ezcema

1. Eczema, Two Thousand
Rashes and Three
Creams
A Dermatology Primer for
Mid Level Practitioners

2. Critical components of the
physical exam of the skin should
include:
 Type
 Color
 Shape
 Arrangement
 Duration
 Distribution

3. Adequate history should
include:
 Skin symptoms
 Constitutional symptoms
 Travel/Occupation
 Systems review
 Self care

4. Types of lesions
 Macule
 Papule-plaque
 Wheal
 Nodule
 Cyst
 Vesicle-bulla
 Ulcer
 Pustules
 Hyperkeratosis
 Exudative: dry/wet
 Erosion
 Scar
 Lichenification

5. Shapes of Lesions
 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. Distribution of Lesions
 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

8. Eczema - Common Definitions
 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

9. Eczema-Dermatological
Definition
 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

10. Characteristics of Acute Eczema
 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

11. Acute Eczema
(Note the erythema, vesicles and
swelling)
 Term dyshidrotic is a misnomer as sweat
glands are not involved
 Also known as pompholyx

13. Characteristics of Subacute
Eczema
 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. Subacute Eczema
 Note erythema, swelling and
desquamation

15. Characteristics of Chronic
Eczema
 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

16. Chronic Eczema
 Note lichenification, scaling and fissuring

17. Acute - Subacute - Chronic
Swelling and erythema
Punctate erythema,
desquamation Lichenification

18. Acute, Subacute or Chronic?
 Check for erythema, swelling,
desquamation, lichenification

19. Acute, Subacute or Chronic?
 Check for erythema, swelling,
desquamation, lichenification

20. Classification of
Eczema/Dermatitis
Historically
 Endogenous (occurring from within)
dermatitis was given the name “eczema”
 Exogenous dermatitis (occurring from
without) was termed “dermatitis”

21. Classifications of Eczema
Endogenous
 Atopic or IgE
 Seborrheic
 Discoid or nummular
 Pompholyx
 Venous
 Asteatotic
 Juvenile plantar
 Erythoderma
Exogenous
 Allergic
 Toxic irritant contact
 Photosensitive

22. Atopic/IgE Eczema
(endogenous or exogenous?)
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 in Westerners 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

23.  Characteristics:
 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
Atopic/IgE Eczema cont.

24. Atopic/IgE Eczema
Distribution
Note:
•Bilateral
•Skin folds and
flexor surfaces

25. Atopic/IgE Eczema cont.
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

26. Atopic/IgE Eczema cont.
Triggers (cont’d):
Infections
Bacterial
Viral
1. Cold and other URI viruses
2. GI viruses
Fungal
Environmental
Extremes in temperature and/or humidity
Perspiration
Stress

27. Atopic/IgE Eczema cont.
Confused with:
 Scabies, seborrhea, psoriasis
and, contact dermatitis

28. Atopic/IgE Eczema cont.
 Treatment:
 Avoid scratching, clean and cool environment,
use of soap substitutes
 Emollients
 Topical steroids
 Topical immunomodulators –tacrolimus
 Systemic antihistamines
 Soaks
 Tar preparations

29. Atopic/IgE Dermatitis

30. Allergic (Contact)Eczema
(exogenous or endogenous?)
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

31. Allergic (Contact) Eczema cont.
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

32. Causes of Allergic/Contact
Eczema
 Metals- nickel, platinum (10% of women)
 Detergents
 Plants and fibers
 Chemicals and dyes
 Polyethylene glycol and polysorbate 60
 Topical antibiotics and medications
 Animal keratin

33. Allergic/Contact Eczema
cont.
 Treatment – remove causative agent, Burow’s
soaks 1:40, or saline 1tsp/pt warm water,
Aveeno or oatmeal baths, calamine
 Systemic antihistamines
 Topical steroids, oral steroid taper
 Antibiotics for secondary infection
 Confused with – Atopic eczema, seborrhea,
HSV

34. Allergic/ Contact Eczema
Distribution

35. Allergic/ Contact Eczema
Distribution

36. Note:
distribution

37. Note:
Linear
distribution
with satellite
lesions

38. What do you
think?

39. Bilateral
but…..

40. Subacute Allergic Eczema
 Note slight swelling and erythema
 No lichenification
 Location – what could be the cause?

41. Chronic Allergic Eczema
 Note the hyperkeratosis, lichenification
and fissuring

42. Toxic / Irritant Eczema
(occurring in non allergic skin)
 Characteristics:
 Accounts for 75% of exogenous eczema
 Age, race and sex are insignificant
 Results from repeated exposure to toxic or
subtoxic agents
 Severity of skin symptoms vary with the
individual and the type of irritant and the length
of contact
 Includes sx of itching, stinging and burning
 Usually associated with chronic disturbance of
the barrier function of the skin

43. Toxic/Irritant Eczema cont.
Common causes:
 Repeated exposure to alkaline detergents
 Repeated exposure to organic solvents
 Corrosive agents
 Industrial chemicals
 Chronic self perpetuating habits that
irritate the skin

44. Toxic/Irritant Eczema cont.
Treatment:
 Remove the cause
 Application of emollients
 Use of soap substitutes
 Barrier creams
 Borrow’s or potassium permanganate
soaks twice daily
Biopsy/testing- usually not necessary

45. Acute Toxic/Irritant Eczema
Note:
distribution,
swelling and
weeping

46. Subacute Toxic/Irritant
Eczema
Lip licking
 often seen in children who have atopic
eczema
 Variant of irritant eczema
compare

47. Chronic Toxic/Irritant Eczema
 Note:papulosquamous dermatosis with
hyperkeratosis, maceration, fissuring and
erosions
 Eruptions tend to
be sore rather than
itching

48. Acute, subacute, or chronic?
Swelling? Erythema? Desquamation?
Lichenification?

49. Comparison of Classifications of
the 3 common types of eczema
ACUTE Atopic
IgE
Toxic/
Irritant
Allergic
Contact
Erythema X X X
Papules X NA X
Vesicles X X X
Erosions X X X
Crusts X X X
Scales X NA X
Sharp/ confined NA X X
Spreading peripherally Flexor surfaces,
neck, eye lids, d
foot
X NA
Onset rapid Before age
12
X Usually as
adult
Onset slow NA NA X
Concentration L/H NA H L
Incidence Other signs Anyone Sensitized

50. Comparison of Classifications
Chronic Atopic
IgE
Toxic/Irritant Allergic/Contact
scaling X X X
fissues X X X
crusts NA X X
papules NA X X
excoriation X NA X
lichenification X NA X
Periorbital
pigmentation
X NA NA
Infraorbital folds in
the eyelids
X NA NA
Foillicular papules X more common
in the black pop.
NA NA

51. Pompholyx
(from Greek word meaning
blister)
 Characteristics:
 Intense itching and burning proceed lesions
 Blisters and vesicles on hands/ feet
 Becomes highly exudative
 Dries up in about 2 wks leaving painful fissuring
 Acute symptom of a chronic problem
 Usually no cause but can be due to trichophytin
and associated with fungal infection of the feet

52. Pomhpolyx cont.
 Treatment:
 Avoidance of soap
 Emollients
 Soaks ( burrows or potassium permanganate)
 Potent or very potent topical steroids with or with
occlusion
 Antibiotics for infection
 Systemic steroids
 Coal tar extracts
 Biopsy/testing- usually not necessary

53. Pompholyx
Where else
should you
look?
What else
might this be
call?

54. Nummular Eczema
 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

55. Nummular Eczema cont.
 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

56. Nummular Eczema cont.
 Confused with – contact dermatitis/eczema,
atopic eczema, psoriasis, impetigo, tinea
corporis
 Biopsy/testing – not usually necessary

57. Note:
•Coin shaped
lesions
• dorsal surface
arms
•bilateral

58. What else
should you
think about?

59. Seborrehea
 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

60. Seborrhea cont.
Treatment:
Scalp –
 try OTC preps first (antidandruff, tar or ketoconazole
shampoo)
 Steroid lotions for very short term use
 10% Liquor Carbonis Detergens HS and shampoo in AM
with Dawn Detergent
Skin -
 try OTC’s first
 corticosteroids (mild to moderate potency) and/or
ketoconazole topically

61. Seborrhea cont.
Eye lashes-
 Warm compresses and gentle debridment
with Q tip
 Sulfacetamide ophthalmic ointment applied topically
** Areas that become exudative may be treated with
potassium permanganate or burrow’s soaks
Confused with – atopic dermatitis, eczema, psoriasis,
discoid lupus, tinea
Biopsy/testing – usually none

62. Seborrhea Distribution

63. What
else
could
this
be?

66. Asteatotic Eczema
(Xerotic Eczema, “Winter Itch”)
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

67. Localized Neurodermatitis
Cont.
 Treatment:
 Stop the scratching
 Occlusive steroid dressings esp. at night
 Lubrication
 Doxepin ointment and/or po 10-20mg
 Hydroxyzine at night
 Intralesional steroid injection
 Stress management and/or medication
 Treatment is longterm and may be unsatisfactory
 Confused with – atopic eczema, psorasis, tinea,
seborrhea
 Biopsy / testing – none usually necessary

68. Localized Neurodermatitis
(known as Lichen Chronicus Simplex)
 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

69. Localized Neurodermatitis
(known as Lichen Chronicus Simplex) CONT.
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”

70. Localized Neurodermatitis Distribution
(known as Lichen Chronicus Simplex)

71. What should
you think about
in this man?

72. TREATMENT

73. Stepped Approach to Treatment
of Eczema
 Conservative Therapy
1. Education (chronicity, prevention, and trigger id)
2. Use of astringents and emollients/moisturizers
3. OTC products (hydrocortisone, Benadryl, Calamine,
etc.)
 Low to mid potency steroid creams
 High potency steroid creams
 Immunomodulators - Elidel and Protopic creams
 Nontraditional agents
 PO therapy: antiprurutics, steroids, cyclosporine,
methotrexate
 Coal Tar
 PUVA therapy (phototherapy)

74. Conservative
Therapy

75. Education
 Chronicity of eczema
 Association of other conditions: AR,
asthma
 Vast number of sensitizing chemicals used
currently in our soaps, shampoos,
detergents, foods, etc.
 Likelihood of finding a trigger low
 Detailed sensitizers/triggers (see Pocket
Guide to Medications used in Dermatology
by Scheman and Severson)

76. Patient Resources
 The Eczema Survival Guide – 30 page guide by
the NEASE
 http://www.medlineplus.com – the single best
general patient medical resource on the internet
– sponsored by NIH
 http://www.eczema.org - National Eczema
Society
 http://www.nationaleczema.org – National
Eczema Assoc. for Science and Education
 http://dermatlas.med.jhmi.edu/derm/ - online
dermatology atlas from Johns Hopkins Univ.

77. Prevention Checklist
 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

78. Soaps and Cleansers
 Any product that removes skin oils (sebum), dirt, other
undesirable substances
 Range from very moisturizing to neutral to very drying
 “If it is dry, wet it; and if it is wet, dry it” – derm mantra
 Normal skin pH is 5.6-5.8; most soaps are basic and
therefore can be irritating
 Rinsing may be an issue if irritating
 Choose the appropriate cleanser to match your patient’s
skin type (most eczema patients will need hydration of
the skin and neutral or acidic pH)
 Again, see Pocket Guide to Medications used in
Dermatology for detailed ingredients of skin products

79. Soap Free Cleansers
 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).

80. Emollients/Moisturizers
 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 Advanced Therapy
 Minerin

81. Astringents
 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

82. Burow’s Solution
(aluminum acetate)
Indication:
 Used as an astringent wet to dry dressing for relief of
inflammatory conditions of the skin such as insect bites,
poison ivy, allergy, eczema, and athlete’s foot.
Directions: One tablet or one pack per pint of water =
1:40 solution
Actions:
 Collagenase enzyme activity may be inhibited by
aluminum acetate solution because of the metal ion and
low pH.

83. Burow’s Solution
As a compress or wet dressing: Saturate a
clean, soft, white cloth in the solution. Gently
squeeze and apply loosely to affected area. May
cover with dry dressing. Saturate the cloth in
solution every 15 to 30 minutes and apply to
affected area. Repeat as often as necessary
As a soak: Soak affected area in solution for 15
to 30 minutes. Discard solution after each use.
Repeat 3 times a day

84. Burow’s Solution
Precautions:
 Discontinue use if intolerance, irritation, or
extension of inflammatory condition being
treated occurs. If symptoms persist >7 days,
discontinue use and consult physician
 Do not use plastic or any other impervious
material to prevent evaporation
 Avoid contact with the eyes

85. OTC Therapy

86. OTC Meds
 Antiinflammatory topicals
Hydrocortisone creams, 0.5% to 1%
 Antipruritics and others
1. Benadryl (diphenhydramine 25-50mg q6h prn)
2. Calamine Lotion (zinc oxide and ferric oxide used
as a mild astringent)
3. Caladryl Lotion (both of above)
4. Burow/s solution

87. Prescription Therapy
of Eczema

88. Properties of the Ideal Drug
(prescription or otc)
 (Acronym IDEA)
 Inexpensive
 Dosage – once daily or bid or less
 Effective
 Adverse effects absent

89. Steroid Creams

90. Basic Rules of Dermal Absorption
 The larger the surface area the formulation is
applied to, the greater the absorption
 Formulations or dressings that increase the
hydration of the skin generally improve
absorption
 The greater the amount of rubbing in of the
formulation, the greater the absorption
 The more active inflammation or open vesicles
or ulcers present, the greater the absorption
 The longer the formulation remains in contact
with the skin, the greater will be the absorption

91. Steroid Classifications

92. Topical Vehicles
Creams:
 Less greasy and most
acceptable to patient
 Applies more easily
 Penetrates skin well
 Works well in intertriginous
and hairy areas
 Can be drying
 Have a cooling effect
 Easy to wash off
Lotions: more water content and
less viscous than creams
Ointments:
 Petrolatum based
 Alleviates dryness by
prevention of evaporation
 Removes scales
 Enables medication to
penetrates skin well
 Water repellant
 Remains on the skin
 Occlusive and protective
 Soothing and lubricating

93. Prescription Topical Steroids
Low and Medium Potency
Do consider use in:
 Allergic/Contact
Dermatitis
 Seborrheic Dermatitis
 Intertrigo of axillary, crural
or inframammary regions
 Atopic Eczema
 Neurodermatitis
 Otic eczema
Do not use:
 Large body areas
because of expense,
difficulty with application,
and question of internal
absorption

94. Prescription Topical Steroids
High Potency and Fluorinated
Do consider use:
 With or without
occlusive dressing in
palmar or plantar
atopic dermatitis
 Localized
neurodermatitis
Do not use:
 Face
 Intertriginous areas
** prolonged use in any
area may cause
thinning of the skin,
telangiectasia, striae

95. Immunomodulators
(Topical immunomodulators-TIM’s)

96. Elidel
Elidel (pimecrolimus) 1% cream
Indications:
 Short term and repeated courses for mild to moderate eczema in
nonimmunocompromised patients greater that 2 years of age in
whom the use of alternative conventional treatment is inadvisable or
those with are none responsive to conventional treatment.
 Can be used anywhere on the skin
Precautions:
Do not use in treatment of infected atopic dermatitis, including
eczema herpeticum
Patients who develop lymphadenopathy should have a complete
evaluation to R/O lymphoma
Avoid sun light exposure as sun exposure and use of pimecrolimus
shortens time of skin lesion to skin tumor formation in animals
Do not use occlusive dressings

97. Elidel (cont’d)
Adverse Effects (often resolve after a few days of therapy):
Warmth or burning where applied
Headache
Cold-like symptoms (st, cough, rn)
Fever
Viral skin infection
Dosage:
Apply BID
Discontinue when symptoms resolved
Further evaluation needed if symptoms persist > 6 weeks
MOA:
Calcineurin inhibitor
Cost:
30 grams: $63; 60 grams $117

98. Protopic
Protopic (tacrolimus) adults 0.03% & 0.1% ointment
Indications:
Protopic ointment 0.1% for adults only
Protopic ointment 0.03% for children age 2 and older
Short term and repeated courses of moderate to severe eczema in
whom the use of alternative conventional treatment is inadvisable or
those who are not responsive to conventional treatment
Can be used anywhere on the skin
Precautions:
Do not use in treatment of infected atopic dermatitis, including
eczema herpeticum
Patients who develop lymphadenopathy should have a complete
evaluation to R/O lymphoma
 Avoid sunlight, tanning salons, phototherapy (PUVA), as sunlight
shortens time of skin lesion to skin tumor formation in animals
Do not use occlusive dressings

99. Protopic (cont’d)
Adverse reactions ( often resolve after few days of application):
Skin stinging and burning (dependent on degree of eczema)
Increased skin infections
Dosage:
Apply BID
Discontinue 1 week after symptoms resolved
Further evaluation needed if symptoms persist > 6 weeks
MOA:
Calcineurin inhibitor
Cost:
30 grams: $62; 60 grams $130

100. Potential problem with both TIM’s
(Elidel and Protopic)
 Feb. 15th 2005: the Pediatric Advisory Committee of the FDA met
and recommended that a “black box warning” be added to both
Elidel and Protopic due to “potential cancer risk”
 This is due to animal studies where animals swallowed large
amounts of both drugs over a long period of time, achieved
significant blood levels of the drugs, and developed lymphomas.
 March 10, 2005: The FDA issued a Public Health Advisory warning
the public about potential carcinogenic safety issues involving both
TIM’s.
 The American Academy of Dermatology, the Nat’l. Eczema Assn. for
Science and Education (NEASE), and the Inflammatory Skin
Disease Institute (ISDI) all have issued statements declaring the
FDA action premature and all feel that the drugs are safe when used
appropriately
 There are already websites dedicated to class action litigation
against both manufacturers
 Bottom Line: I would not adivse using in any pediatric patients, or in
any patient that can be controlled with less expensive and
efficacious therapy.

101. Nontraditional Agents
Problem: these are not deemed safe or effective by the
FDA
Herbal remedies
1. Licorice as topical gel
2. Guava leaves (as tea)
3. Chinese herbal teas
4. St. John’s wort (as lotion or tea)
 Probiotics – thought to help relieve inflammation
 Homeopathic – arsenicum alba and calcara carbonica
 Hypnosis
 Acupuncture
 Gamma linoleic acid oils
1. Evening primrose oil
2. Borage oil

102. PO Prescription Drug Therapy
 Antipruritics
1. Hydroxyzine 10-25mg q6h prn itching
2. Doxepin 10-25mg q12-24h prn itching (off label)
also can be compounded as a cream)
 Oral Steroids
1. May give in tapering short courses for selected
episodes of acute and/or severe eczema
2. Effective, inexpensive, qd dosing, few side effects
in most people with short term use
 Cyclosporine – reserve for specialty use
 Methotrexate – reserve for specialty use

103. Coal Tar Preparations
 Tegrin cream and lotion
 Medotar ointment
 PsoriGel gel
 Polytar and Tegrin 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

104. Coal Tar Preparations
(cont’d)
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.

105. PUVA Therapy
Indications: Psoriasis, eczema, pruritic rashes of
other causes
Consists of PO psoralen (photosensitizing agent)
followed by UVA phototherapy
Must avoid sunlight for 24h after po psoralen
Sessions are 3d/wk, may be from 12-30 sessions,
increasing in duration
Side effects are redness, burning, occasional
nausea
Litigation very high in some states

106. Summary of Treatment
1. Conservative Therapy
a) Education (chronicity, prevention, and trigger id)
b) Use of astringents and emollients/moisturizers
c) OTC products (hydrocortisone, Benadryl, Calamine, etc.)
2. Low to mid potency steroid creams
3. High potency steroid creams
4. Immunomodulators - Elidel and Protopic creams
5. Nontraditional agents
6. PO therapy: antiprurutics, steroids, cyclosporine,
methotrexate
7. Coal Tar
8. PUVA therapy (phototherapy)

107. Midlevel Provider’s Role in
theTreatment of Eczema
 Identification
 Treatment
 Education

108. Identify
Acute-Chronic; Allergic,Atopic,
Toxic/Irritant

117. Extra Credit!!!!!

118. The End