Eczema: Diagnosis and Management

00:01 The clinical presentation it is very characteristically a papular vascular lesion.

00:08 So little kind of vesicles or little tiny blisters.

00:13 And there will be erythema edema and varying amounts of pruritus or itchiness. Typically we'll see this on the folds, the intertriginous surfaces, but it clearly can also involve the entire body. And this poor soul has got a significant amount of eczema over his trunk. So the symptoms may be very mild.

00:34 You'll notice here that our guy in bed is asleep.

00:37 His eyes are closed. He may have a little bit of dry skin, intermittently, will be itchy and overall the disease has minimal impact. Here are our sleeper has got furrowed eyebrows.

00:50 There's going to be more frequent pruritis, it's going to be much more itchy.

00:55 There may be more noticeable erythema that's just inflamed blood vessels down in the dermis. There may be localized skin thickening that's due to the edema and to the inflammatory infiltrate.

01:06 Excoriation just means scratch marks.

01:08 So it depends on the degree of pruritus that's happening.

01:11 And there may be moderate impact on activities.

01:14 And sleep will be frequently disturbed.

01:16 And then this poor devil is completely awake.

01:19 Severe symptoms. It's just way out on the spectrum.

01:23 Constant itchiness. Very severe redness.

01:27 Again, there is an inflamed kind of diathesis that's going on within the dermis.

01:31 And as a result of that, we have profound, uh, vascular congestion. So that will make everything look red.

01:40 There will also be increased vascular permeability because of the inflammation that will cause edema. So there will be extensive skin thickening because of the scratching, the excoriation, there will be bleeding and oozing and cracking. You get the picture.

01:53 It has a severe impact on general activities and psychosocial function.

01:57 And clearly sleep. What do we do about diagnosis? Well, in fact, like most things in dermatopathology or dermatology, it's a clinical thing.

02:05 You take a good history. You just look at it.

02:06 It looks like a nice rash with papular vesicular lesions.

02:10 It's a little red. It's a little itchy.

02:12 You may get the history of allergic rhinitis.

02:15 Every fall, they have terrible hay fever.

02:18 You may get a history of asthma in them or a related family member.

02:22 So again, you can probably make the diagnosis in the majority of cases just on clinical grounds. But if you want to nail it, you can look at serum IgE which is going to be elevated in a significant proportion of patients.

02:33 You may do a skin biopsy which will demonstrate the spongiotic dermatitis and that kind of dermal infiltrate of lymphocytes.

02:42 A confounder in all of this, and one you need to rule out because you would treat it quite differently, is infections with various fungi.

02:51 So tinea corpora is something that we need to exclude.

02:54 So you can do a potassium hydroxide, a Koh, prep, scrape the skin, look for fungal hyphae, and then you can also do patch testing to rule out a contact dermatitis.

03:05 In other words, contact dermatitis, something in their environment that is causing the rash is is in fact driving the inflammatory response. And it's not primarily eczema.

03:18 So you can do patch testing looking for common things like laundry detergent or a rayon sensitivity, etc.

03:25 and then if you really want to do it and spend a lot of money, you can do genetic testing, but that's usually not indicated.

03:32 How do we manage it? Well, this is what your patients want you to really understand. So we want to eliminate as much as possible any exacerbating factors and in fact any, any contact hypersensitivity that could be part and parcel of causing a break in the barrier function.

03:49 We want to go after that.

03:51 We want to treat associated skin infections.

03:53 So going after the staph aureus or herpes simplex.

03:57 A very simple especially for mild disease approach is skin hydration.

04:02 Just add emollients and moisturizers.

04:04 And that can often reduce a lot of the inflammatory process and create a little bit more of a barrier function.

04:11 For more severe disease, you want to dampen the immune response.

04:15 So let's get some corticosteroids.

04:17 Do be aware that corticosteroids also cause a change in the normal synthesis of keratinocytes, and in the normal synthesis of the stratum corneum, so that you may end up with skin atrophy which may cause other problems. So you can't do it forever and ever.

04:35 As a second line, if you want to do anti-inflammatory treatment, you can use calcineurin inhibitors that you apply topically.

04:42 And then phosphodiesterase 4 inhibitors are kind of potent. One-stop shopping if you want to have an anti-inflammatory effect.

04:53 Those inhibit the breakdown of cyclic AMP, elevated cyclic AMP tends to be immune inhibitory.

05:01 Oral antihistamines for some of the itchiness.

05:04 Oral immunosuppressants.

05:05 So you can give cyclosporin systemically as a way to go after the immune system.

05:10 This would really be probably only indicated for super severe disease.

05:14 Monoclonal antibodies against IL four.

05:17 Remember this is a Th2-like pathway predominantly.

05:21 So we can pull out the big guns with monoclonal antibodies.

05:25 It's expensive. It has other downsides but it's certainly possible.

05:29 And you can do phototherapy so you can hit the skin with UV light and that and in the appropriate setting say with PUVA then we're going to be able to kill off the cytotoxic T cells or the inflammatory infiltrate that's there.

05:45 And with that, we've covered a very important topic.

05:48 A very common topic of eczema.

05:50 And hopefully you have a better understanding for what's driving it and how to approach the treatment of it.