczema
management. Emollients are effective first-line treatments for all types of eczema, and regular, liberal use will
reduce topical steroid requirements. The greasier products have more emollient effect. They are often underused
and the need to educate the patient regarding use of sufficient quantities is vital. Dry skin is aggravated by soap
and bath products, and therefore an emollient soap substitute for washing is advisable.
Topical corticosteroids
Topical steroids act as anti-inflammatory agents and are extremely useful and important in managing eczema. In
recent years, the public have veered from overuse of topical steroids causing long-lasting side effects, to high
levels of anxiety regarding possible side effects concerning their use. This can commonly lead to under treatment
in children. Therefore, patient education regarding appropriate topical steroid use is a crucial part of eczema
management.

20. Topical steroids are classified into four main groups according to potency: mild, moderately potent, potent and very potent.
The choice of topical steroid is dependent on the site and severity of skin disease. Potent and very potent steroids should be
avoided on delicate sites such as the face, genitals and flexures. The periorbital region should be treated with caution due to
the thin skin increasing the likelihood of absorption and risk of cataracts or glaucoma. Treatment should be reviewed
regularly and tailored accordingly. It is also important to remember that any form of occlusion will increase the absorption of
steroid applied.
Mild (Hydrocortisone 1%, Desonide 0.05%)
Generally safe for chronic application.
Safest among steroids for use on face, under occlusion/bandage, in neonates/infants.
Not expected to cause local or systemic side effects in the course of normal use
Moderately potent (Betamethasone valerate 0.05-0.1%, Clobetasone butyrate 0.05%, Mometasone
furoate 0.1%, Fluticasone propionate 0.01%)
Hydrocortisone butyrate 0.1% may be used on chronic dermatoses on extremities.
Used for limited periods only on face and/or intertriginous areas of adults and children,
under close supervision and follow-up.
Potent (Betamethasone dipropionate 0.05%, Halcinonide 0.025%-0.1%)
To be used on recalcitrant chronic dermatoses of adult-elder children only.
Can cause local or systemic side effects.
Very potent (Clobetasol propionate 0.05%)
To be used for limited period of time (2 weeks at a time) as the risk of side effects is
highest.
Use only in extremities and thickened skin lesions
To be used only when follow-ups/supervision is good.

21. Side effects are mainly local and include striae (stretch marks), telangiectasia (visible dilated small blood vessels),
epidermal thinning, purpura (bruising), acne and perioral dermatitis. Lower frequency side effects include poor wound
healing, spread or worsening of untreated infections and hypertrichosis. Hypopigmentation is a temporary side effect of
long-term topical steroid use and is frequently exploited in illegal ‘skin bleaching’ agents. Rarely, adrenal suppression or
Cushing's syndrome due to systemic absorption may occur.
Local and systemic side effects are extremely rare with appropriate use and duration of topical steroid treatment.
Patients should be advised to spread preparations thinly either once or twice daily.
Topical corticosteroids are available in ointment (oil based), cream (water based), aqueous or alcoholic solution, gel,
foam or shampoo formulation for the scalp. In general, ointment preparations are preferable to creams in eczema
management because they are absorbed better and have fewer preservative chemicals. Alcoholic solutions may lead to
irritation and should not be applied to acutely inflamed or broken skin.
Striae Telangiectasia Epidermal thinning Purpura Acne Perioral dermatitis
Hypertrichosis Hypopigmentation

22. Allergies
Both immediate and delayed hypersensitivity reactions to topical corticosteroids can occur, although not commonly.
These can be reactions to either the steroid molecule itself or the vehicle in which it is found. Allergic reactions to one
topical steroid may cross-react to others. Therefore, allergy testing is mandatory for such patients. Betamethasone may
be less likely to cause allergic reactions than other topical preparations.
Antibiotics and steroid combinations
Combination preparations can be useful in treating mild bacterial infection of eczematous skin. Long-term use should
be limited due to the risks of sensitisation and antibiotic resistance. In general, invasive infection is best managed with
oral antibiotics.
Calcineurin Inhibitors
Topical calcineurin inhibitors are used for the treatment of chronic eczema. These non-steroid immunomodulators
inhibit calcineurin phosphatase which is important in T-lymphocyte activation. The main side effect is burning or
stinging on initial application, but this usually improves after a few days. Although a theoretical risk of increased
malignancy exists with these agents, studies have not shown an association between exposure to topical calcineurin
inhibitors and increased rates of cutaneous malignancy. Calcineurin inhibitors should not be used on infected skin and
are generally not very useful in severely inflamed eczematous skin. Their greatest value appears to be in maintenance
therapy.

23. Tacrolimus ointment (Protopic®) is a calcineurin inhibitor derived from the oral transplant medicine FK506. The
0.1% and 0.03% preparations are indicated in the treatment of moderate to severe atopic dermatitis in adults and
children over the age of 2 years. Tacrolimus is now also used in clinical practice as a second-line agent for other
steroid responsive dermatoses.
Pimecrolimus 1% cream (Elidel®) is indicated for short-term or intermittent long-term use in mild to moderate
atopic dermatitis. Studies have shown that it is effective, well tolerated and has minimal adverse effects in the long-
term control of eczema in children aged over 2 years. Furthermore, this has resulted in the reduced use of topical
steroids leading to a lower risk of steroid-induced side effects.
Antihistamines
Pruritis is the most distressing feature of eczema. Oral antihistamines have no direct effect on pruritis in eczema; their
main effect is sedation. Sedating antihistamines may cause day time drowsiness, and caution should be taken when
driving and also if prescribed to school age children.
Topical imidazoles
Ketoconazole as a shampoo or cream is effective in reduction of Pityrosporum ovale on the skin and is therefore
useful in the treatment of seborrheic dermatitis. As the disease runs a chronic, relapsing course, regular or intermittent
use is usually necessary.

24. Coal tar preparations
Tar creams and ointments can be used in the management of hyperkeratotic,
lichenified eczema. Coal tar preparations reduce itching and skin inflammation
and are available as crude coal tar (1%-3%) or liquor carbonis detergens (5%-
20%). They have been used in combination with topical corticosteroids, as
adjuncts to permit effective use of lower corticosteroid strengths, and in
conjunction with ultraviolet light therapies. Patients can apply the product at
bedtime and wash it off in the morning. Factors limiting coal tar use include its
strong odour and staining of clothing. Coal tar preparations should not be used
on acute oozing lesions, which would result in stinging and irritation.
Hyperkeratotic,
lichenified eczema
Systemic therapies
Systemic steroids
Oral prednisolone can be used as a short-term treatment in the management of severe acute eczema that needs rapid
control. Long-term treatment with oral steroids is now rarely used due to the risk of side effects including
hypertension and osteoporosis.
Ciclosporin
Ciclosporin is a systemic immunosuppressant that blocks activation of T-lymphocytes. It is effective as a short-term
bridging therapy in severe chronic adult eczema and has a rapid onset of action. Intermittent courses at doses of 2.5–5
mg/kg/day are useful, but dose-related renal nephrotoxicity is inevitable and limits treatment duration to a maximum
of 8–12 months.

25. Other side effects include hypertension and increased risk of malignancy. A detailed patient history is required to
determine if there is a previous history of gynaecologic or prostate malignancy. During treatment with ciclosporin,
patients also require close monitoring of renal function and blood pressure.
Azathioprine
Azathioprine is a purine analogue that inhibits DNA synthesis and can be effective as monotherapy in adult eczema.
Bone marrow suppression and toxicity are the major concerns. A higher risk of marrow suppression occurs in
individuals with low levels of thiopurine methyltransferase (TPMT), and this should be assessed at screening.
Patients with borderline TPMT levels require a lower dose of azathioprine. Patients with low levels of TPMT should
not be offered this treatment.
Methotrexate
Methotrexate is occasionally used in unresponsive adult atopic eczema, but randomised controlled trials are lacking.
A small prospective trial has shown that methotrexate can be effective and well tolerated as a second-line therapy for
the treatment of moderate to severe atopic eczema in adults.
Mycophenolate mofetil
Mycophenolate mofetil is an oral systemic agent that prevents T- and B-cell proliferation, thereby reducing
inflammatory cytokine release. This can be used as an alternative in severe adult atopic dermatitis where azathioprine
or ciclosporin are contraindicated. Side effects are gastro-intestinal upset, bone marrow suppression and an increased
risk of infection.

26. Phototherapy
Phototherapy maybe recommended when the disease is not controlled by topical corticosteroids and calcineurin
inhibitors. It may also be steroid sparing, allowing for use of lower potency corticosteroids, or even eliminating
the need for corticosteroids in some cases.
The potential side effects of all types of phototherapy include burning, premature ageing and a small increased
risk of skin cancer. A small proportion of patients have photosensitive eczema, and this should be determined by
taking a detailed patient history before prescribing phototherapy treatment. A treatment course requires a patient
to attend two or three times a week for at least 6 weeks.
PATIENT EDUCATION
Provide the patient with information regarding
• causative factors,
• avoidance of substances that trigger skin reactions and
• potential benefits and limitations of nondrug and drug therapy.

27. THANK YOU
AFFIFA MAQBOOL HUSSAIN