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Common Rashes Eczema Eczema Eczema Eczema Eczema

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					Common Rashes                                                                         November 4, 2006




                                                                    Eczema
                                                 • Condition: Chronic, itching that leads to scaly
                                                   excoriated erythematous patches, often with
                                                   lichenification and secondary infection.
               Common Rashes
                                                 • Predilection: Flexural areas in chidren and
                                                   adults, such as the antecubital and popliteal
                      Tho Q Nguyen, MD             fossa, neck, eyelids, wrists, and ankles. Infants
                  Clinical Assistant Professor
                  Department of Dermatology
                                                   often have cheek and extensor leg involvement
                UT Southwestern Medical Center     with sparing of the diaper areas.
                           Dallas, TX




                       Eczema                                       Eczema




                       Eczema                                       Eczema
                                                 • Etiology: Unknown, often hereditary (FH 50%)
                                                   with familial and personal tendencies toward
                                                   allergic rhinitis (FH 50% and PH 50%), and
                                                   asthma (FH 25% and PH 25%).
                                                 • Prevalence: Varies worldwide 2 to 17% and the
                                                   incidence is increasing in developed countries.
                                                 • Genetics: 77% Concordance in monozygotic
                                                   twins and 15% in dizygotic twins. Exhibit a
                                                   tendency to express a high affinity for IgE
                                                   receptor found on chromosome 11q 13.




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Common Rashes                                                                                       November 4, 2006




                                                                               Eczema
                           Eczema
                                                                          (Atopic Dermatitis)
        • Age: Onset mostly in infants and children, but     • Asian/Pacific Islanders are 7 times more
          adult onset even in the elderly can be seen.
                                                               likely to have an AD related visit than
                                                               whites
        • Course: Chronic, but can be intermittent with
          months to years between flares. In children 50%
          resolve by age 15, and 85 – 90% by age 20. If      • Prevalence is higher in privileged
          the dermatitis persists past age 20 or the onset
          is after 20 years old, then spontaneous              socioeconomic groups, and is higher in
          clearance is rare.                                   urban compared with rural areas




                           Eczema                                                Eczema
        • Risk of AD:                                        • In 1962, AD in 27% Chinese vs 11% in
            Asians born is Australia > newcomer                Caucasians born in San Francisco, 23%
            Polynesian migrants to New Zealand>                vs 3% in Honolulu
            counterparts in their countries
        • AD in 21% of fair-skinned infants
          compared with 44% of Chinese infants
          living in Australia. (1999)




                                                                                 Eczema
                                                             Differential Diagnosis:
                                                             • Infants: Seborrheic dermatitis, psoriasis,
                                                               candidiasis, Wiscott-Aldrich synd., non-bullous
                                                               congenital ichthyosis, ichthyosis vulgaris,
                                                               congenital syphilis, histiocytosis X, biotin or zinc
                                                               deficiencies.
                                                             • Adults: Seborrheic dermatitis, psoriasis, contact
                                                               dermatitis, asteotic dermatitis, nummular
                                                               dermatitis, drug eruptions, lichen planus,
                                                               necrolytic migratory erythema, and mycosis
                                                               fungoides.
                                                             • Lab: Elevated IgE in 80% of patients




2006 VAMA National Convention- Dallas                                                                                 2
Common Rashes                                                                                             November 4, 2006




                               Eczema                                                Eczema
        Treatment:                                             Treatment:
        1.    Educate the patient or parents!!                 2. Discontinue Ivory soap and avoid soaps that dry
           A. The condition is controllable but has a             the skin.
               chronic, usually intermittent course.           3. Switch to soap-free cleansers: Dove for
            B. The patient is not infectious nor contagious.      Sensitive Skin, Cetaphil cleansing lotion or bar,
            C. The condition is not diet related.                 Aveeno bar, or Aquanil lotion.
            D. The condition is not due to uncleanliness.      4. No bubble baths!!
                Frequent washings with soap and water          5. Limit time in bath to 5-15 minutes to hydrate skin.
                worsen the condition.                          6. Moisturize… Moisturize… Moisturize…
            E. The condition has a genetic disposition and        especially right after the bath while skin is
                often runs in families.                           still moist.




                               Eczema                                                Eczema
        Treatment:                                             Treatment:
                                                               10. Tacrolimus (protopic) ointment 0.03 or
        7. Low to mid-potency topical steroids b.i.d.              0.1% applied to areas b.i.d.
            *No Lotrisone cream.                               11. Pimecrolimus (Elidel) cream 1% b.i.d.
        8. Antihistamines (1st generation sedating type)
          are                                                  12. Antibiotics to treat infections.
           particularly helpful at bedtime, but can be used    13. Reinforce to parents that this condition
           during the day also, if drowsiness is not severe.       is controllable, but may last years and the
        9. Educate patients to help avoid triggers: low            child may eventually outgrow the
           humidity, sweating, wearing wool or other               condition.
           scratchy clothing (100% cotton is best). Try to
           minimize stress.




            Adverse Effects of Topical Steroids                      Adverse Effects of Topical Steroids

        •   Striae
        •   Atrophy
        •   Telangiectasia
        •   Acne
        •   Rosacea




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Common Rashes                                                                               November 4, 2006




          Adverse Effects of Topical Steroids                  Seborrheic Dermatitis
                                                       • Condition: A scaly dandruff condition of the
                                                         scalp with a variable presentation from a fine
                                                         white powder to a greasy, yellow scale on an
                                                         erythematous base.
                                                       • Predilection: Frequently spreads beyond the
                                                         scalp to the forehead ears, postauricular areas,
                                                         nasolabial folds, eyebrows, and cheeks.
                                                         Occasionally involvement spreads to the eyelid
                                                         margins (blepharitis), sternal chest, axilla,
                                                         umbilicus, and inguinal folds.




               Seborrheic Dermatitis                           Seborrheic Dermatitis




               Seborrheic Dermatitis                           Seborrheic Dermatitis
        • Etiology: Unknown                            • Differential Diagnosis:
        • Age: Onset at any age from newborns to
          elderly.                                       Psoriasis, atopic dermatitis, tinea capitis,
        • Course: Chronic, often intermittent.           contact dermatitis, histiocytosis X,
        • Associations: High incidence in                pityriasis rubra pilaris.
          Parkinson’s disease, HIV, strokes, stress,
          and major illnesses. Often seen
          concomitantly with rosacea.




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Common Rashes                                                                                              November 4, 2006




                 Seborrheic Dermatitis                                       Seborrheic Dermatitis
        Treatment:                                                   Treatment:
        1. Shampoo several times a week. Tar, zinc pyrithione,
           selenium sulfide, salicylic acid, cyclopirox, and         4. Ketoconazole or cyclopirox cream is effective
           ketoconazole containing shampoos are all effective.          alone or in combination with topical steroids.
                                                                     5. Pimecrolimus (Elidel) cream or tacrolimus
        2. Mid-potency steroid solutions to the scalp, such as          ointment (Protopic) has been helpful in early
           Fluocinolone (Synalar), betamethasone valerate
           (Luxiq), or mometasone (Elocon) qd or bid. .                 studies.
                                                                     6. Blepharitis is treated by washing with baby
        3. Non-fluorinated, low potency topical steroid creams to       shampoo, and sometimes an ophthalmic
           the facial areas, ears, axilla, or groin, especially if      steroid product.
           irritated. Hydrocortisone 2½% or desonide (Desowen)
           cream are commonly used




                  Nummular dermatitis                                         Nummular dermatitis
        • Condition: The condition is defined by the
          clinical presentation of one or more round “coin-
          shaped” lesions. The eruption presents as small
          erythematous papules with minute vesicles that
          itch intensely and enlarge with scratching to form
          round to oval scaly excoriated or crusted
          plaques.
        • Predilection: The lower extremities are most
          commonly affected, but the dorsal hands and
          truck can be involved.
        • Etiology: Unknown




                  Nummular Dermatitis                                         Nummular Dermatitis
        • Age: The peak age for both men and                         • Differential Diagnosis: Atopic dermatitis, lichen
          women is between 55 to 65, but women                         simplex chronicus, drug eruption, contact
                                                                       dermatitis, and mycosis fungoides.
          between age 15 and 25 can also be
          affected.                                                  • Treatment:      1. Potent topical steroids.
        • Associations: 1. Dry skin                                                    2. Oral anti-histamines.
                        2. Irritants-wool,                                             3. Control temperature
                       soap, & overbathing.                                               and humidity.
                                                                                       4. Avoid irritants.
                        3. Seasonal flares.                                            5. UVB phototherapy.
        Lab: Serum IgE is normal.




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Common Rashes                                                                                November 4, 2006




                Dyshidrotic Dermatitis                             Dyshidrotic Dermatitis
        • Condition: Recurrent, often symmetrical
          eruptions of pruritic and burning vesicles on
          palms, soles, and lateral fingers or toes.

        • Etiology: Unknown, but stress sometimes
          implicated.

        • Course: Recurrent, with episodes lasting 2 – 3
          weeks, but may be chronic.




                Dyshidrotic Dermatitis                             Dyshidrotic Dermatitis
                                                           •   Differential Diagnosis: Contact
                                                               dermatitis, atopic dermatitis, “id”
                                                               reactions, and palmoplantar pustular
                                                               psoriasis.

                                                           •   Treatment:
                                                               1. Potent to ultrapotent topical steriods
                                                               in mild to moderate cases.




                Dyshidrotic Dermatitis
        • Treatment:

          2. Wet dressings with Burow’s solution for
          severe blistering eruptions.
          3. Systemic steroid taper over 3 weeks for
          severe bullous eruptions.
          4. PUVA therapy for chronic forms.
          5. Emollients for dry, scaly patches.




2006 VAMA National Convention- Dallas                                                                      6