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More types of Eczema

Nummular Dermatitis
It is a chronic recurring rash that seem to occur in the drier, colder months. The lesions are usually round, disk-like plaques or patches of very dry skin. They usually start as small papules (bumps) or vesicles (small blisters) that become eroded and crusted. They are often very itchy and there is sometimes a burning sensation. This condition is often seen in older individuals. Similar looking round patches of dermatitis may be seen in children with atopic dermatitis.

The cause is unknown. Some feel that stress may cause this condition to flare. It often becomes more common in a dry winter climate. It is most commonly seen on the lower legs, buttocks, forearms and the backs of the hands.

Other conditions that need to be considered when looking at nummular dermatitis are psoriasis, tinea corporis, and parapsoriasis (although this is usually not itchy). Drug eruptions have been reported as presenting with eczema or nummular dermatitis appearance. Other conditions may have superficial similarities including impetigo, Bowen’s disease and mycosis fungoides. In situations where there is doubt, KOH examination or bacterial swabs and / or biopsy may be required.

Patch testing can be useful. In some cases where a contact dermatitis can be identified, clearing can be achieved by avoidance of the allergen.

Hand Eczema - Hand Dermatitis
This is a very common occurring in about 10% of women and 4% of men. Hand eczema, also known as hand dermatitis, starts most commonly with mild dryness and some redness. Scaling can increase leading to fissuring and crusting. Initially the fingers and web spaces are involved.

It can be very itchy. Hands dermatitis is often difficult to treat effectively. It is most commonly seen in those who do a lot of wet work either at home or at work. This condition can be very disabling and can affect the ability to perform at work and home. Homemakers, parents with small children, bartenders, hairdressers, dental workers and surgeons are at risk. The common feature is repetitive wetting and drying of the hands. Cold weather can aggravate the condition. The hands of parents with newborns worsen usually after 3-6 months. Of those with atopic eczema in childhood about 40% will experience irritant hand dermatitis. About 70% of these individuals will have hand involvement if their work involves regular contact with hand irritants.

Subtypes Of Hand Dermatitis:
Contact dermatitis – irritant or allergic dermatitis
Dyshidrotic eczema
Hyperkeratotic dermatitis
Atopic hand dermatitis

Advice For Hand Care

Use a long handled brush for washing the dishes
Consider using a dishwasher instead of hand washing
Avoid heating or cooling the skin, sweating within rubber gloves alone can worsen the dermatitis, cotton gloves should be worn inside loose fitting rubber or vinyl gloves
Avoid the temptation of using very hot water even if wearing gloves
Wear cotton gloves to do general house work as they can be washed instead of washing your hands too often
While preparing food try and minimize contact with fruit juice, fruits, vegetables, raw meat, onion and garlic
House hold cleansers, deodorants, and antibacterial soaps and cleansers should not be used
Shampooing hair should be done while wearing vinyl gloves, if this is not possible use the hand which is least likely to be involved with dermatitis
Keep hand washing to a minimum, keep water temperature luke warm
Avoid harsh or scented soaps, soapless cleansers may be the best to use, E.g. Spectro Jel, Spectro Derm, Cetaphil, Seaquanil, Lipikar Syndet
Take off rings before wet work or hand washing
Patting dry is best
Apply moisturizers after washing, ointments that are clear and sticky seem to work the best but may not be practical, try using a skin protectant with petrolatum or silicone, E.g. Vaseline, Prevex

Lichen Simplex Chronicus
This is a localized itchy, well defined eruption. It usually starts with small papules that join together to become plaques. The chronic nature of this condition can be troubling. The skin thickens in response to rubbing and scratching (lichenification). Increased skin markings occur often in a cross-hatch pattern. Nodules may sometimes occur as part of the thickening skin.

These individuals may be atopic. The cause is not known. Once the itch/scratch cycle is established it is very difficult to break this without treatment. Persistent rubbing causes the epidermis to thicken. Secondary infection of the skin is sometimes seen. There may be sensitization with allergic reactions in response to the topical creams, lotions and ointments used. Most often lichen simplex chronicus is seen around the ankles, shins and the back or side of the neck. The forearms may also be extensively involved. Involvement of the anal-genital areas, especially on the vulva, scrotum and peri-anal areas is also possible. The plaques produced can be either single or in multiple locations.

The aim of treatment is to stop the itch/scratch cycle. Potent topical steroids are usually required. Occlusion is sometimes necessary to try to reduce the itching and to thin out the excessively thickened skin. The response may often take many weeks. Oral antihistamines that are sedating may be of benefit at bedtime. Secondary infection may be seen and topical or sometimes oral antibiotics are required. In persistent lesions a biopsy is required to rule out any other pathology. Occasionally patch testing may also be of value.

Contact Dermatitis
Contact dermatitis can be either irritant or allergic. Irritant dermatitis is usually mild. Micro-vesiculation of tiny blisters can be seen although this is not as prominent as an allergic dermatitis. Chronic exposure can lead to thickening of the skin with scaling and cracking.

Sometimes distinguishing the more acute irritant reaction may be difficult as similar features can sometimes also be seen in allergic reactions. Common abrasives such as cleansing agents, solvents, detergents, soaps and cutting oils are responsible, as is frequent contact with water as well as chemicals with either oxidizing or reducing agents. Contact with animal saliva can also produce irritant dermatitis.

Allergic Dermatitis
This can be mild and have features similar to irritant dermatitis. More severe reactions will produce blisters, redness and swelling. The distribution and configuration of the dermatitis may give clues to the fact that this is allergic. Straight lines, irregular shapes, sharp edges and angular configuration are all clues to aid in diagnosing contact dermatitis.

The location and distribution of the dermatitis can be clue to the causative agent: Eyelids, Face, Scalp, Ears, Neck, Chest, Belt line, Axilla, Vulva, Penis, Thighs, Buttocks, Anal skin, Forearms, Legs.

Common allergens will be latex or rubber. It is estimated that between 6-10% of nurses and doctors in hospitals will be allergic to these products. Individuals who have chronic exposure to rubber such as those requiring on-going catheterization also have a high rate of allergic reaction. There is an immediate reaction to latex which can be urticarial and associated with flushing. There may be respiratory symptoms and tachycardia. The more delayed reactions will be those of acute allergic contact dermatitis.

It has been established that allergic reactions to topical steroids are quite common. These can be reactions to either the steroid molecule itself or the vehicle in which it is found. Allergic reactions to one topical steroid may cross-react to others. Clobetasol and Betamethasone are the least likely allergens.

It is difficult to realize allergic reactions to topical corticosteroids as the steroid effect persists, pressing the excessive allergic reaction. It is therefore important to be suspicious of any eruption that one would expect to settle, but does not, with the use of topical steroids. Patch testing is usually done with tixocortol pivolate, Budesonide and hydrocortisone butyrate. These are good screening molecules for other steroids.

Occupational Contact Dermatitis
Allergic contact dermatitis is common in certain occupations. Irritant dermatitis is seen in 20% of people who work in the following professions:

Hairdressers
Dentists
Florists
Construction workers

Hairdressers develop irritant dermatitis quite commonly and also react to PPD dyes. They also react to substances such as glycerol, monothioglycerol, and nickel, which are found in perms. Dentists can become allergic to the acrylic cements as well as anesthetics. Glutaraldehyde, used in cold sterilization, can also be a problem. Florists develop both allergic and irritant contact dermatitis. Patch testing is usually required although the most common reaction is to sesquiterpene lactone.

Sunscreen Allergies
Allergies to sunscreen are seen. These can be irritant, allergic, or photo-allergic.

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