Dermatitis/Eczemas



Dermatitis/Eczemas


Noreen Heer Nicol






DERMATITIS AND ECZEMA


I. OVERVIEW

A. Dermatitis and eczema are two general terms that are generally interchangeable and describe a particular type of inflammatory response in the skin.

B. Diseases that are considered eczematous disorders are generally characterized by pruritus, lesions with indistinct borders, and epidermal changes.

C. These lesions can appear as erythema, papules, or lichenification of the skin.

D. The disorder presents in an acute, subacute, or chronic phase.

E. The inflammatory process of eczema or dermatitis takes place primarily at the level of the epidermis; however, the dermis can be involved.

F. There are many different types of eczema or dermatitis (Box 9-1, Figure 9-1).


II. COMMON THERAPEUTIC MODALITY

Basic Skin Care for All Patients with Dermatitis or Eczema (Boxes 9-2 and 9-3).

A. Methods of skin hydration and moisturization

B. Proper methods of application of medications

C. Ways to incorporate treatments into daily routines

Tips for All Patients with Dermatitis or Eczema to Reduce Skin Irritation (Box 9-4)

III. RESOURCES FOR ALL TYPES OF DERMATITIS AND ECZEMA (BOX 9-5)


ATOPIC DERMATITIS


I. OVERVIEW

A. Definition

1. AD is the most common chronic, relapsing inflammatory skin disease of children and is a global health problem.

2. The disorder leads to pruritus and disruption of the skin surface.

3. The disease is usually associated with a personal or family history of asthma, allergic rhinitis, or eczema.

B. Etiology

1. The exact pathogenesis is unknown.

2. Commonly, there is a family history of AD, asthma, and/or allergic rhinitis and/or food allergy.

3. Precipitating factors in AD.

a. Genetic predisposition

b. Age








FIGURE 9-1. Contact dermatitis. A. Allergic contact dermatitis results when a substance comes in direct contact with the skin, leading to a simple inflammatory reaction. B. Irritant contact dermatitis results when the substance causes direct skin damage, pain, or ulceration, such as with tight shoes or prolonged use of latex gloves. (From Cohen, B. J., & DePetris, A. (2013). Medical terminology. Philadelphia, PA: Wolters Kluwer.)




c. Emotional stress

d. Lifestyle

e. Irritants including course clothing such as wool and some synthetic fabrics, sweating, drying cleansers, cosmetics, or other topical preparations

f. Climate and extremes in temperature and humidity: hot/humid or cold/dry



g. Proven and clinically relevant environmental allergens (e.g., dust mite, cat, contact allergens including chemicals)

h. Proven and clinically relevant food allergens (e.g., milk, soy, egg, wheat, fish, and nuts)

C. Pathogenesis

1. Skin barrier abnormalities.

2. T-cell activation.

3. Th1/Th2 cytokine imbalance.

4. Increased IgE production.

5. Staphylococcal aureus and staphylococcal toxins trigger several processes.

D. Incidence

1. The prevalence has increased to at least 20% in children and approximately 3% of adults in the United States and other industrialized countries.

2. Fifty percent of patients with AD go on to develop respiratory manifestations of asthma or allergic rhinitis.

a. Onset of clinical manifestations before 5 years of age in almost 90% of cases

b. Almost 75% of all cases clear by adolescence but can reoccur in adults.


II. ASSESSMENT

A. Clinical manifestations

1. Characterized by basic diagnostic criteria: patient must have three or more basic features (a to d) listed below.

a. Pruritus







FIGURE 9-2. Distribution of infant atopic dermatitis occurs primarily on the face and scalp and extensor surfaces of the extremities. Diaper areas are usually clear. (From Nettina, S. M. (2009). Lippincott manual of nursing practice (9th ed.). Philadelphia, PA: Wolters Kluwer.)

b. Typical morphology and distribution:

(1) Facial and extensor involvement in infants and children. In infants and young children with AD, involvement is commonly present on the scalp, face (cheeks and chin), and extensor surfaces of the extremities (Figures 9-2 and 9-3). Tends to be symmetrical. Is more pronounced in areas not covered by clothing. Diaper area is generally clear in infants.

(2) Flexural lichenification in adults. Older children and adults typically have involvement of the flexor surfaces (antecubital and popliteal fossa), neck, wrists, and ankles (Figures 9-4 and 9-5). In adults, the hands and feet frequently are involved. The flexor surfaces tend to have greater involvement in older patients.






FIGURE 9-3. Infantile atopic dermatitis of the head (A) and of the limbs (B). (Courtesy of Schering.)






FIGURE 9-4. Distribution of atopic dermatitis in older children and adults typically has involvement of the flexor surfaces (antecubital and popliteal fossa), neck, wrists, and ankles. (Courtesy of Noreen Heer Nicol, PhD, RN.)

c. Chronic or chronically relapsing dermatitis

d. Personal or family history of atopy (asthma, allergic rhinitis, AD)

2. Other common skin features associated with AD are listed in Box 9-6.

3. Severity ranges from mild to severe and tends to wax and wane with seasonal variation in select patients, often worsening in the winter due increased dryness.

4. Primary lesions.

a. Some believe no primary lesion can be identified and that all visible skin lesions in AD are secondary to scratching.

b. Erythematous papules that may coalesce or dry scaly patches







FIGURE 9-5. Atopic dermatitis of antecubital fossae with lichenification. (From Goodheart, H. P. (2010). Goodheart’s same-site differential diagnosis: A rapid method of diagnosing and treating common skin disorders. Philadelphia, PA: Wolters Kluwer.)

5. Secondary lesions.

a. Scale

b. Excoriations

c. Lichenification

d. White dermatographism

6. Complications.

a. Secondary bacterial infection usually caused by S. aureus

b. Eczema herpeticum as well as other viral and fungal infections including molluscum and tinea

B. Differential diagnoses

1. Allergic contact dermatitis

2. Immunodeficiency

3. Irritant contact dermatitis

4. Lichen simplex chronicus

5. Mollusca contagiosa with dermatitis


6. Mycosis fungoides (cutaneous T-cell lymphoma)

7. Nummular dermatitis

8. Plaque psoriasis

9. Relative zinc deficiency

10. Scabies

11. Seborrheic dermatitis

12. Tinea corporis

C. Diagnostic tests

1. Serum IgE tests are frequently elevated but are not helpful diagnostically.

2. Allergy testing when allergies are suspected. Prick skin testing, patch testing, and in vitro testing can be useful in assessing triggers. Clinical correlation with allergy results and patient’s exposure to these triggers are necessary prior to any restrictions.

3. Skin cultures and sensitivities in cases of suspected secondary infection.


III. COMMON THERAPEUTIC MODALITIES

A. Treatment

1. Interventions: see Atopic Dermatitis Action Plan (Box 9-7).

a. Relief of xerosis: soak and seal

(1) Soak by taking a bath or shower at least once per day. Use warm, not hot, water for 15 to 20 minutes. Avoid scrubbing skin with a washcloth. Bath time should be relaxing and enjoyable for children and adults alike (Figure 9-6).

(2) Use a gentle cleansing bar or wash such as Dove, Oil of Olay, Eucerin, Basis, Cetaphil, or Aveeno. During a severe flare, limit the use of cleansers to avoid possible irritation. Gentle cleansers are generally perfume-free and dye-free.

(3) Seal by patting gently away excess water after the bath or shower and immediately applying the moisturizer or the special skin medications prescribed onto damp skin. This will seal in the water and make the skin less dry and itchy. Moisturizers should not be applied over the medications. Vaseline is a good occlusive preparation to seal in the water; however, it contains no water, so it only works effectively after a soaking bath. Recommended moisturizers include Aquaphor Ointment, Eucerin Creme, Vanicream, Cetaphil Cream, CeraVe Cream, or Aveeno Cream (Figure 9-7).

(4) Wet wrap therapy twice a day when severe or overnight to treat moderate-to-severe AD with multiple excoriations, crusting, and weeping lesions (Box 9-8, Figure 9-8).

(a) Wet one pair of cotton sleepers, pajamas, or long underwear in warm water, wring out until damp, and put on immediately after applying topical medications.

(b) Special layering when facial wraps required.

(c) Place a dry layer on top of the damp ones.

(d) Not to be used as preventive or maintenance therapy.








FIGURE 9-6. Soak in warm water for 15 to 20 minutes. (Courtesy of Noreen Heer Nicol, PhD, RN.)






FIGURE 9-7. Seal with appropriate topicals and moisturizers immediately after bathing. (Courtesy of Noreen Heer Nicol, PhD, RN.)


Mar 9, 2021 | Posted by in NURSING | Comments Off on Dermatitis/Eczemas
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