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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!”