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March 2007: Eczema

What features clearly distinguish different types of eczema?

When should strong steroids be avoided?

When might 'eczema' be phytodermatitis?

What features clearly distinguish different types of eczema?

When should strong steroids be avoided?

When might 'eczema' be phytodermatitis?

?Eczema is one of the most common skin problems seen in primary care.

In the UK, 30 per cent of general practice consultations and 10-20 per cent of dermatology referrals are for atopic eczema.1

Atopic eczema affects 10 – 20 per cent of children in the UK.2 There is an 80 per cent chance that any offspring will be affected by atopic eczema if both parents are affected, and a 60 per cent chance if only one parent is affected.3 In 1995/6 it was estimated that the annual cost of atopic dermatitis in children aged one to five years in the UK?was £47 million.4

Seborrhoeic eczema affects 3-5 per cent of all adults between the ages of 18 and 40 and is more common in men than women.

People affected by eczema are continually plagued with itchy, sore skin and have to live with the perpetual social stigma associated with the condition. They long for remissions and live in fear of relapse. In some cases this may lead to depression or even suicide.

Treatments are improving but currently there is no cure for the majority of patients.

1 Atopic eczema

Atopic eczema typically starts at around three months of age, with dry skin and irritation. There is usually a strong family history of eczema, hay fever, allergic rhinitis or asthma. Raised levels of IgE are always present in serum.5 Typically the eruption starts on the face and spreads to the trunk and limbs, especially at the flexures.

The rash is symmetrical, and signs of rubbing and scratching are usually present.

Secondary infection can occur with bacteria such as Staphylococcus aureus. There is an increased chance of developing molluscum contagiosum and viral warts in affected areas.

Management consists of the liberal application of emollients, prevention of scratching, application of topical steroids and the education of parents and carers.

NICE published a technology appraisal on the use of topical steroids in 2004.6 This recommends that topical corticosteroids for atopic eczema should be prescribed for application only once or twice daily.

2 Asteatotic eczema

Asteatotic eczema is typically associated with old age. Sufferers may have dry skin and chapping. Common contributory factors are thought to include over-washing, leading to a reduction in surface lipids, diuretics, low humidity during the winter, central heating and hypothyroidism.

The legs are usually affected, with itchy eczema against a background of dry, fissured skin. The fissuring is fine, red and superficial, with a ‘crazy-paving' type pattern.

The appearance is characteristic, making diagnosis straightforward. Further investigation is only necessary in very severe cases, to look for an underlying cause such as a malabsorption syndrome or internal malignancy.7

Treatment consists of the liberal application of a greasy emollient to rehydrate the affected area and the use of a mild to moderate topical steroid if necessary. Soap should be avoided to prevent further drying. Once the condition has settled it can usually be well controlled by emollients.

3 Seborrhoeic eczema

Seborrhoeic eczema affects the scalp, face, pre-sternal areas, upper back and flexures. Affected areas look dry, with scaly erythema. Itchiness is a predominant feature when the scalp is affected. Seborrhoeic eczema is common, and recently the yeast Pityrosporum has been implicated in the condition.8

The peak incidence is around 40 years of age, and it is less common in older people. It usually responds to mild topical steroids, such as hydrocortisone in combination with a topical antifungal, but will recur when treatment is stopped. Tar-basedshampoos and antifungals such as ketoconazole9 can be useful when treating the scalp.

Seborrhoeic eczema is uncommon in pre-adolescent children. In this age group a differential diagnosis of tinea is more likely and mycology testing should always be carried out.

4 Pompholyx

Pompholyx occurs when eczema affects the hands and feet. It has a different appearance from eczema elsewhere on the body; this is because the stratum corneum is so thick in these areas that vesicles develop and persist as tense, fluid-filled swellings of various sizes. The condition is also called dyshydrotic eczema because of the increased incidence of hyperhydrosis in these areas.

Pompholyx tends to occur symmetrically, in the first half of adult life (patients aged 20-40 years). Itchy vesicles occur in crops on the sides of fingers and toes, and on the palms and soles. Painful and deep fissuring is common as the areas dry. The aetiology is unknown, and some cases may persist and become chronic.

Liberal amounts of topical emollients and steroids should be applied once or twice daily. Secondary infection is common and should be treated with antifungals or antibiotics.

5 Varicose eczema

Varicose eczema is usually associated with venous insufficiency, typically seen with varicose veins. It usually affects the lower legs but may be seen on the upper limbs. The eczema overlies areas of venous stasis with erythema and dryness.

Distribution is patchy and chronic. Associated oedema and haemosiderin deposition is common. Sufferers have a tendency to develop hypersensitivity to topical treatments and scratching can cause ulcers.

Treatment consists of the elimination of oedema by compression, elevation and diuretics. Moderately potent topical steroids may also be required. In some cases it may be appropriate to treat the underlying varicosities surgically, although this does not always lead to resolution of the eczema.

6 Lip licker's eczema

Lip licker's eczema is common in young children. It is caused by repeated contact with saliva and presents as a characteristic eczematous rash affecting the lips and surrounding skin.

Treatment of the condition is simple, and involves the avoidance of licking and very regular application of a topical barrier, such as petroleum jelly or a lip salve. The treatment should be applied every 30 minutes to one hour throughout the day and before the child goes to bed.

7 Discoid eczema

Also known as annular or nummular eczema, discoid eczema is distinctive and easily recognisable. The aetiology is unknown. The lesions are very discrete, sometimes with oozing and surface crust, and typically affect the extensor surfaces of the limbs. Secondary infection is common. The lesions are scattered and very itchy, and tend to occur later in life in men than in women. Prognosis is variable, and remissions and relapses are common. Mild to moderate strength topical steroids, with either topical or oral antibiotics, are the mainstay of treatment.

8 Infected eczema

Secondary bacterial infection with Staphylococcus aureus may occur with many types of eczema. The eczema typically looks redder than usual, is more painful and has a tendency to weep, ooze and develop a golden yellow crust. An infection should always be considered when eczema fails to respond to topical steroids; it is a common error to keep increasing the strength of the steroids when a course of oral antibiotics is actually required.

9 Eczema herpeticum

Eczema herpeticum is also known as Kaposi's varicelliform eruption. Patients with a pre-existing dermatosis, such as eczema,10 are particularly susceptible to widespread secondary super-infection with herpes simplex virus 1 and 2, coxsackievirus A16 or vaccinia virus. The infection is often spread from a cold sore. Patients with eczema should be advised to be particularly careful to avoid contact with cold sores.

Eczema herpeticum may be severe, requiring hospitalisation in some cases. It is essential to avoid use of the newer immunomodifying agents, such as tacrolimus and pimecrolimus, on any infected skin to prevent exacerbation of the infection.11

10 Tinea incognito

Many patients are happy to have a go at treating a rash themselves. However, if the infection is tinea and the cream used is a strong steroid, this may result in tinea incognito. The steroid alters the appearance of the tinea, making it appear more like eczema. The condition may be exacerbated if stronger steroids are applied.

It is important to take a careful history of all treatments patients have tried, and to ask whether the rash has changed since it was first noticed. Tinea should be considered as a differential diagnosis if eczema does not improve with strong steroids. Mycology testing can be used to confirm the diagnosis.

11 Contact eczema

In contact eczema, also called contact dermatitis, the distribution of the rash is often a big clue as to the aetiology. Unlike atopic eczema, contact eczema is unusual in childhood, and occurs as the result of an immunological type IV delayed hypersensitivity reaction to an external agent. Once a patient develops this type of reaction, susceptibility is usually life-long. Although there are many chemicals that can cause this type of reaction, among the most common are:

• Nickel

• Cobalt

• Balsam of Peru

• Wood alcohols

• Formaldehyde

• Chromate.

Contact eczema is especially prevalent in certain occupations, such as hairdressing.12

Diagnosis is by patch testing. A battery of test allergens are applied to the skin under patches, and reactions are recorded at 48 and 96 hours.13

Management initially consists of diagnosing the cause, then stopping the causative agent from coming into contact with the skin. The rash should then resolve.

It is worth remembering that contact dermatitis can occur with medication such as chloramphenicol eye drops, causing periorbital dermatitis, as well as with topical treatments.14

12 Phytodermatitis

Phytodermatitis should always be considered when a bizarre-looking rash affecting the upper or lower limbs presents in the summer and autumn months. There are a number of plants that can cause an eczema-type rash if they come into direct contact with the skin. The rash usually occurs in the same pattern as the contact. In some cases the plant will increase sensitivity to ultraviolet light, causing phytophotodermatitis. One such example is furocoumarin, used therapeutically as psoralens.15

Treatment is the same as in eczema, but severe cases may require oral steroids.

Atopic eczema. The eruption typically starts on the face and spreads to the trunk and limbs Figure 1: Atopic eczema Asteatotic eczema is associated with old age and usually affects the legs Figure 2: Asteatotic eczema Seborrhoeic eczema. Affected areas look dry and have scaly erythema Figure 3: Seborrhoeic eczema Pompholyx. Vesicles develop and persist as tense, fluid-filled swellings Figure 4: Pompholyx Varicose eczema. Distribution is patchy and overlies areas of venous stasis Figure 5: Varicose eczema Lip licker's eczema. Patients should avoid licking the lips and surrounding skin and a topical barrier should be applied Figure 6: Lip licker's eczema Discoid eczema. Lesions are discrete, scattered and

very itchy Figure 7: Discoid eczema Infected eczema appears redder than usual. It tends to weep, ooze and develop a golden yellow crust Figure 8: Infected eczema Eczema herpeticum. Patients with eczema should be advised to avoid contact with cold sores to reduce risk of secondary super-infection Figure 9: Eczema herpeticum Eczema herpeticum. Patients with eczema should be advised to avoid contact with cold sores to reduce risk of secondary super-infection Figure 10: Tinea incognito Contact eczema. The causative agent should be determined by patch testing and subsequently avoided Figure 11: Contact eczema Phytodermatitis results from direct contact with

certain plants Figure 12: Phytodermatits Author

Nigel Stollery
GP, Kibworth, Leicestershire and clinical assistant in dermatology, Leicester Royal Infirmary

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