ECZEMA

 Eczema, or dermatitis, terms that are used interchangeably to describe inflammatory skin disease. It represents a reaction pattern to a variety of stimuli, some of which are recognized but many of which are unknown.

The term 'eczema' literally means 'to boil over' (Greek), and this well describes the acute eruption in which blistering occurs.

CLASSIFICATION is as follows :

1. Constitutional or endogenous-

• Atopic ezema
• Seborrhoeic eczema
• Discoid eczema
• Chronic hand/foot eczema
• Venous eczema
• Asteatotic eczema
• lichen simplex

      2.Exogenous or contact

• Irritant contact eczema
• Allergic contact eczema

      3. Duration

• acute, sub acute or chronic

       Fig.1 ,Erythema and oedema are seen with papules, vesicles and
sometimes large blisters.It is painful an pruritic.

IN ACUTE ECZEMA, there occurs epidermal oedema (spongiosis) + separation of keratinocytes = formation of epidermal vesicles. Th dermal vessels dilate and inflammatory cells invade the dermis and epidermis

Fig. 2 Chronic dermatitis. Lichenification, scaling and fissuring of the hands due to repeated exposure to irritants. Allergic contact dermatitis cannot be excluded on the appearance alone.

IN CHRONIC ECZEMA, there is thickening of the prickle cell layer (acanthosis) and stratum 
corneum (hyperkeratosis) with retention of nuclei by some corneocytes (parakeratosis). The rete ridges are lengthened, dermal vessels dilated and inflammatory mononuclear cells infiltrate the skin

Atopic eczema

It is a chronic pruritic inflammation of the epidermis and dermis, which is often associated with a personal or family history of asthma, allergic rhinitis, conjunctivitis or atopic eczema. Uncontrollable scratching is prominent in this case.

 Aetiopathogenesis- it defines an inherited tendency, present in 15-25% of the population, to produce high levels of circulating IgE antibodies, commonly to inhalant allergens (e.g. house dust mite). A Th2 cell response seems to be predominant over Thl and the resultant cytokine profile favours IgE production. 

Incidence About 12-15% of infants are affected. It usually starts within the first 6 months of life, and by 1 year, 60% of those likely to develop it will have done so. Two-thirds have a family history of atopy. Remission occurs by the age of 15 years in 75%, although some relapse later.

fig 3

CLINICAL PRESENTATION:

 1. Infancy Babies develop an itchy vesicular exudative eczema on the face (Fig. 3) and hands, often with secondary infection. Less than half continue to have eczema beyond 18 months. 

fig.4

fig.5

.Childhood After 18 months, the pattern often changes to the familiar involvement of the antecubital and popliteal fossae (fig4), neck, wrists and ankles. The face often shows erythema and infraorbital folds. 

Lichenification, excoriations and dry skin (Fig. 5) are common, and palmar markings may be increased. Post-inflammatory hyperpigmentation occurs in those with a pigmented skin. Scratching or rubbing cause most of the clinical signs and are particularly a problem at night when they can interfere with sleep.

3.Adults The commonest manifestation in adult life is hand dermatitis, exacerbated by irritants, in someone with a past history of atopic eczema. However, a small number of adults have a chronic severe form of generalized and lichenified atopic eczema which may interfere with their employment and social activities. Stressful situations, such as examinations or marital problems, often coincide with exacerbations. 

SEBORRHOEIC ECZEMA

It is a chronic, scaly inflammatory eruption usually affecting the scalp and face. 

Aetiopathogenesis Sebum production is normal, but the eruption often occurs in the sebaceous gland areas of the scalp, face and chest. Endogenous and genetic factors, and an overgrowth of the commensal yeast Pityrosporum ovale, are involved. 

fig.6

fig 7

 

fig 8

fig 9
PITYROSPORUM FOLLICULITIS

 Clinical presentation There are four common patterns: • Scalp and facial involvement: excessive dandruff, with an itchy scaly erythematous eruption affecting the sides of the nose, scalp margin, eyebrows and ears (Fig. 7,8)• Blepharitis may occur. Most common in young adult males. • Petaloid: a dry scaly eczema over the presternal area. « Pityrosporum folliculitis: an erythematous follicular eruption with papules or pustules over the back (Fig. 9). • Flexural: involvement of the axillae, groins and sub-mammary areas by a moist intertrigo, often secondarily colonized by Candida albicans. Seen in the elderly (do not confuse with the similarly named infantile eruption.

fig.10

DISCOID ECZEMA

It is an eczema of unknown aetiology characterized by coin shaped lesions; symmetrical and intensely itchy; may be vesicular or chronic and lichenified. Typically, affects middle aged or elderly men.

VENOUS ECZEMA

fig.11

It affects the lower legs (Fig. 11) and is associated with underlying venous disease. Incompetence of the deep perforating veins increases the hydrostatic pressure in the dermal capillaries. Peri-capillary fibrin deposition leads to the clinical changes. Most patients are middle-aged or elderly women. Leashes of venules and haemosiderin pigmentation around the ankles are early signs. Eczema develops, sometimes with fibrosis of the dermis and subcutaneous tissue ,(lipodermatosclerosis), and ulceration.

ASTEATOTIC ECZEMA

FIG 12 Asteatotic czema

Asteatotic eczema (eczema craquele) is a dry eczema with fissuring and cracking of the skin, often affecting limbs in the elderly (Fig. 12). Overwashing of patients in institutions, a dry winter climate, hypothyroidism and use of diuretics, can contribute to eczema in elderly atrophic skin. The skin of the limbs and trunk is erythematous, dry and itchy and shows a fine crazy-paving pattern of fissuring. 

Lichen simplex chronicus (neurodermatitis) 

fig 13 (neurodermatitis)

 Neuro dermatitis is an area of lichenified eczema due to repeated rubbing or scratching, as a habit or due to 'stress'. It usually occurs as a single plaque on the lower leg, back of the neck or in the perineum. The skin markings are exaggerated and pigmentation may occur. Asians and Chinese are particularly susceptible. Sometimes a nodular lichenification known as prurigo nodularis develops on the shins and forearms. 

CONTACT DERMATITIS

Dermatitis that is precipitated by an exogenous agent, often a chemical, is known as contact dermatitis. It is particularly common in the home, amongst women with young children, and in industry .

Aetiopathogenesis - Irritants cause more cases of contact dermatitis than do allergens, although the clinical appearances are often similar. Allergic contact dermatitis is an example of type IV hypersensitivity.

Irritants cause dermatitis in a number of different ways, but usually by a direct noxious effect on the skin's barrier function. The most important irritants are: 

•  water and other fluids 
• abrasives i.e. frictional irritancy
•  chemicals, e.g. acids and alkalis
•  solvents and detergents.                         

     A strong irritant causing necrosis of epidermal cells will produce a reaction within hours, but in most cases the effect is more chronic. Repetitive and cumulative exposure over several months or years to water, abrasives and chemicals can induce dermatitis, commonly on the hands. Individuals with a history of atopic eczema are more susceptible to irritants.

 Clinical presentation- Contact dermatitis may affect any part of the body, although the hands and face are common sites. The appearance of a dermatitis at a particular site (Fig. 4) suggests contact with certain objects.

fig.14 allergic contact dermatitis to henna

fig.15  allergic contact dermatitis to tattoo

Diagnosis is often not easy as a history of irritant or allergen exposure is not always forthcoming. Knowing the patient's occupation, hobbies, past history and use of cosmetics or medicaments helps in listing possible causes. Nickel sensitivity is the commonest contact allergy, affecting 10% of women and 1% of men. Usually it only causes an inconvenient eczema at jewellery or metal contact sites. Medicaments and cosmetics can also induce allergic or irritant reactions. 

Differential diagnosis Contact dermatitis of the hands needs to be differentiated from endogenous eczema, latex contact urticaria, psoriasis and fungal infection. Acute Contact dermatitis contact dermatitis of the face may resemble angioedema or erysipelas.

HOMOEOPATHIC TREATMENT

Acet-ac., acon., agar., agn., alum., alumn., am-c., am-m., ambr., anac., ant-c., ant-t., apis., arg-m., arn., Ars-i., Ars., arund., asaf., asar., aster., aur., Bar-c., bar-m., bell., bism., bor., bov., bry., calad., Calc-s., Calc., camph., cann-s., canth., caps., carb-an., carb-s., carb-v., Caust., cham., chel., chin-a., chin-s., chin., chlor., cic., cimic., cina., cist., clem., cob., cocc., coff., colch., coloc., con., cop., croc., crot-t., cupr., cycl., dig., dros., dulc., elaps., eupho., euphr., fl-ac., graph., guai., hell., hep., hyos., ign., iod., ip., Jug-c., Jug-r., kali-ar., kali-bi., kali-br., Kali-c., kali-n., kali-p., Kali-s., kreos., lach., laur., led., Lyc., mag-c., Merc., Mez., mosch., mur-ac., nat-a., nat-c., Nat-m., nat-p., nit-ac., olnd., op., par., Petr., ph-ac., phos., plat., plb., Psor., puls., ran-b., ran-s., rheum., rhod., Rhus-t., rhus-v., rumx., ruta., sabad., samb., sars., sec., sel., seneg., Sep., Sil., spig., spong., squil., stann., staph., stram., stront., sul-ac., sul-i., Sulph., tarax., teucr., thuj., tub., valer., verat., verb., viol-t., zinc.

There are a lot of medicines for the treatment of eczema, but homoeopathy works on the basis of individuality. So, the remedy varies from one individual to another. Still, on general , most often used medicines for the treatment of eczema are as follows:

1. Sulphur- It is the best remedy for treating eczema associated with severe itching causing intense scratching. For eczema that have been treated with ointments. Burning sensation after too much scratching. complaints increases in warmth and moisture.Dry, scaly, unhealthy; every little injury suppurates. Pimply eruption, pustules, rhagades, hang-nails. Excoriation, especially in folds. often recurs in spring-time, in damp weather.
2. Graphites-  Rough, hard, persistent dryness of portions of skin unaffected by eczema. Early stage of keloid and fibroma. Pimples and acne. Eruptions, oozing out a sticky exudation. Rawness in bends of limbs, groins, neck, behind ears. Unhealthy skin; every little injury suppurates. Ulcers discharging a glutinous fluid, thin and sticky. Swelling and induration of glands. Gouty nodosities. Cracks in nipples, mouth, between toes, anus. Phlegmonous erysipelas of face; burning and stinging pain.
3. Mezereum- Eczema; intolerable itching; chilliness with pruritus; worse in bed. Ulcers itch and burn, surrounded by vesicles and shining, fiery-red areola. Zona, with burning pain.vBones, especially long bones, inflamed and swollen; caries, exostosis; pain worse night, touch, damp weather. Eruptions ulcerate and form thick scabs under purulent matter exudes
4. Petroleum- Itching at night. Chilblains, moist, itch and burn. Bed-sores. Skin dry, constricted, very sensitive, rough and cracked, leathery. Herpes. Slightest scratch makes skin suppurate. Intertrigo; psoriasis of hands. Thick, greenish crusts, burning and itching; redness, raw; cracks bleed easily. Eczema. Rhagades worse in winter.
5. Natrum mur- Greasy, oily, especially on hairy parts. Dry eruptions, especially on margin of hairy scalp and bends of joints. Fever blisters. Urticaria; itch and burn. Crusty eruptions inbends of limbs, margin of scalp, behind ear. Warts on palms of hands. Eczema; raw, red, and inflamed; worse, eating salt, at seashore. Affects hair follicles. Alopecia. Hives, itching after exertion. Greasy skin.

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