Eczema

Background

The word eczema is derived from a Greek word which means boiling over. It is a clinical diagnosis with a very broad range of diseases which can elicit this condition. Clinically, there is weeping of the skin with small vesicle formation. The histologic correlate is a spongiotic dermatitis. It is characterized by intercellular edema which causes widening between keratinocytes. In time, this widening may lead to intraepidermal vesicles and occasionally bullae formation. As the spongiosis and vesicles resolve, parakeratosis forms above the areas of spongiosis. Spongiosis may be seen in combination with all inflammatory skin histopathologic reaction patterns. There are many conditions which may mimic eczema including viral exanthems and drug eruptions. The pathologist faces a daunting task of searching for subtle clues which may lead to a correct diagnosis. Frequently, however, the pathologist relies on the clinical history provided by the treating physician and may make a diagnosis of a spongiotic dermatitis with features consistent with...(name of disease). A persistent eczema may sometimes be biopsied to exclude the possibility of mycosis fungoides, a cutaneous T-cell lymphoma.

Eczematous Disorders
Actinic reticuloid
Allergic contact dermatitis
Arthropod bites
Atopic dermatitis
Autoeczematization (Id reaction)
Blaschko dermatitis
Chronic superficial dermatitis
Dermatophytoses
Erythema annulare centrifugum
Erythroderma
Grover's disease
Hyperkeratotic dermatitis of the hands
Irritant contact dermatitis
Juvenile plantar dermatitis
Mycosis fungoides
Nummular dermatitis
Papular acrodermatitis of childhood
Photoallergic dermatitis
Phototoxic dermatitis
Pigmented purpuric dermatoses
Pityriasis alba
Pityriasis rosea
Polymorphous light eruption
Pompholyx (Dyshidrotic eczema)
Protein contact dermatitis
Spongiotic drug reaction
Stasis dermatitis
Sulzeberger-Garbe syndrome
Seborrheic dermatitis
Toxic erythema of pregnancy
Toxic shock syndrome
Vein graft donor-site dermatitis

In addition to these disorders, there are at least three other histologic patterns which may present with eczema but have different histologic presentations. These are eosinophilic spongiosis, miliarial spongiosis, and follicular spongiosis. Some of these disorders overlap in multiple categories.

Eosinophilic Spongiosis
Allergic contact dermatitis
Atopic dermatitis
Arthropod bites
Bullous pemphigoid
Cicatricial pemphigoid
Drug reactions
Eosinophilic folliculitis (Ofuji's disease)
Herpes gestationis
Id reaction
Idiopathic eosinophilic spongiosis
Incontinentia pigmenti (first stage)
Pemphigus (precursor urticarial stage)
Pemphigus vegetans

Miliarial Spongiosis (Spongiosis centered upon the acrosyringium)
Miliaria crystallina
Miliaria profunda
Miliaria rubra

Follicular Spongiosis (Spongiosis centered upon the follicular infundibulum)
Infundibulofolliculitis
Atopic dermatitis
Apocrine miliaria
Eosinophilic folliculitis

OUTLINE

Disease Associations

Gross Appearance and Clinical Variants

Prognosis

Treatment

Commonly Used Terms

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DISEASE ASSOCIATIONS CHARACTERIZATION

MELANOCYTIC NEVI

Is high mole count a marker of more than melanoma risk? Eczema diagnosis is associated with melanocytic nevi in children.

Dellavalle RP, Hester EJ, Stegner DL, Deas AM, Pacheco TR, Mokrohisky S, Morelli JG, Crane LA.

Veterans Affairs Medical Center, Department of Dermatology, University of Colorado, Denver, CO 80262, USA.

Arch Dermatol. 2004 May;140(5):577-80. Abstract quote

BACKGROUND: The number of melanocytic nevi is the best single marker of increased melanoma risk. In a previous study, adults with severe eczema were reported to have significantly fewer nevi than adults without eczema.

OBSERVATIONS: In a nested case-control design within a randomized, controlled interventional trial of additional sun protection vs standard care in 269 children, a history of eczema was reported by the parents of 44 (16%) of the children. More nevi were found in children with a parental report of previous eczema diagnosis than in children without reported eczema (median, 7.5 nevi vs 5.0 nevi; P =.01). Eczema diagnosis was most significantly associated with more melanocytic nevi in children with lightly pigmented skin (8.5 nevi vs 6.0 nevi; P <.001). In multivariate logistical regression analysis, including assessment of hair color, sun protection practices, and study assignment (intervention vs standard care), eczema status remained significantly predictive of nevi number in children (P <.001).

CONCLUSIONS: In contrast to a previous study that associated severe eczema with fewer nevi in adults, in the present study children with a reported history of eczema had more nevi than children without a reported history of eczema.

CLINICAL VARIANTS CHARACTERIZATION

FOOT DERMATITIS

The etiology of allergic-appearing foot dermatitis: A 5-year retrospective study.

Shackelford KE, Belsito DV.

Division of Dermatology, University of Kansas Medical Center.
J Am Acad Dermatol 2002 Nov;47(5):715-21 Abstract quote
OBJECTIVES: The objectives of this 5-year retrospective investigation were threefold. (1) Among patients with dermatitis of the feet consistent with allergic contact dermatitis (ACD), what were the final diagnoses of those with dermatitis only on the feet and those whose foot dermatitis was accompanied by other cutaneous involvement? (2) Among those patients determined to have ACD, what were the relevant allergens? (3) Have the allergens in shoes in the United States changed as a consequence of modifications in footwear manufacture and style design?

METHODS: Of 704 patients patch-tested at the University of Kansas Medical Center with the North American Contact Dermatitis Group's standard allergen tray and/or the University of Kansas "shoe and rubber" tray, 70 patients presented with a clinical pattern suggestive of ACD of the foot.

RESULTS: Compared with those without foot dermatitis, these patients were more likely to be atopic and male with bimodal age distribution: <19 and 41 to 60 years. Despite clinical evidence suggesting allergy, only 23 (32.9%) patients had ACD to components of shoes, whereas 30 (42.9%) had psoriasis. Among the remaining patients, 4 (5.7%) had a non-shoe allergy, 3 (4.3%) had dyshidrosis, 2 (2.9%) had nummular dermatitis, 2 (2.9%) had tinea pedis, and 1 (1.4%) each had pityriasis rubra pilaris, juvenile plantar dermatosis, atopy, id reaction, and traumatic/frictional dermatitis as their primary diagnosis. One patient had not received a diagnosis when last seen.

CONCLUSIONS: When evaluated by sites of involvement, psoriasis was diagnosed as often as ACD to shoes when the dermatitis was confined to the foot but was more frequent than ACD when both the hands and feet were involved. With respect to shoe dermatitis, rubber components were the principal allergens, followed by chromated leather and adhesives. Iatrogenic ACD was also common, and among all allergens, bacitracin caused the most frequently observed relevant reaction.

PROGNOSIS AND TREATMENT CHARACTERIZATION

PROGNOSIS

Scalpdex: A Quality-of-Life Instrument for Scalp Dermatitis.

Chen SC, Yeung J, Chren MM.

Department of Dermatology and Emory Center for Outcomes Research, 1639 Pierce Dr, 5001 Woodruff Memorial Building, Atlanta, GA 30033.
Arch Dermatol 2002 Jun;138(6):803-7 Abstract quote
OBJECTIVE: To develop a scalp dermatitis-specific quality-of-life instrument.

METHODS: Based on the results of directed focus sessions with 8 patients with scalp psoriasis or seborrheic dermatitis, we conceptualized 3 major constructs that explain the way scalp dermatoses affect patient quality of life: symptoms, functioning, and emotions. We constructed a 23-item instrument, Scalpdex, and tested its reliability, responsiveness, and validity.

RESULTS: Fifty-two dermatology patients completed the study. We demonstrated construct validity by confirming that the factors derived by principal axes factor analyses with orthogonal rotation correlated to our hypothesized scales (r = 0.76-0.84) and that differences in symptom, functioning, and emotion scores differed among the varying levels of self-reported scalp severity more than would be expected by chance (P<.05 by analysis of variance). The instrument demonstrated reliability with internal consistency (Cronbach alpha, 0.62-0.80) and reproducibility (intraclass correlation coefficient, 0.90-0.97). The quality-of-life scores changed in the expected direction in our test for responsiveness (P</=.05, by paired t test for functioning and emotion for those who improved). We ascertained the discriminant capability of Scalpdex compared with a dermatological generic quality-of-life tool, Skindex, by demonstrating superior responsiveness (P</=.005 by paired t test in functioning and emotion) and improved overall sensitivity in individual items.

CONCLUSIONS: Scalpdex is, to our knowledge, the first quality-of-life instrument specifically for patients with scalp dermatitis that is reliable, valid, and responsive. Clinicians can use the instrument to determine which aspect of the disease most bothers the patient and to evaluate quality of life as one variable of responsiveness to the therapeutic intervention.

TREATMENT

BOTULINUM TOXIN

Treatment of dyshidrotic hand dermatitis with intradermal botulinum toxin.

Swartling C, Naver H, Lindberg M, Anveden I.

Department of Medical Sciences, Dermatovenereology, and the Department of Neuroscience, Neurology, Uppsala University, and the Department of Medicine, Occupational and Environmental Dermatology, Karolinska Institutet, Stockholm
J Am Acad Dermatol 2002 Nov;47(5):667-71 Abstract quote
BACKGROUND: Botulinum toxin (Btx A) has recently been used in the treatment of focal hyperhidrosis. Hyperhidrosis is also an aggravating factor in nearly 40% of patients with dyshidrotic hand eczema.

OBJECTIVE: The objective of this study was to evaluate the effect of intradermal injections of Btx A on dermatitis in patients with vesicular hand dermatitis.

METHODS: Ten patients with vesicular dermatitis were treated on one hand with intradermal Btx A (mean, 162 U BOTOX, Allergan Pharmaceuticals, Irvine, Calif) with the untreated side as a control.

RESULTS: Self-assessment at follow-up 5 to 6 weeks after injection on a 5-point scale (none, slight, moderate, good, or very good effect) showed that 7 of 10 patients experienced good or very good effect. A decrease in itching was shown with a visual linear analogue scale (VAS) for itching, with mean 39% on the treated side compared with an increase by 52% on the untreated side. These findings were supported by the evaluation of clinical signs. Six of 7 patients who experienced good or very good effect also had aggravating hand sweating or worsening during the summer.

CONCLUSION: Btx A can be a valuable alternative for patients with treatment-refractory hand eczema of the vesicular type, especially with hyperhidrosis or worsening during the summer.

METHOTREXATE

Experience with low-dose methotrexate for the treatment of eczema in the elderly.

Shaffrali FC, Colver GB, Messenger AG, Gawkrodger DJ.

Departments of Dermatology, Royal Hallamshire Hospital, Sheffield, England.
J Am Acad Dermatol 2003 Mar;48(3):417-9 Abstract quote
There is very little published information on the use of methotrexate in treating eczema.

We have used methotrexate in 5 elderly patients with eczema, with a successful response in 4; in 1 patient therapy was stopped as a result of other ongoing medical problems.

Methotrexate can be considered as an option in the treatment of eczema unresponsive to topical therapy in elderly patients.

TACROLIMUS

Topical tacrolimus (FK506) and mometasone furoate in treatment of dyshidrotic palmar eczema: A randomized, observer-blinded trial

Christina Schnopp, MD
Roland Remling, MD
Matthias M�hrenschlager, MD
Lorenz Weigl, MD
Johannes Ring, PhD, MD
Dietrich Abeck, MD

Munich, Germany

J Am Acad Dermatol 2002;46:73-7 Abstract quote

Background: Dyshidrotic palmoplantar eczema is a frequent disease often running a chronic relapsing course. Topical glucocorticosteroids form the mainstay of therapy, and alternatives are urgently warranted.

Objective: This study was performed to compare the efficacy of tacrolimus (FK506) 0.1% ointment and mometasone furoate 0.1% ointment in the treatment of dyshidrotic palmoplantar eczema. Methods: Sixteen patients were included in the study after a randomized, observer-blind, intrapersonal comparison protocol. After a 2-week washout period, the active treatment phase amounted to 4 weeks with twice-daily topical application of test substances and additional use of emollients at will. Thereafter, patients were monitored at weekly intervals up to 8 weeks.

Results: The dyshidrotic area and severity index showed a more than 50% reduction of baseline values after 2 weeks of active treatment both for FK506 (P = .003) and mometasone furoate (P = .022) in palmar areas. After active treatment, a nonsignificant increase in the dyshidrotic area and severity index was seen with FK506 treated areas. Fourteen of 16 patients had recurring symptoms requiring further therapy within 3 weeks after the active treatment phase.

Conclusion: Treatment with FK506 offers the possibility for rotational therapy with mometasone furoate in long-standing cases of chronic dyshidrotic palmar eczema.

Weedon D. Weedon's Skin Pathology. Churchill Livingstone. 1997.
Fitzpatrick's Dermatology in General Medicine. 5th Edition. McGraw-Hill. 1999.

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Last Updated 6/7/2004

PROGNOSIS AND TREATMENT	CHARACTERIZATION
PROGNOSIS
Scalpdex: A Quality-of-Life Instrument for Scalp Dermatitis. Chen SC, Yeung J, Chren MM. Department of Dermatology and Emory Center for Outcomes Research, 1639 Pierce Dr, 5001 Woodruff Memorial Building, Atlanta, GA 30033.	Arch Dermatol 2002 Jun;138(6):803-7 Abstract quote OBJECTIVE: To develop a scalp dermatitis-specific quality-of-life instrument. METHODS: Based on the results of directed focus sessions with 8 patients with scalp psoriasis or seborrheic dermatitis, we conceptualized 3 major constructs that explain the way scalp dermatoses affect patient quality of life: symptoms, functioning, and emotions. We constructed a 23-item instrument, Scalpdex, and tested its reliability, responsiveness, and validity. RESULTS: Fifty-two dermatology patients completed the study. We demonstrated construct validity by confirming that the factors derived by principal axes factor analyses with orthogonal rotation correlated to our hypothesized scales (r = 0.76-0.84) and that differences in symptom, functioning, and emotion scores differed among the varying levels of self-reported scalp severity more than would be expected by chance (P<.05 by analysis of variance). The instrument demonstrated reliability with internal consistency (Cronbach alpha, 0.62-0.80) and reproducibility (intraclass correlation coefficient, 0.90-0.97). The quality-of-life scores changed in the expected direction in our test for responsiveness (P</=.05, by paired t test for functioning and emotion for those who improved). We ascertained the discriminant capability of Scalpdex compared with a dermatological generic quality-of-life tool, Skindex, by demonstrating superior responsiveness (P</=.005 by paired t test in functioning and emotion) and improved overall sensitivity in individual items. CONCLUSIONS: Scalpdex is, to our knowledge, the first quality-of-life instrument specifically for patients with scalp dermatitis that is reliable, valid, and responsive. Clinicians can use the instrument to determine which aspect of the disease most bothers the patient and to evaluate quality of life as one variable of responsiveness to the therapeutic intervention.
TREATMENT
BOTULINUM TOXIN
Treatment of dyshidrotic hand dermatitis with intradermal botulinum toxin. Swartling C, Naver H, Lindberg M, Anveden I. Department of Medical Sciences, Dermatovenereology, and the Department of Neuroscience, Neurology, Uppsala University, and the Department of Medicine, Occupational and Environmental Dermatology, Karolinska Institutet, Stockholm	J Am Acad Dermatol 2002 Nov;47(5):667-71 Abstract quote BACKGROUND: Botulinum toxin (Btx A) has recently been used in the treatment of focal hyperhidrosis. Hyperhidrosis is also an aggravating factor in nearly 40% of patients with dyshidrotic hand eczema. OBJECTIVE: The objective of this study was to evaluate the effect of intradermal injections of Btx A on dermatitis in patients with vesicular hand dermatitis. METHODS: Ten patients with vesicular dermatitis were treated on one hand with intradermal Btx A (mean, 162 U BOTOX, Allergan Pharmaceuticals, Irvine, Calif) with the untreated side as a control. RESULTS: Self-assessment at follow-up 5 to 6 weeks after injection on a 5-point scale (none, slight, moderate, good, or very good effect) showed that 7 of 10 patients experienced good or very good effect. A decrease in itching was shown with a visual linear analogue scale (VAS) for itching, with mean 39% on the treated side compared with an increase by 52% on the untreated side. These findings were supported by the evaluation of clinical signs. Six of 7 patients who experienced good or very good effect also had aggravating hand sweating or worsening during the summer. CONCLUSION: Btx A can be a valuable alternative for patients with treatment-refractory hand eczema of the vesicular type, especially with hyperhidrosis or worsening during the summer.
METHOTREXATE
Experience with low-dose methotrexate for the treatment of eczema in the elderly. Shaffrali FC, Colver GB, Messenger AG, Gawkrodger DJ. Departments of Dermatology, Royal Hallamshire Hospital, Sheffield, England.	J Am Acad Dermatol 2003 Mar;48(3):417-9 Abstract quote There is very little published information on the use of methotrexate in treating eczema. We have used methotrexate in 5 elderly patients with eczema, with a successful response in 4; in 1 patient therapy was stopped as a result of other ongoing medical problems. Methotrexate can be considered as an option in the treatment of eczema unresponsive to topical therapy in elderly patients.
TACROLIMUS
Topical tacrolimus (FK506) and mometasone furoate in treatment of dyshidrotic palmar eczema: A randomized, observer-blinded trial Christina Schnopp, MD Roland Remling, MD Matthias M�hrenschlager, MD Lorenz Weigl, MD Johannes Ring, PhD, MD Dietrich Abeck, MD Munich, Germany	J Am Acad Dermatol 2002;46:73-7 Abstract quote Background: Dyshidrotic palmoplantar eczema is a frequent disease often running a chronic relapsing course. Topical glucocorticosteroids form the mainstay of therapy, and alternatives are urgently warranted. Objective: This study was performed to compare the efficacy of tacrolimus (FK506) 0.1% ointment and mometasone furoate 0.1% ointment in the treatment of dyshidrotic palmoplantar eczema. Methods: Sixteen patients were included in the study after a randomized, observer-blind, intrapersonal comparison protocol. After a 2-week washout period, the active treatment phase amounted to 4 weeks with twice-daily topical application of test substances and additional use of emollients at will. Thereafter, patients were monitored at weekly intervals up to 8 weeks. Results: The dyshidrotic area and severity index showed a more than 50% reduction of baseline values after 2 weeks of active treatment both for FK506 (P = .003) and mometasone furoate (P = .022) in palmar areas. After active treatment, a nonsignificant increase in the dyshidrotic area and severity index was seen with FK506 treated areas. Fourteen of 16 patients had recurring symptoms requiring further therapy within 3 weeks after the active treatment phase. Conclusion: Treatment with FK506 offers the possibility for rotational therapy with mometasone furoate in long-standing cases of chronic dyshidrotic palmar eczema.

Disease Associations
Gross Appearance and Clinical Variants
Prognosis
Treatment
Commonly Used Terms
Internet Links