Eczema, Two Thousand Rashes and Three Creams

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Eczema, Two Thousand Rashes and Three Creams

• A Dermatology Primer for
• Mid Level Practitioners

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Critical components of the physical exam of the
skin should include

• Type
• Color
• Shape
• Arrangement
• Duration
• Distribution

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Adequate history should include

• Skin symptoms
• Constitutional symptoms
• Travel/Occupation
• Systems review
• Self care

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Types of lesions

• Macule
• Papule-plaque
• Wheal
• Nodule
• Cyst
• Vesicle-bulla
• Ulcer

• Pustules
• Hyperkeratosis
• Exudative dry/wet
• Erosion
• Scar
• Lichenification

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Shapes of Lesions

• The shape of a lesion frequently gives clues to
  the etiology of the skin lesion.
• Shapes include lesions that are round,
  polygonal, polycyclic, annular, iris,
  serpiginous, umbilicated,and target.
• Margination is also important are the lesions
  well or ill defined
• Arrangement are the lesions grouped or
  disseminated

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Distribution of Lesions

• A significant number of skin diseases are limited
  to specific regions of the body
• Are the lesions isolated, localized, regional, or
  generalized
• Are the lesions symmetrical limited to exposed
  areas, sites of pressure, or intertriginous areas

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Eczema - Common Definitions

• Any itching rash
• Any red itching rash
• Any red itching rash that has scales or is dry
• The itch that rashes
• Any rash that cannot otherwise be identified

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Eczema-Dermatological Definition

• An acute, subacute but usually chronic pruritic
  inflammation of the epidermis and the dermis,
  often occurring in association with a personal
  family history of hay fever, asthma, allergic
  rhinitis or atopic dermatitis. 1
• 1 Color Atlas and Synopsis of Clinical
  Dermatology

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Characteristics of Acute Eczema

• Well demarcated plaques of erythema and edema on
  which are superimposed and closely spaced small
  vesicles filled with clear fluid with punctate
  erosions and crusting
• Distribution may be isolated and localized or
  general

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Acute Eczema (Note the erythema, vesicles and
swelling)

• Term dyshidrotic is a misnomer as sweat glands
  are not involved
• Also known as pompholyx

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Characteristics of Subacute Eczema

• Plaques of mild erythema with small dry scales
  and or superficial desquamation, sometimes
  associated with small red, pointed or round
  papules
• Distribution may be isolated and localized or
  general

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Subacute Eczema

• Note erythema, swelling and desquamation

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Characteristics of Chronic Eczema

• Plaques of lichenification with deepening of the
  skin lines with satellite, small, firm flat or
  round top papules, excoriations and pigmentations
  or mild erythema
• Distribution isolated and localized or
  generalized

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Chronic Eczema

• Note lichenification, scaling and fissuring

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Acute - Subacute - Chronic
Swelling and erythema
Punctate erythema, desquamation
Lichenification
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Acute, Subacute or Chronic?

• Check for erythema, swelling, desquamation,
  lichenification

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Acute, Subacute or Chronic?

• Check for erythema, swelling, desquamation,
  lichenification

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Classification of Eczema/Dermatitis

• Historically
• Endogenous (occurring from within) dermatitis was
  given the name eczema
• Exogenous dermatitis (occurring from without) was
  termed dermatitis

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Classifications of Eczema

• Endogenous
• Atopic or IgE
• Seborrheic
• Discoid or nummular
• Pompholyx
• Venous
• Asteatotic
• Juvenile plantar
• Erythoderma

• Exogenous
• Allergic
• Toxic irritant contact
• Photosensitive

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Atopic/IgE Eczema (endogenous or exogenous?)

• Characteristics
• 60 have onset in the first year of life
• Influenced by genetics and environmental factors
• More common in males that females
• Ethnicity may be a factor less common in
  Asians more common in Westerners and higher
  socioeconomic families
• Theory is - manifestation of well nourished
  immune system rarely challenged by infection
• Rare to have adult onset
• 2/3 of patients have family history of asthma,
  hay fever or allergic rhinitis

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Atopic/IgE Eczema cont.

• Characteristics
• May persist months to years
• All patients have dry skin
• Exacerbations caused by allergens, stress,
  hormones, climate, skin dehydration
• Physical characteristic may include all phases
• Distinctive Characteristics
• Lesions are usually bilateral
• Located frequently in skin folds/creases and
  flexor surfaces

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Atopic/IgE Eczema Distribution

• Note
• Bilateral
• Skin folds and flexor surfaces

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Atopic/IgE Eczema cont.

• Triggers
• Irritants
• Dry skin bathing without moisturizing
• Harsh/perfumed soaps, detergents
• Disinfectants
• Contact with wool, occupational chemicals/fumes
• Allergens
• Dust mites
• Pet dander (cat more allergenic than dog)
• Pollens, seasonal and molds
• Foods- strawberries, carrots

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Atopic/IgE Eczema cont.

• Triggers (contd)
• Infections
• Bacterial
• Viral
• Cold and other URI viruses
• GI viruses
• Fungal
• Environmental
• Extremes in temperature and/or humidity
• Perspiration
• Stress

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Atopic/IgE Eczema cont.

• Confused with
• Scabies, seborrhea, psoriasis and, contact
  dermatitis

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Atopic/IgE Eczema cont.

• Treatment
• Avoid scratching, clean and cool environment, use
  of soap substitutes
• Emollients
• Topical steroids
• Topical immunomodulators tacrolimus
• Systemic antihistamines
• Soaks
• Tar preparations

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Atopic/IgE Dermatitis
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Allergic (Contact)Eczema(exogenous or
endogenous?)

• Characteristic
• Delayed, cell mediated hypersensitivity
• Strong sensitizer results in reaction soon after
  exposure
• Weak sensitizer my take months or years to
  develop reaction
• Age does not influence capacity for sensitization
  but more common in adults
• Black skin is less susceptible
• Important cause of disability in industry
• Non seasonal

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Allergic (Contact) Eczema cont.

• Characteristics
• usually clears quite rapidly on withdrawal of
  offending agent
• may appear as erythematous papules, vesicles or
  bullous
• more common where epidermis is thinner
• Distinctive Characteristics
• Initial lesions usually limited to contact area
• not bilateral
• lesions with sharp borders or angles are
  pathognomonic

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Causes of Allergic/Contact Eczema

• Metals- nickel, platinum (10 of women)
• Detergents
• Plants and fibers
• Chemicals and dyes
• Polyethylene glycol and polysorbate 60
• Topical antibiotics and medications
• Animal keratin

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Allergic/Contact Eczema cont.

• Treatment remove causative agent, Burows soaks
  140, or saline 1tsp/pt warm water, Aveeno or
  oatmeal baths, calamine
• Systemic antihistamines
• Topical steroids, oral steroid taper
• Antibiotics for secondary infection
• Confused with Atopic eczema, seborrhea, HSV

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Allergic/ Contact Eczema Distribution
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Allergic/ Contact Eczema Distribution
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Note distribution
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Note Linear distribution with satellite lesions
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What do you think?
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Bilateral but..
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Subacute Allergic Eczema

• Note slight swelling and erythema
• No lichenification
• Location what could be the cause?

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Chronic Allergic Eczema

• Note the hyperkeratosis, lichenification and
  fissuring

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Toxic / Irritant Eczema(occurring in non
allergic skin)

• Characteristics
• Accounts for 75 of exogenous eczema
• Age, race and sex are insignificant
• Results from repeated exposure to toxic or
  subtoxic agents
• Severity of skin symptoms vary with the
  individual and the type of irritant and the
  length of contact
• Includes sx of itching, stinging and burning
• Usually associated with chronic disturbance of
  the barrier function of the skin

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Toxic/Irritant Eczema cont.

• Common causes
• Repeated exposure to alkaline detergents
• Repeated exposure to organic solvents
• Corrosive agents
• Industrial chemicals
• Chronic self perpetuating habits that irritate
  the skin

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Toxic/Irritant Eczema cont.

• Treatment
• Remove the cause
• Application of emollients
• Use of soap substitutes
• Barrier creams
• Borrows or potassium permanganate soaks twice
  daily
• Biopsy/testing- usually not necessary

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Acute Toxic/Irritant Eczema
Note distribution, swelling and weeping
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Subacute Toxic/Irritant Eczema

• Lip licking
• often seen in children who have atopic eczema
• Variant of irritant eczema

compare
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Chronic Toxic/Irritant Eczema

• Notepapulosquamous dermatosis with
  hyperkeratosis, maceration, fissuring and
  erosions
• Eruptions tend to
• be sore rather than
• itching

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Acute, subacute, or chronic?

• Swelling? Erythema? Desquamation? Lichenification?

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Comparison of Classifications of the 3 common
types of eczema
ACUTE Atopic IgE Toxic/ Irritant Allergic Contact
Erythema X X X
Papules X NA X
Vesicles X X X
Erosions X X X
Crusts X X X
Scales X NA X
Sharp/ confined NA X X
Spreading peripherally Flexor surfaces, neck, eye lids, d foot X NA
Onset rapid Before age 12 X Usually as adult
Onset slow NA NA X
Concentration L/H NA H L
Incidence Other signs Anyone Sensitized
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Comparison of Classifications
Chronic Atopic IgE Toxic/Irritant Allergic/Contact
scaling X X X
fissues X X X
crusts NA X X
papules NA X X
excoriation X NA X
lichenification X NA X
Periorbital pigmentation X NA NA
Infraorbital folds in the eyelids X NA NA
Foillicular papules X more common in the black pop. NA NA
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Pompholyx(from Greek word meaning blister)

• Characteristics
• Intense itching and burning proceed lesions
• Blisters and vesicles on hands/ feet
• Becomes highly exudative
• Dries up in about 2 wks leaving painful fissuring
  
• Acute symptom of a chronic problem
• Usually no cause but can be due to trichophytin
  and associated with fungal infection of the feet

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Pomhpolyx cont.

• Treatment
• Avoidance of soap
• Emollients
• Soaks ( burrows or potassium permanganate)
• Potent or very potent topical steroids with or
  with occlusion
• Antibiotics for infection
• Systemic steroids
• Coal tar extracts
• Biopsy/testing- usually not necessary

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Pompholyx
Where else should you look? What else might this
be call?
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Nummular Eczema

• Characteristics
• usually -personal or family history of allergy,
  especially asthma, hay fever, and childhood
  eczema
• Distinctive Characteristics - Coin-shaped
  papulovesicular patches that develop in to
  scaling and crusting lesions lesions may be as
  large as 4-5cm in diameter with distinct
  margins, initial eruptions on arms and legs
  intense itching tends to be chronic

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Nummular Eczema cont.

• Characteristics
• Most severe during winter may be aggravated by
  systematic administration of iodine or bromine
  secondary bacterial infections are common
• Treatment skin hydration, topical
  corticosteroids, intralesional injection, coal
  tar ointments, UVB treatment, treat secondary
  infection

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Nummular Eczema cont.

• Confused with contact dermatitis/eczema, atopic
  eczema, psoriasis, impetigo, tinea corporis
• Biopsy/testing not usually necessary

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• Note
• Coin shaped lesions
• dorsal surface arms
• bilateral

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What else should you think about?
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Seborrehea

• Characteristics Positive family history is
  common
• Seen in all age groups equally
• May occur on presternal area and mid upper back
• Stress may increase symptoms
• Pityrosporum ovale may be causative factor
• Distinctive Characteristics
• Red greasy scaling rash consists of patches and
  plaques with indistinct margins and an underlying
  red glazed look to the skin
• Most commonly located in the hairy areas,
  nasolabial folds, retroauriclar folds
• Excoriations from scratching are rare

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Seborrhea cont.

• Treatment
• Scalp
• try OTC preps first (antidandruff, tar or
  ketoconazole shampoo)
• Steroid lotions for very short term use
• 10 Liquor Carbonis Detergens HS and shampoo in
  AM with Dawn Detergent
• Skin -
• try OTCs first
• corticosteroids (mild to moderate potency)
  and/or ketoconazole topically

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Seborrhea cont.

• Eye lashes-
• Warm compresses and gentle debridment
• with Q tip
• Sulfacetamide ophthalmic ointment applied
  topically
• Areas that become exudative may be treated
  with potassium permanganate or burrows soaks
• Confused with atopic dermatitis, eczema,
  psoriasis, discoid lupus, tinea
• Biopsy/testing usually none

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Seborrhea Distribution
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What else could this be?
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Asteatotic Eczema(Xerotic Eczema, Winter Itch)

• Characteristics
• Seen mainly in elderly
• Worse in the winter
• Precipitated by excessive washing
• Treatment
• Avoid excessive washing and use of soap
• Emollients
• Increase humidity in the environment
• Topical steroids for a short periods of time

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Localized Neurodermatitis Cont.

• Treatment
• Stop the scratching
• Occlusive steroid dressings esp. at night
• Lubrication
• Doxepin ointment and/or po 10-20mg
• Hydroxyzine at night
• Intralesional steroid injection
• Stress management and/or medication
• Treatment is longterm and may be unsatisfactory
• Confused with atopic eczema, psorasis, tinea,
  seborrhea
• Biopsy / testing none usually necessary

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Localized Neurodermatitis(known as Lichen
Chronicus Simplex)

• Characterisitcs
• Origin often small patch of dermatitis or insect
  bite starting the itch scratch- itch cycle
• Condition unrelated to allergies or family
  history
• More common in women
• Nonseasonal
• aggravated by stress
• worse at night
• may be secondary to atopic eczema, contact
  dermatitis, lichen planus, psoriasis, or insect
  bite

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Localized Neurodermatitis(known as Lichen
Chronicus Simplex) CONT.

• Distinctive Characteristics
• Lesions lichenified or excoriated
• usually limited to a single patch at hairline of
  nape of neck or on wrists, ankles, ears, or anal
  area
• Not bilateral
• Llichenification of dark skin develops a
  follicular pattern

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Localized Neurodermatitis Distribution (known as
Lichen Chronicus Simplex)
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What should you think about in this man?
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TREATMENT
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Stepped Approach to Treatment of Eczema

• Conservative Therapy
• Education (chronicity, prevention, and trigger
  id)
• Use of astringents and emollients/moisturizers
• OTC products (hydrocortisone, Benadryl, Calamine,
  etc.)
• Low to mid potency steroid creams
• High potency steroid creams
• Immunomodulators - Elidel and Protopic creams
• Nontraditional agents
• PO therapy antiprurutics, steroids,
  cyclosporine, methotrexate
• Coal Tar
• PUVA therapy (phototherapy)

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Conservative Therapy
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Education

• Chronicity of eczema
• Association of other conditions AR, asthma
• Vast number of sensitizing chemicals used
  currently in our soaps, shampoos, detergents,
  foods, etc.
• Likelihood of finding a trigger low
• Detailed sensitizers/triggers (see Pocket Guide
  to Medications used in Dermatology by Scheman and
  Severson)

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Patient Resources

• The Eczema Survival Guide 30 page guide by the
  NEASE
• http//www.medlineplus.com the single best
  general patient medical resource on the internet
  sponsored by NIH
• http//www.eczema.org - National Eczema Society
• http//www.nationaleczema.org National Eczema
  Assoc. for Science and Education
• http//dermatlas.med.jhmi.edu/derm/ - online
  dermatology atlas from Johns Hopkins Univ.

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Prevention Checklist

• Moisturize daily
• Wear cotton, avoid wool and tight clothes
• Take lukewarm showers, using mild soap or nonsoap
  cleansers
• Pat dry do not rub
• Apply moisturizer within 3 min. to lock in
  moisture
• Avoid extremes of heat/humidity and perspiration
• Learn triggers and how to avoid them
• Keep fingernails short
• Remove carpets and pets from the home

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Soaps and Cleansers

• Any product that removes skin oils (sebum), dirt,
  other undesirable substances
• Range from very moisturizing to neutral to very
  drying
• If it is dry, wet it and if it is wet, dry it
  derm mantra
• Normal skin pH is 5.6-5.8 most soaps are basic
  and therefore can be irritating
• Rinsing may be an issue if irritating
• Choose the appropriate cleanser to match your
  patients skin type (most eczema patients will
  need hydration of the skin and neutral or acidic
  pH)
• Again, see Pocket Guide to Medications used in
  Dermatology for detailed ingredients of skin
  products

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Soap Free Cleansers

• Cetaphil
• Aquanil
• Aveeno Daily Mositurizer
• Eucerin Gentle Hydrating Cleanser
• Lobana Body Shampoo
• Moisturel
• pHisoderm
• Indications
• For use in those eczema patients who may be
  sensitive to one or more of the various potential
  sensitizers in soaps and shampoos.
• To cleanse, reduce irritation (if sensitive to
  soaps), and reduce dryness (thereby increase
  absorption of other topicals).

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Emollients/Moisturizers

• Aquaphor
• Balmex Daily
• AmLactin
• Cutemol
• DML Forte
• Eucerin Original
• Hydrisinol
• Lanolor
• Indication To soften and soothe rough, dry skin
  and increase absorbability of topical medications
• Directions Apply as necessary or as prescribed
  generally after showering/bathing and pat drying
  apply liberally to affected areas

• Neutrogena Norwegian Formula
• Lac-Hydrin
• Aveeno
• Pen-Kera
• Curel
• Lubriderm Advanced Therapy
• Minerin

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Astringents

• Astringents reduce secretions (by causing
  contraction of tissues) and are antibacterial
• Best used in eczema where vesicular or draining
  lesions are present
• Acetic Acid 5 (white vinegar) especially
  useful in Pseudomonas infections
• Burows Solution (Domeboro and others)
• Potassium Permanganate

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Burows Solution(aluminum acetate)

• Indication
• Used as an astringent wet to dry dressing for
  relief of inflammatory conditions of the skin
  such as insect bites, poison ivy, allergy,
  eczema, and athletes foot.
• Directions One tablet or one pack per pint of
  water 140 solution
• Actions
• Collagenase enzyme activity may be inhibited by
  aluminum acetate solution because of the metal
  ion and low pH.

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Burows Solution

• As a compress or wet dressing Saturate a clean,
  soft, white cloth in the solution. Gently
  squeeze and apply loosely to affected area. May
  cover with dry dressing. Saturate the cloth in
  solution every 15 to 30 minutes and apply to
  affected area. Repeat as often as necessary
• As a soak Soak affected area in solution for 15
  to 30 minutes. Discard solution after each use.
  Repeat 3 times a day

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Burows Solution

• Precautions
• Discontinue use if intolerance, irritation, or
  extension of inflammatory condition being treated
  occurs. If symptoms persist gt7 days, discontinue
  use and consult physician
• Do not use plastic or any other impervious
  material to prevent evaporation
• Avoid contact with the eyes

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OTC Therapy
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OTC Meds

• Antiinflammatory topicals
• Hydrocortisone creams, 0.5 to 1
• Antipruritics and others
• Benadryl (diphenhydramine 25-50mg q6h prn)
• Calamine Lotion (zinc oxide and ferric oxide used
  as a mild astringent)
• Caladryl Lotion (both of above)
• Burow/s solution

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Prescription Therapy of Eczema
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Properties of the Ideal Drug(prescription or otc)

• (Acronym IDEA)
• Inexpensive
• Dosage once daily or bid or less
• Effective
• Adverse effects absent

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Steroid Creams
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Basic Rules of Dermal Absorption

• The larger the surface area the formulation is
  applied to, the greater the absorption
• Formulations or dressings that increase the
  hydration of the skin generally improve
  absorption
• The greater the amount of rubbing in of the
  formulation, the greater the absorption
• The more active inflammation or open vesicles or
  ulcers present, the greater the absorption
• The longer the formulation remains in contact
  with the skin, the greater will be the absorption

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Steroid Classifications
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Topical Vehicles

• Creams
• Less greasy and most acceptable to patient
• Applies more easily
• Penetrates skin well
• Works well in intertriginous and hairy areas
• Can be drying
• Have a cooling effect
• Easy to wash off
• Lotions more water content and less viscous
  than creams

• Ointments
• Petrolatum based
• Alleviates dryness by prevention of evaporation
• Removes scales
• Enables medication to penetrates skin well
• Water repellant
• Remains on the skin
• Occlusive and protective
• Soothing and lubricating

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Prescription Topical SteroidsLow and Medium
Potency

• Do consider use in
• Allergic/Contact Dermatitis
• Seborrheic Dermatitis
• Intertrigo of axillary, crural or inframammary
  regions
• Atopic Eczema
• Neurodermatitis
• Otic eczema

• Do not use
• Large body areas because of expense, difficulty
  with application, and question of internal
  absorption

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Prescription Topical SteroidsHigh Potency and
Fluorinated

• Do consider use
• With or without occlusive dressing in palmar or
  plantar atopic dermatitis
• Localized neurodermatitis

• Do not use
• Face
• Intertriginous areas
• prolonged use in any area may cause thinning
  of the skin, telangiectasia, striae

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Immunomodulators(Topical immunomodulators-TIMs)
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Elidel

• Elidel (pimecrolimus) 1 cream
• Indications
• Short term and repeated courses for mild to
  moderate eczema in nonimmunocompromised patients
  greater that 2 years of age in whom the use of
  alternative conventional treatment is inadvisable
  or those with are none responsive to conventional
  treatment.
• Can be used anywhere on the skin
• Precautions
• Do not use in treatment of infected atopic
  dermatitis, including eczema herpeticum
• Patients who develop lymphadenopathy should have
  a complete evaluation to R/O lymphoma
• Avoid sun light exposure as sun exposure and use
  of pimecrolimus shortens time of skin lesion to
  skin tumor formation in animals
• Do not use occlusive dressings

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Elidel (contd)

• Adverse Effects (often resolve after a few days
  of therapy)
• Warmth or burning where applied
• Headache
• Cold-like symptoms (st, cough, rn)
• Fever
• Viral skin infection
• Dosage
• Apply BID
• Discontinue when symptoms resolved
• Further evaluation needed if symptoms persist gt 6
  weeks
• MOA
• Calcineurin inhibitor
• Cost
• 30 grams 63 60 grams 117

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Protopic

• Protopic (tacrolimus) adults 0.03 0.1
  ointment
• Indications
• Protopic ointment 0.1 for adults only
• Protopic ointment 0.03 for children age 2 and
  older
• Short term and repeated courses of moderate to
  severe eczema in whom the use of alternative
  conventional treatment is inadvisable or those
  who are not responsive to conventional treatment
• Can be used anywhere on the skin
• Precautions
• Do not use in treatment of infected atopic
  dermatitis, including eczema herpeticum
• Patients who develop lymphadenopathy should have
  a complete evaluation to R/O lymphoma
• Avoid sunlight, tanning salons, phototherapy
  (PUVA), as sunlight shortens time of skin lesion
  to skin tumor formation in animals
• Do not use occlusive dressings

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Protopic (contd)

• Adverse reactions ( often resolve after few days
  of application)
• Skin stinging and burning (dependent on degree of
  eczema)
• Increased skin infections
• Dosage
• Apply BID
• Discontinue 1 week after symptoms resolved
• Further evaluation needed if symptoms persist gt 6
  weeks
• MOA
• Calcineurin inhibitor
• Cost
• 30 grams 62 60 grams 130

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Potential problem with both TIMs(Elidel and
Protopic)

• Feb. 15th 2005 the Pediatric Advisory Committee
  of the FDA met and recommended that a black box
  warning be added to both Elidel and Protopic due
  to potential cancer risk
• This is due to animal studies where animals
  swallowed large amounts of both drugs over a long
  period of time, achieved significant blood levels
  of the drugs, and developed lymphomas.
• March 10, 2005 The FDA issued a Public Health
  Advisory warning the public about potential
  carcinogenic safety issues involving both TIMs.
• The American Academy of Dermatology, the Natl.
  Eczema Assn. for Science and Education (NEASE),
  and the Inflammatory Skin Disease Institute
  (ISDI) all have issued statements declaring the
  FDA action premature and all feel that the drugs
  are safe when used appropriately
• There are already websites dedicated to class
  action litigation against both manufacturers
• Bottom Line I would not adivse using in any
  pediatric patients, or in any patient that can be
  controlled with less expensive and efficacious
  therapy.

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Nontraditional Agents

• Problem these are not deemed safe or effective
  by the FDA
• Herbal remedies
• Licorice as topical gel
• Guava leaves (as tea)
• Chinese herbal teas
• St. Johns wort (as lotion or tea)
• Probiotics thought to help relieve inflammation
• Homeopathic arsenicum alba and calcara
  carbonica
• Hypnosis
• Acupuncture
• Gamma linoleic acid oils
• Evening primrose oil
• Borage oil

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PO Prescription Drug Therapy

• Antipruritics
• Hydroxyzine 10-25mg q6h prn itching
• Doxepin 10-25mg q12-24h prn itching (off label)
  also can be compounded as a cream)
• Oral Steroids
• May give in tapering short courses for selected
  episodes of acute and/or severe eczema
• Effective, inexpensive, qd dosing, few side
  effects in most people with short term use
• Cyclosporine reserve for specialty use
• Methotrexate reserve for specialty use

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Coal Tar Preparations

• Tegrin cream and lotion
• Medotar ointment
• PsoriGel gel
• Polytar and Tegrin soaps
• Tegrin, T/Gel, and other shampoos
• Indication to relieve and control itching, and
  flaking skin associated with psoriasis and
  seborrhea as well as eczema
• Directions Depending on product 1-4 times daily

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Coal Tar Preparations(contd)

• Contraindications
• Hypersensitivity
• Precautions
• Do not use on broken skin, genital or rectal area
  except on the advise of your health care
  provider.
• Photosensitivity x 24hr after application
• May stain light colored hair
• Warning
• High concentrations of some chemicals in coal tar
  may cause cancer. Concentrations of 0.5 to 5
  appear to be safe.

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PUVA Therapy

• Indications Psoriasis, eczema, pruritic rashes
  of other causes
• Consists of PO psoralen (photosensitizing agent)
  followed by UVA phototherapy
• Must avoid sunlight for 24h after po psoralen
• Sessions are 3d/wk, may be from 12-30 sessions,
  increasing in duration
• Side effects are redness, burning, occasional
  nausea
• Litigation very high in some states

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Summary of Treatment

• Conservative Therapy
• Education (chronicity, prevention, and trigger
  id)
• Use of astringents and emollients/moisturizers
• OTC products (hydrocortisone, Benadryl, Calamine,
  etc.)
• Low to mid potency steroid creams
• High potency steroid creams
• Immunomodulators - Elidel and Protopic creams
• Nontraditional agents
• PO therapy antiprurutics, steroids,
  cyclosporine, methotrexate
• Coal Tar
• PUVA therapy (phototherapy)

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Midlevel Providers Role in theTreatment of Eczema

• Identification
• Treatment
• Education

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IdentifyAcute-Chronic Allergic,Atopic,
Toxic/Irritant
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Extra Credit!!!!!
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The End