and dermatitis8yto students20103湿疹课件

Eczema and Dermatitis 湿疹与皮炎 中山一院皮肤性病学教研室 章星琪 Xingqi Zhang. M.D, Ph.D. Contact Dermatitis Atopic Dermatitis Eczema Clinical features* Management* Eczema/dermatitis The terms are interchangeable Denoting a polymorphic inflammatory reaction pattern involving the epidermis and dermis. There are many etiologies and a wide range of clinical findings. Polymorphic inflammatory reaction Acute: pruritus, erythema, and vesiculation; chronic: pruritus, xerosis, lichenification, hyperkeratosis, fissuring. Pathogenesis not completely understood Most of them caused by hypersensitivity Insults may not be found Classification of Eczema/dermatitis Contact DermatitisContact Dermatitis 接触性接触性 Atopic DermatitisAtopic Dermatitis 特应性特应性 EczemaEczema Classical Classical 经典性经典性 Site specificSite specific SeboehrricSeboehrric Dermatitis/eczema Dermatitis/eczema 脂溢性脂溢性 Asteatotic Eczema 乏脂性乏脂性 Static Eczema 郁积性郁积性 AutosensitizedAutosensitized eczema eczema自身敏感性自身敏感性 Nummular Eczema Nummular Eczema 钱币型钱币型 Contact Dermatitis Acute or chronic inflammatory reactions to substances that come in contact with the skin. Irritant contact dermatitis (ICD) is caused by a chemical irritant Allergic contact dermatitis (ACD) by an antigen (allergen) that elicits a type IV (cell-mediated or delayed) hypersensitivity reaction. Irritant Contact Dermatitis ICD is caused by exposure of the skin to chemical or other physical agents that are capable of irritating the skin, acutely or chronically. The hands are the most commonly affected area Mostly occupational accidents. Epidemiology ICD is the most common form of occupational skin disease, accounting for up to 80% of all occupational skin disorders. Occupational Exposure Individuals engaged in the following occupations/activities are at risk for ICD: housekeeping; hairdressing; medical, dental, and veterinary services; cleaning; floral arranging; agriculture; horticulture; forestry; food preparation and catering; printing; painting; metal work; mechanical engineering; car maintenance; construction; fishing. Most Common Irritant/Toxic Agents Detergent: Soaps, waterless hand cleaners Acids and alkalis: hydrofluoric acid, cement, chromic acid, phosphorus, ethylene oxide, phenol, metal salts. Industrial solvents: coal tar solvents, petroleum, chlorinated hydrocarbons, alcohol solvents, ethylene glycol ether, turpentine, ethyl ether, acetone, carbon dioxide, DMSO, dioxane, styrene. Plants: Euphorbiaceae (spurges, crotons, poinsettias, machneel tree). Racunculaceae (buttercup), Cruciferae (black mustard), Urticaceae (nettles), Solanaceae (pepper, capsaicin), Opuntia (prickly pear). Others: fiberglass, wool, rough synthetic clothing, fire-retardant fabrics, “NCR“ paper. Irritant Contact Dermatitis industrial solvent massive blistering on the palm. This airport worker had repeatedly spilled kerosene over his hands and developed acute bullous and extremely painful ICD 24 h later. Chronic irritant contact dermatitis in a housewife. There is erythema, hyperkeratosis, scaling, and fissures particularly on the finger tips in a patient with an atopic background. subacute/chronic Erythema, edema, scaling, fissuring, crusting of the palmar aspect of the hand and wrist; a housewife, is atopic and has ignored instructions to wear gloves during work in the kitchen and to use lubricating creams. ICD Clinical features Any one can have With clear border Resolved after removing of causative agent Usually acute and can have bulla Allergen Contact Dermatitis Eczematous dermatitis due to re-exposure to a substance to which the individual is sensitized. Epidemiology Frequent: Accounts for 7% of occupationally related illnesses in the United States. Occupation: One of the most important causes of disability in industry. Pathogenesis A classic, delayed, cell-mediated hypersensitivity reaction DTH, CMI Contact allergens are diverse and range from metal salts to antibiotics, dyes to plant products. Neomycin Usually contained in creams, ointments Procaine, benzocaine Local anesthetics Sulfonamides Terpentine Solvents, shoe polish, printers ink Balsam of Peru Topical Thiuram Rubber Formalin Disinfectant, curing agents, plastics Mercury Disinfectant, impregnation Chromates Cement, antioxidants, industrial oils, matches Nickel sulfate Metals, metals in clothing, jewelry Cobalt sulfate Cement, galvanization, industrial oils p-Phenylene diamine Black or dark dyes of textiles, printers ink Parahydroxybenzoic acid ester Conserving agent in foodstuffs CONTACT ALLERGENS Allergic contact dermatitis Common allergens Nickel, toxicodendrons (poison ivy), fragrance, thimerosal, formaldehyde, bacitracin, and rubber compounds Clinical manifestations A pruritic, eczematous reaction Well demarcated and localized to the site of contact with the allergen Testing for sensitivity Patch test Chinese screen set Subacute ACD in the breast region. The distribution of the papular eruption suggested a causative role of the bra and indeed the patient proved to have a type IV hypersensitivity to latex. Allergic phytodermatitis of leg: poison ivy Linear vesicular lesions with erythema and edema on the calf at sites of direct contact of the skin 5 days after exposure with the poison ivy leaf. Mild subacute ACD on the ear and the side of the neck, unilateral, hypersensitive to the plastic cover of his cellular phone. 中国筛查系列 CH-1000 化合物名称产品编号 1氯化钴C017A 2巯基混合物Mx05A 3咪唑烷基脲I001A 4对苯二胺基质P006 5N-环己基硫酞内酯C034 6重铬酸钾P014A 7亚乙基二胺E005 8松香C020 9甲醛F002A 10环氧树脂E002 11溴硝丙醇 B015A 12秋兰姆混合物Mx01 13对苯类（混合物）Mx03C 14硫酸镍N002A 15倍半萜烯内酯混合物 Mx18 16芳香混合物Mx07 17Cl-Me-异噻唑（卡松CG）C009A 18黑橡胶混合物Mx04 19卡巴混合物Mx06 20夸特15C007A Irritant CDAllergic CD SymptomsAcuteStinging itching Itching pain ChronicItching/painItching/pain LesionsAcuteErythema vesicle erosion crust scaling Erythema papules vesicles erosions crust scaling ChronicPapules, plaques, fissures, scaling, crusts Papules, plaques, scaling, crusts Margination and site AcuteSharp, strictly confined to site of exposure Sharp, confined to site of exposure; usually tiny papules ChronicIll-definedIll-defined, spreads EvolutionAcuteRapid (few hours after exposure) Not so rapid (12 to 72 h after exposure) ChronicMonths to years of repeated exposure Months or longer; exacerbation after reexpos. Causative agents occurs only above threshold level Relatively independent of amount applied Incidence May occur in everyone Occurs only in the sensitized Management of ICD Prevention Avoid irritant or caustic chemical(s) by wearing protective clothing (i.e., goggles). If contact does occur, wash with water or weak neutralizing solution. Barrier creams. In occupational ICD that persists, change of job may be necessary. Treatment Acute Identify and remove the etiologic agent. Wet dressings with gauze soaked in Burows solution, changed every 2 to 3 h. Subacute and Chronic Identify and remove etiologic/pathogenic agent. Employ a potent topical glucocorticoid preparation, betamethasone dipropionate or clobetasol propionate, and provide adequate lubrication. chronic ICD Topical-pimecrolimus and tacrolimus PUVA Topical Therapies Principles Choose right therapeutic reagents Choose right solvents Acute With erosion and secretion: solution Without erosion and secretion: powder, lotion Topical Therapies Principles Choose right therapeutic reagents Choose right solvents Subacute With some degree of secretion: paste, oil Without secretion: emulsion, paste Chronic Emulsion, ointment, plaster, film Management of ACD Topical Therapy Wet dressings with cloths soaked in Burows solution changed every 2 to 3 h. Topical glucocorticoid ointments/gels (classes I to III) The newer immunomodulating topicals pimecrolimus and tacrolimus Systemic Therapy Glucocorticoids are indicated if severe Immunosuppression with oral cyclosporine In airborne ACD where complete avoidance of allergen may be impossible, Clinical application of ACD Alopecia area (AA) Tropical immune treatment of severe type of AA DPCP Atopic Dermatitis (AD) “Atopy” “Out of place”, “strange”, “unusual”, “no/without place” Hereditary tendency to develop allergies to food and inhalant substances Eczema, asthma, rhinitis and hay fever Atopic DiseasesAtopic Diseases Barnetson and Rogers. BMJ 2002;324:13769 051015 发病率发病率 年龄年龄( (岁岁) ) 特应性皮炎ADAD(湿疹) 食物过敏 哮喘 鼻炎 Key Features Chronic, relapsing dermatitis associated with intense pruritus Three stages: infantile, childhood and adulthood Often associated with xerosis a personal or family history of atopy asthma and allergic rhinitis A genetic basis that is influenced by environmental factors Immuno-aberration Serum IgE elevation and eosinophilia Th2 predominance in acute lesions evolves into a predominance of IFN- producing T cells in chronic lesions Epidemiology 70-95% of cases arise before the age of 5 years Prevalence 10-20% of schoolchildren; F:M=1.3:1 On the rise, 2-10 fold over last 30 yrs Significant higher chance with familiar atopic history Interaction of environmental and genetic factors Degree of urbanization Hygiene theory: infection and atopy Pathogenesis Genetics Skin barrier Dysregulation of immune responses Barrier-disrupted skin: Impaired barrier function* *Target for treatment Ceramide-water holding, ceramidase Sphingomyelin deacylase Filaggrin Clinical featuresthe itch that rashes Severe dryness, irritated, itchy, secondary infection Immunological Reactions Th2 dominance in acute phase Cytokine IL-4 and IL-5 IL-10 IgE, eosinophil Th1 dominance in chronic phase IFN- producing T cells Langerhans cell Infantile AD 60% of AD present in the first year of life, 2m-2yr Sites most affected Cheeks, then spread to neck, forehead, wrists, and extensor extremities Eruption: acute and moist in feature Erythematous patches, vesicles, exudate, crust, pustules 奶癣, fungal infection due to milk Causes Food allergy egg, milk, chicken, fish peanut, wheat, soy Maternal ingest of allergen Inherited skin barrier dysfunction Adolescent and Adult AD Eruption Adolescents Similar to childhood AD Older adults Localized plagues, erythematous, scaly or papular, lichenified, and scaly Sites less characteristic Dry skin, itchy Emotional stress, depression, anxiety, and exercise can be the trigger Improvement occurs, and AD resolves before middle life Diagnosis Criteria for Diagnosis 1. Williams: Pruitus plus 3/5 items 2. AAD 3. UK working Partys Diagnostic Criteria for AD Major criteria: three of these Pruritus Typical morphology and distribution lichenification in adults Facial and extensor involvement in infancy Chronic or chronically relapsing dermatitis Personal or family history of atopic disease UK working Partys Diagnostic Criteria for AD Minor criteria: three of these Xerosis Ichthyosis IgE reactivity Elevated serum IgE Early age of onset Tendency for cutaneous infections Tendency to nonspecific hand/food dermatitis Nipple eczema Cheilitis Recurrent conjunctivitis Dennie-Morgan infraorbital fold Keratoconus Anterior subcapsular cataracts Orbital darkening Facial pallor/facial erythema Pityriasis alba Itch when sweating Intolerance to wool and lipid solvents Perifollicular accentuation Food hypersensitivity Course influenced by environmental and/or emotional factors White dermographism or delayed blanch to cholinergic agents Differential Diagnosis Dermatoses Seborrheic dermatitis Allergic contact dermatitis Nummular dermatitis Scabies Psoriasis Immunodeficiency syndrome in infants Management of AD: General Infancy and Childhood Avoid external irritation, scratching, soap, hot shower, food allergens Antihistamine with sedative effect Adults Avoid cold and heat, over-bathing, hot shower, soap, wearing wool, emotional stress Use moisturizers to get skin hydrated Tackle the itch: ice cubes Management of AD: specific therapies 1 Topical Hydration: 10%urea cream, Cod liver ointment Stages of lesion Oozing: 3% boric acid solution, potassium permanganate solution Subacute: Zinc Oxide oil, Calamine lotion Corticosteroid cream Calcineurin inhibitors cream Systemic Antihistamines, antibiotics-S.aureus Immune modulator Cyclosporine, IVIg Management of AD: specific therapies 2 Phototherapy PUVA, UVB, UVA Immune suppressive Langerhans cells IL-10NK and T cells Apoptosis of T cells He-Ne Laser 632.8nm Freezing Eczema Greek word, ekzein, meaning “boil out” or “effervesce” A morphologic category Loosely defined as a group of diseases with epidermal changes of scale, parakeratosis and spongiosis Tendency to persist and relapse Pathogenesis less well understood than AD and contact dermatitis The most common locations for eczema are: Face, neck, front of the elbows, behind the knees, arms and legs (extremities) Skin lesion Thickened, scaly, pink-to-red elevated areas (papules) and sheets of skin (plaques) are seen in these areas. Areas with infection in the affected areas (superimposed infection) can develop thick crusts. Severity Mild few, scattered areas that are easily treated with self-care measures Moderate more extensive areas that are more difficult to control with self-care measures and may require prescription therapy Severe widespread (diffuse) affected areas that are difficult to treat even with prescription therapy Clinical TypesClinical Types Regional EczemaRegional Eczema EarEar EyelidEyelid Breast Breast HandHand DiaperDiaper ClassicalClassical Dyshidrotic Seborrheic Asteatotic Stasis Special typesSpecial types CircumileostomyCircumileostomy Autosensitization/dissemiatedAutosensitization/dissemiated Infectious Infectious eczematoideczematoid Dyshidrotic Eczema Secondary infection may complicate the course pustules, crusts, cellulitis, lymphangitis, and painful lymphadenopathy. Wetdressing For vesicular stage: Burows wet dressings. Large bullae drained with a puncture but not unroofed. In dyshidrotic eczematous dermatitis, vesicles and blisters break and leave well-defined superficial erosions that are painful Seborrheic dermatitis 脂溢性皮炎 Clinical features Symmetric, on forehead, eyebrows eyelids, nasolabial folds Yellowish-red erythema with fine scaling or flaky greasy scales Active sebaceous gland A predilection for areas rich in sebaceous glands such as scalp and face Seborrheic Dermatitis Scalp Pityriasis simplex capillitii (dandruff) white or greasy scaling Treatment Topical azoles as shampoos or creams Topical corticosteroids and emollients Isotretinoine Asteatotic Eczema 乏脂性湿疹 Xerotic eczema, winter itch, dessication dermatitis Related to aging, xerosis, low relative humidity and frequent bathing Driest skin areas Anterior shins, entensor arms, flank Dry, rough, scaly and inflamed skin with superficial cracking Treatment: Limitation of the use of soap, use of moisturizers Disseminated/autosensitization dermatitis Secondary lesions of eczema distant from the primary site of exposure or involvement usually occurs a few days to weeks later Symmetric poorly demarcated patches of eczema, may lead to eczematous erythroderma Often associated with allergic contact dermatitis stasis dermatitis nummular dermatitis Pathogenesis is still unclear what exactly is disseminated via the bloodstream Infectious eczematoid dermatitis Regional EczemaRegional Eczema EarEar EyelidEyelid Breast Breast HandHand DiaperDiaper Ear eczema Ears or otitis externa Helix, postauricular fold, external canal Most caused by seborrheic or atopic dermatitis Infection with G+ cocci antibiotic topical remedies Nickel allergy-ear lob Treatment Removal of causative agents Consult with ENT for local treatment Eyelid dermatitis Causative agents Cosmetics: eye shadow, eye cream Substances on hands: nail polish Contact lenses Volatile gases Hand and Foot Eczema 手足湿疹 Environment-contact, occupation, home makers, AD. Patch test Palmar and plantar impaired barrier plus allergic reaction Clinical manifestations Vesiculobullous-acute eruption Dryness, erythematous hardening with fissure, scaly Discontinue soap and water exposure, moisturizing Legs, hands, or extensor of the arms Discrete, coin shaped, erythematous, edematous, vesicular and crusted patches, can be oozing and then thickened and scaly Nummular/Discoid eczemaNummular/Discoid eczema 钱币状湿疹钱币状湿疹 Long-term process followed by spreading of new lesions Subacute dermatitis Topical steroid and antibiotic 幼年性掌趾角化病 Juvenile plantar dermatosis Age 3 to puberty, atopy Forefoot and plantar Red patch with fissuring and desquamation, scaling Related to athletic shoes Sweet gland occlusion Foot powder, absorbent socks, change of shoes Scrotum eczemaScrotum eczema Thickening and