Definition
A.This pattern of skin inflammation has clinical features of erythema, itching, scaling, lichenification, papules, and vesicles in various combinations. Currently, the term eczema is used interchangeably with dermatitis. Most common variants are atopic dermatitis and atopic eczema. Classification is by cause, either endogenous or exogenous.
Incidence
A.Overall prevalence of all forms of eczema is about 18 in 1,000 in the United States.
B.With atopic dermatitis, 60% of those affected become afflicted between infancy and 12 years of age. It is more common in boys.
Pathogenesis
A.Eczema is characterized by a lymphohistiocytic infiltration around the upper dermal vessels. Epidermal spongiosis or intercellular epidermal edema and inflammation is seen.
Predisposing Factors
A.Family history of atopic triad: Dermatitis, asthma, and allergic rhinitis.
B.Exposure to allergen:
1.Common foods: Cow’s milk, nuts, wheat, soy, and fish.
2.Common environmental allergens: Dust, mold, cat dander, and low humidity (dry air).
C.Exposure to topical medications, most commonly neomycin, lanolin, and topical anesthetics like benzocaine.
D.Skin irritants: Harsh soaps, skin care products with perfumes, chemicals and alcohol, fabrics containing wool, tight clothing
E.Stress.
Common Complaints
Skin changes:
A.Itching, impossible to relieve.
B.Dryness.
C.Discoloration, lichenification, and scaling.
D.Skin thickening.
E.Associated bleeding and oozing skin.
Other Signs and Symptoms
A.Primary lesions, papules, and pustules that may lead to excoriation.
B.Adults will have lesions on face, trunk, neck, and genital area.
C.Other common features include infraorbital fold (Dennie sign), increased palmar creases, facial erythema, and scaling.
Subjective Data
A.Determine whether the onset was sudden or gradual.
B.Ask the patient if the skin is itchy or painful.
C.Assess if there is any associated discharge (blood or pus).
D.Ask if the patient has recently taken any antibiotics, other oral drugs, or topical medications.
E.Ask the patient about use of soaps, creams, or lotions.
F.Assess for any preceding systemic symptoms (fever, sore throat, anorexia, vaginal discharge).
G.Ask the patient about recent travel abroad.
H.Rule out insect bites.
I.Rule out any possible exposure to industrial or domestic toxins.
J.Elicit what precipitates itching.
K.Evaluate for increased stress level at home, work, relationships, and so on.
Physical Examination
A.Check temperature (if indicated).
B.Inspect.
1.Inspect skin for lesions.
2.Recognize bacteria-infected eczema; Staphylococcus aureus is the most common pathogen. It appears with acute weeping dermatitis; crusted, and small, superficial pustules.
Diagnostic Tests
A.Culture skin lesions to determine viral, bacterial, or fungal etiology.
B.Blood work: Serum immunoglobulin E (IgE) is elevated with atopic dermatitis.
Differential Diagnoses
A.Atopic dermatitis, acute or chronic.
B.Allergic or irritant contact dermatitis, acute or chronic.
C.Seborrheic dermatitis.
D.Ichthyosis vulgaris.
E.Bacterial/fungal infections.
F.Neoplastic disease.
G.Immunologic and metabolic disorders.
H.Psoriasis.
I.Scabies.
Plan
A.General interventions:
1.Frequently treat the dry skin with emollients (Aquaphor, Eucerin).
2.Pat, do not rub skin.
3.Avoid wool products and lanolin preparations.
4.Keep fingernails cut short to prevent scratching/scarring skin.
5.May need to treat secondary bacterial infections as appropriate
6.Eliminate trigger foods one at a time for 1 month at a time to see improvement. Begin with eliminating cow’s milk products. Consider soy-based foods instead.
7.Allergy testing may be considered if symptoms continue.
8.Ointments are usually recommended over creams for moisturizing.
B. 
See Section III: Patient Teaching Guide Eczema.
C.Pharmaceutical therapy:
1.Atopic: Acute, adult:
a.Wet dressings with Burow’s solution and changed every 2 to 3 hours.
b.Topical corticosteroid:
i.Mild (low potency): Desonide 0.05% or hydrocortisone 2.5% one to two times per day for 2 to 4 weeks.
ii.Moderate (medium to high potency): Fluocinolone 0.025%, triamcinolone 0.1%, betamethasone dipropionate 0.05% one to two times per day up to 2 weeks.
c.Antihistamine of choice: Cetirizine Hcl (Zyrtec) or diphenhydramine Hcl (Benadryl).
d.Severe cases: Oral steroid—prednisone 1 mg/kg (40–60 mg/d) tapered over 2 to 3 weeks.
2.Atopic: Chronic, adult:
a.Short course of potent topical corticosteroid betamethasone dipropionate (Diprolene) or clobetasol propionate (temovate) twice daily for 7 days
3.Secondary bacterial infections:
a.Antibacterial treatments for secondary bacterial infections: Treat per C&S results:
i.S. aureus:
•Augmentin 875 mg by mouth twice a day for 10 to 14 days.
•Keflex 500 mg by mouth four times a day for 10 to 14 days.
•Erythromycin 500 mg by mouth four times a day for 10 to 14 days or
•Dicloxacillin 250 mg every 6 hours for 10 days.
Follow-Up
A.See patient in office in 1 to 2 weeks and then every month until condition is stabilized.
B.Monitor the patient for superimposed staphylococcal infection; may use oral erythromycin or dicloxacillin.
C.Patient may be seen every 3 to 6 months thereafter for patient education updates.
Consultation/Referral
A.Eczema herpeticum (herpes simplex type 1) may progress rapidly. Refer the patient to a dermatologist.
B.Refer the patient to a dermatologist:
1.Diagnosis is uncertain.
2.Skin eruptions are severe or fail to respond to conservative treatment.
3.If second-line therapies may be required such as phototherapy, cyclosporine, or methotrexate.
Individual Considerations
A.Pregnancy: Avoid oral steroids.
B.Young adults and elderly: Nummular eczema is commonly seen, characterized by coin-shaped vesicles and papules seen on extremities and/or trunk.
C.Geriatrics:
1.Avoid first-generation anticholinergics because of risk of confusion, dry mouth, constipation, and other anti-cholinergic effects or toxicity.
2.Research indicates that atopic dermatitis in elderly patients show high rates of positivity for IgE antibodies against house dust mites and are associated with IgE allergic asthmatic exacerbations. In moderate to severe cases with geriatric patients suffering with atopic dermatitis, oral corticosteroids combined with standard treatments may be needed.
3.Avoid higher potency steroid topicals to face and skin folds of the elderly and use no more than 5 to 7 days. Skin atrophy could result from overuse.