Download Itchy Rash

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Patient itch/
Itchy Rash
Prof. DOULAT RAI BAJAJ
FCPS, MCPS
Professor & Chairman
Dept. of Dermatology
LUMHS
Goals of Presentation
At the end of presentation you would be able
to:
1. Clinically evaluate a patient with itch or
itchy rash
2. Make a working diagnosis
3. Manage it at the best
How to Evaluate?
 History
 Examination
 Lab
investigations
History: Age of patient

Infant/child:
Atopic Dermatitis
Scabies, Pediculosis
Infantile seb. dermatitis
psoriasis
Mastocytosis
Insect bites (papular urticaria)
Urticaria







Age of patient: Young adult




Specific dermatoses: Atopic Dermatitis, Contact
Dermatitis, Psoriasis, P. Rosea, lichen simplex
chronicus, Prurigo,
Infections: Scabies, body lice, Yeast & fungal
infections (tineas, P. versicolor)….
Hypersensitivity reactions: urticaria, Dermatitis
herpetiformis
Miscellaneous: cut. Lymphoma, psychogenic……
History:
Old age:

Dermatitis Herpetiformis

Xerosis
psoriasis
Aging of skin
Drug reactions,
Systemic diseases




History:
Acute vs Chronic
 Acute: scabies, pediculosis, drugs, insect bites,
urticaria
 Chronic: AD, ACD, Psoriasis, LSC, prurigo,
systemic diseases

Gender: pregnancy associated dermatoses

Family history: Scabies, pediculosis, psoriasis,
AD,
History:

Presence of Systemic Disease:
Renal: CRF, Pt on dialysis
 Endocrine: DM, hypo-and hyperthyroidism,
 Liver Disease
 Malignancies: any internal malignancy
 AIDS:
 Hematological: Polycythmia, anaemia
 Psychogenic

Examination:

Type of lesion: macule/patch, papule/plaque,
nodule, vesicle/bullae, pustule, erosion/ulcer ..
Sites and Distribution:
 Shape: annular, discoid, polygonal, arcuate…
 Pattern: discrete, grouped, linear, segmental,

dermatomal
Colour, consistency, margins etc
 Secondary features: crust, scale, excoriation,

Investigations:
 Woods’
light examination
 Scrappings
 Skin
for fungal infections
Biopsy:
Atopic Dermatitis
ATOPIC DERMATITIS
“ATOPY” is a genetically determined tendency to
produce increased amounts of reagens (IgE), in
response to allergens.
Clinically manifested by:
 ASTHMA
 HAY FEVER
 ATOPIC DERMATITIS
Antigen
Macropha
ge
IL-1
IgG
IgM
IgA
IgD
IgE
IMMUNITY
T cell
IL-4
B cell
Plasma
cell
ALLERGY
Antigen
Macrophage
IL-1
IgE
T cell
Plasma
cell
IL-4
B cell
Major features (must have 4)

Pruritus

Early age of onset

Typical morphology and distribution

Infants & Children: Face & extensors

Adults: Flexureal lichenification & linearity

Chronic course

Personal or family history of atopy (asthma, rhinoconjuctivitis, dermatitis).
Minor features

Dryness of skin

Ichthyosis , palmar hyperlinearity/keratosis pilaris

Hand/foot dermatitis

Lip dermatitis

Nipple eczema

Increased cutaneous infections e.g. Staph. aureus &
H.Simplex)
Common Clinical Features:

Itching

Erythematous Macules, Papules, vesicles

Eczema with crusting, Lichenification,
Excoriation

Dry skin

Secondary infection
ACUTE vs Chronic AD
Acute AD
 Redness
 Swelling
 Papules
 Vesicles
 Exudation
 Cracking
Chronic AD

Less vesiculation/ exudation

More Thickening,
pigmentation &
Lichenification (due to
rubbing & scratching)

Fissures

Scratch marks
Adult AD
Infantile/childhood AD

Red Itchy scaly lesions on
scalp, cheeks, wrists &
trunk

Diaper area spared

Extensor aspects of limbs
(begins to Crawl)

Irritable & restlessness

Crusts

Pustules

Lichenified, pigmented
papules, plaques scattered
all over body

Bothering itch

Prominent infra-orbital
crease

General dry skin
Sebhorroic Dermatitis
Seb. Derm
Characterized by:
 Erythematous scaly plaques
 Greasy scaling
 yellow crusted patches & plaques
 There is very minimal itch (vs AD)
 Age of onset:
 Below
06 months: infantile SD
 After puberty: adult SD
Sites:
Infantile SD:



Scalp (Cradle Cap),
Face & Neck (eye brows, Ears & sides of neck).
Trunk & Flexures, starting in napkin area.
Adult SD:

Scalp
 Forehead
 Face: Eyebrows, Nasolabial folds, ear canals,
behind pinnae,
 Trunk: sternal area, interscapular region & flexures
Contact Dermatitis
1.
2.
Irritant Contact Dermatitis
Allergic Contact Dermatitis
Irritant Contact Dermatitis

Non-allergic reaction of the skin caused by
exposure to irritating substance

Any person can develop ICD if concentration &
duration of contact sufficient

About 80% of occupational dermatitis is irritant in
nature

C/F: Erythema, Edema, Vesiculation, Weeping
ALLERGIC CONTACT DERMATITIS

Immunologically-mediated, Delayed (type IV)
hypersensitivity

Occurs in persons already sensitized

Not dose related, Not restricted to area of contact

C/F: erythema, edema, papules, papulovesicles
it is difficult to distinguish C/F of ACD from
irritant or constitutional dermatoses(AD, SD)

Common sensitizer:
1.
2.
3.
4.
5.
Hair dyes
Nickel, Chromate, cobalt
Leather, Rubber
Topical Drugs: neomycin, gentamicin,
lignocaine
Plants
Pathogenesis ACD
Dry scaly dermatitis
ACD due to items in pocket
LEATHER
ADHESIVE TAPE
PLANTS
Tatoos causing ACD
TREATMENT
Treatment Principles
Avoid known triggers
 Moisturize, moisturize, moisturize
 Itch Control
 Topical corticosteroids
 Other topical therapies
 Systemic therapy

Avoid Irritants
Allergen avoidance during pregnancy
and or infancy (mild benefit shown from
avoiding cow’s milk, eggs, and dust
mites)
 Big Five: dryness, dust mites, animal
dander, cigarette smoke, wool
 Others include water and chemicals

Dry Skin Care
Baths and showers not hot and short
 Mild soap (Dove) – best to avoid alkali soaps
 Blot dry and immediately moisturize (skin
should still be slightly damp)
 Creams and ointments better than lotions and
oils

Itch Control
Avoid topical antihistamines
 Products containing menthol, camphor &
weak conc: of phenol may be helpful
 Cool compresses
 Avoid hot/sweaty conditions

Antihistamines



In children generally sedating AH used. No role of
non-sedating AH in children with AD
A combination of sedating & non-sedating AH
indicated in adults with eczema.
For AD: Zonalon=topical doxepin – qid for
maximum of eight days. Never occlude, some
systemic absorption, very sedating, risk of ACD
TOPICAL STEROIDS

Steroid
1.
2.
3.
4.
5.
6.
7.
8.
Potency
Vehicle
Amount
Site
Clinical stage of eczema
Weather
Duration of treatment
Disease
Super Potent Potent
Moderate
Mild
Potent
Clobetasol
Fluticasone propionate
propionate 0.05% (cutivate)
(dermovate)
Amcinonide
Diflucortolone
valerate (volog)
Mometasone Furoate
(hivate)
Flucinolone
acetonide 0.2%
Betamethasone
dipropionate (diprolene)
Halcinonide
Betamethasone valerate
0.1% (betnovate)
Triamcinolone acetonide
(kenacomb)
Desonide (desone)
Methylprednisolone
aceponate 0.1% (advantan)
Betamethason
valerate
0.025%
Prednicarbate
Hydrocortisone
Methyl
prednisolone
acetate 0.25%
Flucinolone
acetonide
0.0025%
Other Topical Therapies



Tar
Salicylic acid
Topical Tacrolimus, pimecrolimus
Antimicrobials
Antibiotics for culture proven infections
 Ketoconazole for head and neck based
atopic dermatitis (reduce yeast counts)

Phototherapy
UVB
 Narrow Band UVB
 UVA/PUVA
 Sunlight

Other Therapies
 Leukotriene
Inhibitors do not work
 Oral cromolyn sodium results conflicting
 Interferon gamma daily s/c inj. helps
 Cyclosporine
 Azathioprine
 Hydroxychloroquine
Some Specific Types of
Eczema
Discoid/Nummular eczema

Circular or oval plaques

A clearly demarcated edge

Related to atopy, emotional stress, bacterial
infection

Usually lesions dry.

Exudative ones always associated with bacterial
infections.

Treatment: Emollients, topical steroids,
antibacterials
Lichen Simplex Chronicus
An eczematous dermatosis characterized by

Lichenified plaques, usually 1-2 in number

Typical sites: nape of neck, scrotum, wrists

skin thickened, pigmented with prominent skin
markings

Associated with atopy, emotional stress

Tr: Superpotent steroids with keratolytic agents.
I/L steroid injections
LSC
Nodular Prurigo
Characterized clinically by chronic, intensely
itchy papules & nodules
 lesions range from small papules to hard
nodules, 1–3 cm in diameter, with a raised,
warty surface.
 The early lesion is red later becoming
pigmented.
 Tr: superpotent steroids, oral steroids, UVB,
PUVA, thalidomide

Pompholyx

Pompholyx is characterized by the





sudden onset of clear vesicles over hands.
Symptoms: No erythema, less pruritus but more
heat and prickling sensation.
Sites: sides and dorsa of fingers & hands
Vesicles may become confluent and present as
large bullae, especially on feet.
Itching may be severe, preceding the eruption of
vesicles
Pityriasis Rosea (P. rosea)

An acute, self-limiting disease, probably infective in
origin, affecting mainly children and young adults.

The first lesion is “Herald patch” a large circular, sharply
defined eryhematous patch with fine scales on thigh/trunk.

This is followed by an eruption of discrete oval lesions, dull
pink in colour, covered by fine, dry, silvery scales forming a
collarette at edges.

The centre tends to clear and assumes a wrinkled, atrophic
appearance.

The lesions appear in crops.
P.Rosea contd…….
The lesions tend occur in ‘chrismas tree’
pattern along the rib cage.
 There are usually no symptoms. Some pts.
have mild to moderate pruritus
 Tr: The common asymptomatic, self-limiting

cases require no treatment. If itch is severe or
the appearance distressing, a topical steroid
(moderate potent) or UVB can be helpful.
Asteototic Eczema

Eczema developing in dry skin
 Seen on legs, arms and hands.
 Tends to be more marked in the winter and in
elderly people.
 Skin is dry, scaly showing a criss-cross skin
markings. Finger pulps are dry and cracked;
retaining a prolonged depression after pressure
(‘parchment pulps’).
 Associated with hypothyroidism, zinc deficiency,
diuretic use and cimetidine use
Pityriasis alba

A mild eczema in which hypopigmentation is the most
conspicuous feature. (NO CALCIUM Deficiency
Predominantly seen in children b/w ages of 3 -16 ys.
The individual lesion is circular, oval or irregular
hypopigmented patch with NOT well defined edges.
Lesions often slightly erythematous & have fine scale

Common sites: cheeks & around the mouth & chin



Less commonly on neck, arms, shoulders & trunk.
 D/D: vitiligo, P. versicolor, PIH
 Tr: mild steroids, emollients
SUMMARY
Disease
Typical morphology
Diagnostic clues
Irritant CD
Sharply demarcated macular
erythema, little vesiculation
More burning less itch,
only at area of contact
Allergic CD
Exzematous, scaly edematous
plaques with vesiculation
Atopic
Dermatitis
Eczematous, honey-crusted scaly
plaques, lichenified in chronic cases
Pruritis, primary lesion at
area of contact
,
Flexural areas, neck
predominance
Sebhorroic
dermatitis
Greasy scaly papules, minimal itch
Hair bearing areas,
glabella, nasolabial folds
Xerotic/asteot Crackled parchment like patches, no
ic eczema
edema, no vesiculation
Lower legs
Nummular
/discoid
eczema
Coin-shaped, well demarcated, scaly
or weepy plaques, bilateral,
symetrical, kissing lesions
Arms, legs, dorsal hands
Pompholyx
Deep seated papulo-vesicles on
palmar plantar surfaces, volar edges
Palms, soles, typical
dorsal involvement
Conclusions
Eczema management rests on three
pillars: avoid irritants, moisturize, topical
management
 Use steroids to quiet a flare then switch
to a nonsteroidal therapy
 Treating hot spots can prolong
remissions
 Control itch!

THANK YOU
This presentation is available on
www.lumhs.edu.pk/DFHC/html