Dermatitis/Eczemas
Noreen Heer Nicol
OBJECTIVES
After studying this chapter, the reader will be able to:
Recognize that eczema and dermatitis are terms that describe the same response in the skin.
Define several types of eczemas and their various clinical presentations including atopic dermatitis, seborrheic dermatitis, contact dermatitis (allergic or irritant), and nummular eczema.
Identify the therapeutic interventions frequently used to treat these various eczemas.
Discuss important patient teaching points for managing various eczemas.
KEY POINTS
Dermatitis and eczema are terms that can be used interchangeably to describe a type of inflammatory disease characterized by pruritus and lesions with indistinct borders. They can present in multiple phases including acute, subacute, and chronic.
Atopic dermatitis is a complex, common, chronic, and relapsing skin disorder of infants and children but can affect patients of any age. It is a global health problem.
Seborrheic dermatitis is a common eczematous condition that mainly affects the scalp and other oily areas of the body, such as the face, upper chest, and back.
Contact dermatitis can be divided on the basis of etiology into two types: irritant contact dermatitis and allergic contact dermatitis. Irritant contact dermatitis is more common of the two, accounting for approximately 80% of cases.
Nummular eczema, also called discoid eczema, is a chronic eczematous disorder that causes coin-shaped rashes on the skin.
Good daily skin care, which emphasizes regular use of moisturizers, is the cornerstone to treatment of most eczematous conditions.
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.
II. COMMON THERAPEUTIC MODALITY
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
Box 9-1. Types of Dermatitis (Eczema)
Allergic contact dermatitis (allergic contact eczema). A red, itchy, weepy reaction where the skin has initially come into contact with a substance that the immune system recognizes as foreign, such as poison ivy or certain preservatives in creams and lotions. This is a delayed hypersensitivity reaction.
Atopic dermatitis (atopic eczema). A chronic skin disease characterized by itchy, inflamed skin associated with a personal or family history of asthma, allergic rhinitis, or eczema.
Diaper dermatitis (Diaper rash). An inflammatory reaction localized to the area of skin usually covered by the diaper. It can have many causes, including infections (yeast, bacterial, or viral), friction irritation, chemical allergies (preservatives, perfumes, soaps, etc.), sweat, decomposed urine, and plugged sweat glands.
Dyshidrotic eczema. Irritation of the skin on the palms of the hands and soles of the feet characterized by clear, deep blisters that itch and burn.
Irritant contact dermatitis (irritant contact eczema). A localized reaction that includes redness, itching, and burning where the skin has come into contact with a substance acting as an irritant such as an acid, a cleaning agent, other chemical, or even water.
Neurodermatitis (lichen simplex chronicus). Scaly patches of the skin on the head, lower legs, wrists, or forearms characterized by skin lichenification secondary to excessive scratching and rubbing of the skin.
Nummular eczema (discoid eczema). Coin-shaped patches of irritated skin—most common on the arms, back, buttocks, and lower legs—that may be crusted, scaling, and extremely itchy.
Seborrheic dermatitis (seborrheic eczema). Yellowish, oily, scaly patches of skin on the scalp, face, and occasionally other parts of the body.
Stasis dermatitis. A skin irritation on the lower legs, generally related to circulatory problems, which often presents with hyperpigmented areas.
Xerotic eczema (“xerotic dermatitis,” “eczema craquele,” “asteatotic eczema,” “Winter itch,” and “Winter eczema”). Irritated skin that occurs when the skin becomes abnormally dry, itchy, and cracked. It can appear in red bumpy or scaly.
 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.) |
Box 9-2. Patient Education: All Types of Dermatitis and Eczema
Spend time listening to the patient and/or the parent.
Individualize treatment.
Explain the nature of the disease and clarify that the goal is control, not cure.
Explain the role and the correct use of each therapy, including risks and benefits.
Demonstrate the technique and how much of various topical agents to apply (e.g., emollients, sealers, medications).
Reinforce the need to use emollients frequently and liberally.
Explain the factors that need to be taken into account to decide whether to prescribe topical corticosteroids, topical calcineurin inhibitors, and other systemic therapies:
Patient’s age
Site to be treated
Previous response to other therapies
Extent/severity of disease
Explain how skin infection (bacterial or viral) can cause deterioration in condition, and teach the signs and symptoms of skin infection.
Provide written recommendations with step care moving up and down regarding all therapies including bathing and/or showering.
Include written instructions for prescription as well as over-the-counter products.
Distribute patient-education brochures.
Recommend individualized environmental measures to avoid skin irritants and proven allergens.
Recommend psychosocial support as appropriate.
Adapted from Nicol, N. H. (2005a). Atopic triad: Atopic dermatitis, allergic rhinitis and asthma. American Journal for Nurse Practitioners, (Suppl), 36-40; Nicol, N. H. (2005b). Use of moisturizers in dermatologic disease: The role of healthcare providers in optimizing treatment outcomes. Cutis, 76(Suppl 6), 26-31; Nicol, N. H., & Ersser, S. J. (2010). The role of the nurse educator in managing atopic dermatitis. In M. Boguniewicz (Ed.), Immunology and allergy clinics of North America: Atopic dermatitis (pp. 369-383). Philadelphia, PA: Saunders-Elsevier.
Box 9-3. Basic Principles of Skin Care for Patients with Dermatitis or Eczema
Intact and healthy skin is the body’s first line of defense. Hydration and moisturization will prevent the breakdown of the skin. “Soak and Seal” is the cornerstone to good daily skin care.
Soak by taking at least one bath or shower per day; use warm water, for 10 to 15 minutes.
Use a gentle cleansing bar or wash in the sensitive skin formulation (fragrance-free, dye-free) as needed.
Seal by patting away excess water and immediately (within 3 minutes) apply moisturizer (fragrance-free moisturizers available in one pound jars or large tubes including Aquaphor ointment, Vaniply ointment, Eucerin Creme (various formulations), Vanicream, CeraVe cream, or Cetaphil cream). Vaseline is a good occlusive preparation to seal in but is most effective after bath or shower. Topical maintenance medications may be used in place of moisturizers or sealer when prescribed.
Use moisturizers liberally throughout the day. Moisturizers and sealers should not be applied immediately over any topical medication.
Avoid skin irritants and proven/clinically relevant allergens.
Adapted from Nicol, N. H., & Boguniewicz, M. (2008). Successful strategies in AD management. Dermatology Nursing, (Suppl), 3-19.
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
Box 9-4. Tips for Patients with Dermatitis or Eczema to Reduce Skin Irritation
Recognize that skin sensitivity varies among people and according to their health status.
Avoid skin irritants and proven/clinically relevant allergens.
Learn to read product labels carefully and critically.
Use fragrance-free, dye-free products whenever possible. Recognize that even products labeled as for sensitive skin may have a masking or regular fragrance.
Add a second rinse cycle to ensure removal of detergent. Changing to a liquid and fragrance-free, dye-free detergent may be helpful.
Wear garments that allow air to pass freely to your skin. Open weave, loose-fitting, cotton-blend clothing may be most comfortable.
Work and sleep in comfortable surroundings with a fairly constant temperature and humidity level. Humidifiers remain controversial and should be used with great caution and cleaned very routinely when used.
Keep fingernails very short and smooth to help prevent damage due to scratching.
Carry a small tube of moisturizer/sunscreen at all times. Daycare/school/work should have a separate supply of moisturizer.
After swimming in chlorinated pool or using hot tub, shower or bathe using a gentle cleanser to remove chemicals and then apply moisturizer.
Adapted from Nicol, N. H., & Boguniewicz, M. (2008). Successful strategies in AD management. Dermatology Nursing, (Suppl), 3-19.
Box 9-5. Dermatitis/Eczema Resources and Patient Education
American Academy of Dermatology www.aad.org
American Academy of Allergy, Asthma, and Immunology www.aaaai.org
American Cancer Society www.cancer.org
American College of Allergy, Asthma, and Immunology www.acaai.org
American Skin Association www.americanskin.org
Centers for Disease Control and Prevention www.cdc.gov
Food Allergy and Anaphylaxis Network www.foodallergy.org
National Eczema Association www.nationaleczema.org
National Eczema Society in the United Kingdom www.eczema.org
National Psoriasis Foundation www.psoriasis.org
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) www.niams.nih.gov
The Skin Cancer Foundation www.skincancer.org
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
Box 9-6. Skin Features Associated with Atopic Dermatitis
Atopic pleat (Dennie-Morgan fold)—extra fold of skin that develops under the eye
Cheilitis—inflammation of the skin on and around the lips
Hyperlinear palms—increased number of skin creases on the palms
Hyperpigmented eyelids—eyelids that have become darker in color from inflammation or hay fever
Ichthyosis—dry, rectangular scales on the skin
Keratosis pilaris—small, rough bumps, generally on the face, upper arms, and thighs
Lichenification—thick, leathery skin resulting from constant scratching and rubbing
Papules—small raised bumps that may open when scratched and become crusty and infected
Urticaria—hives (red, raised bumps) that may occur after exposure to an allergen, at the beginning of flares, or after exercise or a hot bath
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.
Box 9-7. Atopic Dermatitis Action Plan
Basic or Daily Care for Patient with Atopic Dermatitis: “Soak and Seal”
Soak by taking at least one bath or shower per day; use warm water, for 10 to 15 minutes.
Use a gentle cleansing bar or wash in the sensitive skin formulation (fragrance-free, dye-free) as needed.
Seal by patting away excess water and immediately (within 3 minutes) apply moisturizer (fragrance-free moisturizers available in one pound jars or large tubes. Moisturizers include Aquaphor ointment, Vaniply ointment, Eucerin Creme (various formulations), Vanicream, CeraVe cream or Cetaphil cream). A sealer (Vaseline is a good occlusive preparation to seal in and is most effective after bath or shower), or maintenance medication if directed. Use moisturizers liberally throughout the day. Moisturizers and sealers should not be applied immediately over any topical medication.
Avoid skin irritants and proven/clinically relevant allergens.
Mild-to-moderate atopic dermatitis
Bathe as above for 10 to 15 minutes in comfortably warm water, one to two times a day.
Use a gentle cleansing bar or wash in the sensitive skin formulation as needed.
Use moisturizers as above to healed and unaffected skin, twice daily especially after baths and at midday total body.
Apply to affected areas of the face, groin, and underarms twice daily especially after baths ___________ (low-potency topical corticosteroid), or __________ (topical calcineurin inhibitor), or other topical preparation as directed __________.
Apply to other affected areas of the body twice daily especially after baths __________ (low- to midpotency topical corticosteroid), or _________ (topical calcineurin inhibitors), or other topical preparation as directed ________.
Other medications as directed: _________ (e.g., oral sedating antihistamines, topical or oral antimicrobial therapy)
Pay close attention to things that seem to irritate the skin or make condition worse.
Moderate-to-severe atopic dermatitis
Bathe as above for 10 to 15 minutes in comfortably warm water, two times a day, in the morning and before bedtime. Your health care provider may recommend dilute bleach baths.
Use a gentle cleansing bar or wash in the sensitive skin formulation as needed. May consider an antibacterial cleanser.
Use moisturizers as above to healed and unaffected skin, twice daily especially after baths and at midday total body.
Apply to affected areas of the face, groin, and underarms twice daily especially after baths _____________________ (low-potency topical corticosteroid), or ________________________ (topical calcineurin inhibitors), or other topical preparation as directed ________________________.
Apply to other affected areas of the body twice daily especially after baths ____________________ (mid- to high-potency topical corticosteroid), or ______________________ (topical calcineurin inhibitor), or other topical preparation as directed ______________________.
Use wet wraps to involved areas selectively as directed per policy and procedure. Wet wraps are left in place at a minimum of 2 hours. If left in place, need to be rewet every 2 to 3 hours. In general, wet wraps should be removed after 4 hours. If patient falls asleep with wet wraps in place, they may be left on overnight. Stop rewetting during the night. Apply moisturizer to total body after wet wraps are removed.
Add other medications as directed: ____________________________ (e.g., oral sedating antihistamines, topical or oral antimicrobial therapy).
Pay close attention to things that irritate skin or make condition worse.
Step down to moderate plan as above as the skin heals.
Adapted from Nicol, N. H., & Boguniewicz, M. (2008). Successful strategies in AD management. Dermatology Nursing, (Suppl), 3-19. This may be modified and used for patient care citing National Jewish Health Atopic Dermatitis Program as source.
 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.) |
Box 9-8. Wet Wrap Therapy Procedure
Wet wrap therapy is to be used to relieve inflammation, itching, and burning of atopic dermatitis.
Wet wraps facilitate the removal of scale and increase penetration of topical medications in the stratum corneum.
Skin protection provided by the wraps allows healing to take place and cooling of the skin.
Wet wrap therapy should only be used during flares of atopic dermatitis under the supervision of a health care provider. They should not be used as routine maintenance therapy.
Supplies:
1. Topical medications and moisturizers
2. Tap water at comfortably warm temperature
3. Basin for dampening of dressings
4. Clean dressings of approximate size to cover involved area
Face: 2 to 3 layers of wet Kerlix gauze held in place with SurgiNet.
Arms, legs, hands, and feet: 2 to 3 layers of wet Kerlix gauze held in place with Ace bandages or tube socks, or cotton gloves, or wet tube socks followed by dry tube socks. Tube socks may be used for wraps for hands and feet, and larger ones work as leg/arm covers.
Total body: Combination of above or wet pajamas or long underwear and turtleneck shirts covered by dry pajamas or sweat suit. Pajamas with feet work well for the outer layer.
4. Blankets to prevent chilling
5. Nonsterile gloves if desired
Procedure
Be certain that the patient’s room is warm and insure privacy. Gather supplies appropriate to the individual.
If wraps are to be applied to a large portion of the body, work with two people if possible. It is necessary to work rapidly to prevent chilling.
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