Transcript Eczema & Psoriasis

Eczema & Psoriasis
Dr. Jerald E. Hurdle
Kennebec Medical Consultants
Waterville, ME 04901
Learning Objectives
 To familiarize you with the many
presentations of eczema & psoriasis,
 To understand how to get the most out of
topical therapies, and
 To recognize newer therapies now
becoming available.
Eczema
 From the Greek “to boil over”
 Eczema = Dermatitis
 Wastebasket term for many undiagnosed
rashes
 Histology shows edema or spongiosis
Eczema is itchy!
 Acute: Vesicles
 Sub acute: Juicy Papules
 Chronic: Lichenification
 Lesions tend to have
indistinct borders
Eczema is itchy!
 Acute: Vesicles
 Sub-acute: Juicy Papules
 Chronic: Lichenification
 Lesions tend to have
indistinct borders
Eczema is itchy!
 Acute: Vesicles
 Sub acute: Juicy Papules
 Chronic: Lichenification
 Lesions tend to have
indistinct borders
New patients presenting to a
dermatology clinic
Types of Dermatitis






Essential:
Contact:
Atopic:
Seborrheic:
Stasis:
Lichen Simplex Chronicus (LSC):
Source: Hershey Medical Center Dermatology Clinic
11.4%
2.8%
2.6%
3.7%
0.4%
0.8%
Essential Dermatitis
 Pruritus
 Eczematous lesions
not conforming to
other patterns of
dermatitis
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Essential Dermatitis
 Dyshidrotic
 Autosensitization
 Xerotic
 Nummular
“tapioca” on lateral borders of fingers
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Essential Dermatitis
 Dyshidrotic
 Autosensitization
 Xerotic
 Nummular
Hypersensitivity to a substance
produced by local dermatitis
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Essential Dermatitis
 Dyshidrotic
 Autosensitization
 Xerotic
 Nummular
• “crazy paving" appearance:
• affects elderly particularly in winter
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Essential Dermatitis
 Dyshidrotic
 Autosensitization
 Xerotic
 Nummular
Coin-shaped lesions
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Contact Dermatitis
 Irritant vs. Allergic
 Only affects area of contact
 Rx : avoid contactant
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Contact Dermatitis
Cosmetics
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Contact Dermatitis
Nickel
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Contact Dermatitis
Poison Oak
or
Poison Ivy
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Contact Dermatitis
Irritant
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Atopic Dermatitis
 Triad of atopic disease
 Pruritus
 Waxing/waning course
 Hands/face/neck
common in adults
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Seborrheic Dermatitis
 Dandruff on the body
 Hypersensitivity to
yeast
 Rx: Anti yeast &
steroids
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Stasis Dermatitis
 Eczema overlying
edematous legs
 Chronic

: Compression
 Beware of Ulcers
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Lichen Simplex Chronicus
 Localized chronic
dermatitis
 Occluded steroids
may help
Itch
Scratch
Scratch
Itch
Essential • Contact • Atopic • Seborrheic • Stasis • Lichen Simplex Chronicus
Treatment Of Eczema
 Gentle skin care
 ↓ Frequency of washing
 Cooler Water
 Avoid Soap
Treatment Of Eczema
 Use cream based emollients as soap
 Encourage greasiest
 Copious quantities
increasing greasiness
Treatment Of Eczema
Topical Steroids
Potency
clobetasol
 Ointments > Cream
 Use lowest effective
potency
 BID
fluocinonide
triamcinolone
aclomethasone
hydrocortisone
Psoriasis
Psoriasis
 2-5% Caucasians
 Onset at any age
 2 peaks in 20s & 50s
 May be pruritic
Psoriasis: precipitants
 Genetics
 Stress
 Infections -- i.e. Strep
 Trauma (Koebner)
 Medications: Lithium, β Blockers
 Obesity (insulin resistance)
 Alcohol
Chronic Plaque
 Commonest
 Extensor surfaces
 Stable disease
Guttate
 Explosive onset
 May be preceded by
Strep infection
 Consider other Dx:
Pityriasis Rosea &
syphilis
Palmar Plantar Pustulosis
 Commoner in smokers
 Tends to be difficult to
treat
 Groups of sterile
pustules
Erythrodermic Pustular
 Rare
 Skin often painful
 Pustules tiny (look
close)
 Later get lakes of pus
 Need to admit patient
to stabilize
Nail Psoriasis
 Commoner in pts with Ps
arthritis
 Pitting
 Oil spots
 Onycholysis
 Difficult to Rx
Treatments
 Emollients
 Remember Koebner
 Topical Agents
 Point to a scar
 UV light
 Systemics
 Biologics
Treatments
 Emollients
 Topical Agents
 Corticosteroids (potent &
super potent)
 UV light
 Vit D Analogue (Dovonex)
 Systemics
 Tars (LCD)
 Biologics
 Anthralin (Dithrocream)
Treatments
 Emollients
 Topical Agents
 Immunosuppressant
 UVB (Narrow band vs.
broadband
 UV light
 PUVA: Psoralen + UVA
 Systemics
 Biologics
 Treatment course 3x weekly
for 6 weeks
 Beware of skin cancer!
Treatments
 Emollients
 Topical Agents
 UV light
 Systemics
 Biologics
 Retinoids: Acitretin monitor
LFTs & Lipids (avoid in ♀ of
childbearing potential)
 Methotrexate (once weekly)
monitor LFTs & CBC
 Cyclosporine : monitor BP &
Renal function : great rescue
drug but need exit strategy!
Treatments
 Emollients
 Anti-TNF: Etanercept,
infliximab & adalumimab
 Topical Agents
 IL 12/23 blockers
 UV light
 Watch out for TB/infections
 Systemics
 Biologics
 No long term safety data
 $$$$
 Not Better than CyA or MTX
Treatments
 Avoid systemic corticosteroids!!!
Snowbird
Eczema: Key Points
 Appearance varies from blisters to scaling
plaques
 Itching is prominent
 Distribution can be localized or generalized
Psoriasis: Key Points
 Well demarcated erythematous, silvery,
scaling plaques
 Elbows, knees & scalp are typically
involved
 Inflammation and epidermal proliferation
Learning Objectives
 To familiarize you with the many
presentations of eczema & psoriasis,
 To understand how to get the most out of
topical therapies, and
 To recognize newer therapies now
becoming available.
And Remember…
For scaling rashes of
uncertain etiology…
“if it scales,
scrape it!”