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ECZEMA (DERMATITIS)

ECZEMA  (DERMATITIS)

Eczema represents superficial inflammation of the skin and may also be called Dermatitis. It is the most common reaction pattern of the skin seen by Dermatologists.  The clinical appearance and biopsy findings are virtually the same for all the different forms of eczema. The causes which are not always identifiable are different.  The clinical changes include redness and swelling of the skin. In the more acute stages, there may be blisters or weeping of clear fluid from the skin.  If the lesions persist over time, the weeping ceases and more crusting or scaling develops on the surface.  Because eczema is nearly always itchy which leads to chronic rubbing and scratching, the skin becomes thickened and develops changes in pigmentation, especially if the rash remains active for several weeks or months.

Atopic Eczema or Dermatitis is probably the most common type of eczema seen by dermatologists.  Atopic Dermatitis runs in families. About 70 percent of patients have a family history of an atopic tendency which includes the dermatitis, seasonal allergies, and asthma. These patients tend to have an exaggerated response to extremes of heat, cold, and humidity. Intermittent flare ups of atopic eczema occur during their lifetime in the majority of patients when they are under physical or emotional stress. About one-third of relapses are related to bacterial infections. Several abnormalities of the immune system have been associated with atopic eczema including elevated IgE antibodies in the blood, an increased number of allergy cells in the blood called eosinophils, and a reduced immune response to certain viral infections which cause warts, molluscum, and herpes.  The following clinical features are commonly seen in patient with atopic eczema, especially in children but also in adults: extremely dry skin of the arms and legs, increased skin markings of the palms, and extra folds of the lower eyelids, and a vexing but harmless condition on the upper arms and legs called keratosis pilaris.  Keratosis pilaris is a mild form of eczema around the hair follicles resulting in small red and sometimes spiny bumps that resemble and feel like goose skin.

Contact Dermatitis results from the application to the skin of chemicals in the environment that are either irritant or allergenic. Irritant Contact Dermatitis accounts for about 80 percent of the cases. The most common contact irritants are probably soap and water which causes dermatitis when the hands are washed frequently such as in the following occupations: Healthcare, childcare, food service, and hair styling. Other common irritants besides detergents include organic solvents such as alcohol and acetone, oils, acids or alkaline chemicals, fiberglass, and wood dust.

Allergic Contact Dermatitis is a delayed type hypersensitivity reaction to a specific chemical.  Poison Ivy or Oak Dermatitis represents the most familiar example of the mechanism of Allergic Contact Dermatitis. After the first exposure to the skin of the resin from the poison ivy plant, it takes 2-3 weeks for the immune system to become sensitized.  Upon the next exposure to the plant resin, the reaction in the skin may be elicited within 48 hours. Besides poison ivy, there are many common allergens in every day use at home and in occupations that can cause sensitization followed by Allergic Contact Dermatitis, for example nickel, fragrances, preservatives, hair dye, rubber, leather, and formaldehyde.  There are even some common over-the-counter topical cream medicines that can cause Allergic Contact Dermatitis including Neomycin, Bacitracin, and Benzocaine.  Because of their increased use in practice, allergy to natural rubber latex in gloves has become an occupational hazard for doctors, dentists, and their assistants.  About 10 percent of healthcare workers have become sensitized to latex, and 1-2 percent of these show evidence of Dermatitis.

Nummular Eczema is a form of Dermatitis which begins on the legs or trunk of adults. The initial lesions are coin-shaped, about 1-5cm in diameter with a tendency to clearing in the center. They are red and scaly and sometimes blistery, weeping, or crusted. They are nearly always extremely itchy and may become secondarily infected from scratching.  The cause is not known, but occasionally there is a history of atopy or a preceding serious emotional stressor.  Nummular Eczema has a reputation for being treatment resistant. It tends to be chronic and recurs in the original locations.

Dyshidrotic Eczema may be associated with increased sweating of the palms and soles, however, about half of the patients have a history of atopy. The rash is distinctive: Many 0.1- 0.5cm superficial clear blisters resembling tapioca develop on the sides of the fingers, palms and soles.  The lesions are usually associated with itching. When the blisters dry up, there is superficial peeling of the skin.  Flare ups may be associated with stress such as in a student preparing for final examinations.

The Treatment of Eczema may be complicated because there are several different types of eczema and they may be short-lived or chronic long standing cases.  However, some general principles may be applied.  If the eczema is in an acute weeping stage, then treatment with an astringent and aseptic compress such as Burow’s solution applied 2-3 times daily will help dry up the lesions. Following the compress, a medium to high potency corticosteroid cream should be applied for a couple of weeks followed by the application of bland emollient creams. For itching, antihistamines of the sedating type may be helpful in the early stages such as Diphenhydramine (Benadryl), Zyrtec, or Hydroxyzine by prescription.  Secondary infection is a common problem seen with eczema because of the scratching that follows the itching.  We usually prescribe Mupirocin ointment for localized lesions or oral broad spectrum antibiotics that have good anti-staph and anti-strep coverage if the rash is more generalized on the body.

For acute  severe flare ups of either Allergic Contact Dermatitis or Atopic Eczema, a burst of systemic steroids in the form of Prednisone, Medrol Dosepak, or Intramuscular Kenalog is very helpful in rapidly reducing the inflammation and associated itching and making the patient comfortable. It may also be necessary to apply medium to high potency topical steroid creams or ointments. For the maintenance of chronic Atopic Eczema, a newer class of medicines called topical immunomodulators has been developed (Elidel or Protopic).  Both of these are safe for use on facial dermatitis and for rash in the body fold areas such as the elbow and knee creases.  For the more severe, resistant to therapy, or generalized cases of eczema, we frequently recommend Narrow Band Ultraviolet B Light  for the entire body skin on a ongoing basis.  For the patients with chronic dyshidrotic eczema we utilize a treatment called Bath PUVA which consists of a 15 minute soak in a chemical which makes the palms and soles more sensitive to the light followed by exposure to long wave ultraviolet A light .

DRY SKIN

Dry skin is a problem which all of us have encountered at one time or another.  The medical term for dry skin is Xerosis. Simply put, dry skin is caused by the loss of water from the skin. It is necessary for skin to be hydrated in order for it to have a smooth supple texture. Factors that lead to dehydration or dryness of the skin include excessive bathing or showering, detergents and solvents applied to the skin, cold temperatures, and low humidity.

While dry skin can affect any part of the body, the most commonly involved areas are the  lower legs, backs of the arms and hands, back, flanks, abdomen, and waist. Areas that have more sweat and oil glands such as the scalp, face, underarms and groins are usually moist and spared from having dry skin.

Dry or xerotic skin in the affected areas appears to have an irregular surface with small flakes or scales and possibly fine cracks or fissures on the surface of the skin. Because dry skin is usually itchy skin, scratching and rubbing ensues which produces inflammation and more itching.  Thus, a vicious cycle develops. In persons who are prone to eczema, the dry itchy skin may lead to a full blown flare up of eczema requiring more aggressive treatment than just the moisturization of skin.

Dry skin is also a very common problem for the elderly.  That is because older skin loses sweat glands and oil glands and is more prone to water loss through the epidermis. In other words, the barrier function of the outer lipid layer of skin is gradually lost with aging. Moreover, elderly persons may have other medical conditions or treatments which predispose to dry skin including atopic eczema, kidney disease, malnutrition, decreased thyroid function, high blood pressure treated with diuretics (water pills) which may produce dehydration unless the patients replace water loss by drinking fluids.

Treatment and prevention of dry skin have to be discussed together.

  1. Frequent use of soap and water can have the effect of making the skin even drier. In addition, hot water also dries out the skin more. Therefore, whenever possible, we recommend using soap less often and using a milder soap that is fragrance-free. Here are some examples of soaps we recommend in either their liquid or bar forms in alphabetical order:  Aquanil, Basis, Cerave, Cetaphil, Dove white unscented, Oilatum, Oil of Olay, and Vanicream.
  2. When showering, reduce the heat of the water to a tepid temperature and try not to stay in the shower longer than five minutes. The hotter the water and the longer the exposure, the more difficult it will be to prevent dryness of the skin.
  3. After showering, especially dry skin patients may benefit from applying an oil such as Keri or Johnson’s baby to a wet washcloth and rubbing it over your damp skin followed by gently patting your skin dry with a towel. Please do not rub the skin vigorously with a towel as the friction of the towel will remove more skin cells from the surface than is necessary and may aggravate dryness.  We do not recommend adding oil to the bath because of the danger of slipping in the tub when getting out.
  4. As soon as possible after drying off your skin, apply the moisturizer of choice as quickly as possible to the entire body.  It is important to do this before the skin dries, within 3 minutes of bathing or showering. Moisturizers come in many different shapes, sizes, brands, and vehicles.  Here are some tips for you to decide which vehicle to choose. Ointments are the greasiest, creams are intermediate and lotions are the most watery. Ointments are the least easy to spread and the least elegant preparation but penetrate best and give the most moisture to the skin. Creams are a little easier to apply and more elegant and more substantial than lotions. Lotions are the most watery and therefore the easiest and quickest to spread but have the least durability. While it may be necessary to reapply all of these preparations during the day both at home and at work in order to keep the skin moist, lotions will have to be applied most often. Here are some examples of ointments we recommend to our patients in alphabetical order: Aquaphor, Crisco (original), and Vaseline petroleum jelly. Examples of products that are available in both cream and lotion forms in alphabetical order are: Aveeno, Cerave, Cetaphil, Eucerin, Oil of Olay, Purpose, and Vanicream.
  5. In more temperate or Northern climates, the forced air heating dries out the skin rapidly, but in our subtropical climate, constant exposure to conditioned cool air also dries out the skin. Therefore, it is necessary to have a humidifier in the home in both situations.

Here is another pearl  for persons who complain of excessive dryness on their back.  It may be that those individuals allow the suds from their shampoos to run down their backs when washing their hair. I recommend that after the scalp is lathered that the person lean forward and allow the soapy water and residue wash forward and not run down the shoulders and back but rather run off the top of the head past the face and onto the shower floor.  This is because the chemicals in the shampoo are detergents which remove the oils from the scalp and while passing over the back skin may do the same there and aggravate  the dryness problem.

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