What is the proper terminology for eczematous skin conditions. How are eczematous dermatoses diagnosed and classified. What are the most effective treatment approaches for various types of eczema. How can clinicians improve their diagnosis and management of eczematous disorders.

Understanding Eczematous Dermatoses: Definitions and Terminology

The field of dermatology often grapples with imprecise terminology, and the terms “eczema” and “dermatitis” are prime examples. Many clinicians use these words interchangeably, while others attempt to distinguish between them based on the chronicity of the condition. This lack of clarity can lead to confusion in both clinical practice and research.

Are “eczema” and “dermatitis” truly synonymous? The short answer is that there is no clear consensus. Some dermatologists prefer to use “eczema” for chronic conditions and “dermatitis” for acute presentations. However, this distinction is not universally accepted or applied.

The term “eczematous dermatitis” itself has come under scrutiny. Critics argue that it is redundant, akin to saying “ulcerative ulcer.” Instead of providing clarity, such terminology may further muddy the waters of dermatological diagnosis.

The Challenge of Defining Eczema

Renowned dermatopathologist A. Bernard Ackerman has highlighted the lack of a clear, universally accepted definition for eczema. At its core, eczema refers to skin inflammation involving epidermal changes. However, this broad description encompasses a wide range of conditions with varying presentations, causes, and treatment approaches.

Classification of Eczematous Disorders: A Practical Approach

Given the challenges in terminology, how can clinicians effectively classify and diagnose eczematous conditions? A more practical approach focuses on specific subtypes and their clinical features:

• Atopic dermatitis
• Contact dermatitis (allergic and irritant)
• Seborrheic dermatitis
• Nummular eczema
• Dyshidrotic eczema
• Stasis dermatitis
• Lichen simplex chronicus

By focusing on these more specific diagnoses, clinicians can better tailor their treatment approaches and communicate more effectively with patients and colleagues.

Clinical Presentation and Diagnosis of Eczematous Conditions

How do dermatologists accurately diagnose eczematous disorders? The process typically involves a combination of clinical history, physical examination, and sometimes additional testing:

1. Detailed patient history: Onset, duration, exacerbating factors, personal and family history of atopy
2. Physical examination: Distribution and morphology of lesions, associated signs (e.g., xerosis, lichenification)
3. Patch testing: For suspected allergic contact dermatitis
4. Skin biopsy: In cases where the diagnosis is unclear or to rule out other conditions

What are the key features that distinguish different types of eczematous conditions? While there is often overlap, certain characteristics can help guide diagnosis:

• Atopic dermatitis: Often begins in childhood, involves flexural areas, associated with personal or family history of atopy
• Contact dermatitis: Localized to areas of exposure, may have clear temporal relationship to allergen or irritant
• Seborrheic dermatitis: Affects sebum-rich areas (scalp, face, chest), often with greasy scale
• Nummular eczema: Coin-shaped lesions, often on extremities
• Dyshidrotic eczema: Vesicles on palms and soles
• Stasis dermatitis: Lower legs, associated with venous insufficiency
• Lichen simplex chronicus: Localized, thickened plaques due to chronic scratching

Treatment Strategies for Eczematous Dermatoses

What are the most effective treatment approaches for eczematous conditions? While specific treatments may vary depending on the subtype and severity, some general principles apply:

1. Skin barrier repair: Emollients and moisturizers are crucial for all types of eczema
2. Topical anti-inflammatory agents: Corticosteroids and calcineurin inhibitors
3. Trigger avoidance: Identifying and eliminating irritants or allergens
4. Itch management: Antihistamines and targeted therapies like doxepin
5. Systemic treatments: For severe or refractory cases (e.g., cyclosporine, methotrexate, dupilumab)
6. Phototherapy: UVB or PUVA for certain subtypes

How do clinicians choose the appropriate treatment for each patient? The decision depends on factors such as:

• Specific eczema subtype
• Severity and extent of involvement
• Patient age and comorbidities
• Previous treatment history and response
• Patient preferences and adherence considerations

Emerging Therapies and Research in Eczematous Disorders

What new treatments are on the horizon for eczematous conditions? The field of dermatology is experiencing rapid advances, particularly in the realm of targeted therapies:

• Biologics: Expanding beyond dupilumab to include other targeted antibodies
• JAK inhibitors: Both topical and oral formulations showing promise
• Microbiome-based therapies: Targeting skin dysbiosis associated with certain eczemas
• Novel barrier repair agents: Advanced emollients and prescription barrier creams
• Personalized medicine approaches: Tailoring treatments based on genetic and biomarker profiles

How might these emerging therapies change the landscape of eczema treatment? While it’s too early to say definitively, the hope is that they will provide more targeted, effective options with fewer side effects than traditional systemic treatments.

Patient Education and Self-Management in Eczematous Dermatoses

Why is patient education crucial in managing eczematous conditions? Eczema, in its various forms, is often a chronic condition requiring long-term management. Empowering patients with knowledge and self-care strategies can significantly improve outcomes.

What key points should be emphasized in patient education?

• Consistent use of emollients and proper bathing techniques
• Identification and avoidance of individual triggers
• Proper application of topical medications
• Itch management strategies
• When to seek medical attention for flares or complications
• Importance of adherence to treatment plans

How can healthcare providers effectively deliver this education? Consider a multi-pronged approach:

1. Verbal instruction during clinic visits
2. Written materials and handouts
3. Video demonstrations of proper skincare techniques
4. Referral to reputable online resources and patient support groups
5. Follow-up calls or telemedicine visits to reinforce key points

Psychosocial Impact of Eczematous Disorders

How do eczematous conditions affect patients beyond the physical symptoms? The impact can be far-reaching, influencing various aspects of life:

• Mental health: Increased rates of anxiety and depression
• Sleep disturbances: Due to itching and discomfort
• Social interactions: Self-consciousness about visible skin lesions
• Work or school performance: Absenteeism and presenteeism
• Financial burden: Cost of treatments and lost productivity
• Quality of life: Overall decreased life satisfaction

What strategies can healthcare providers employ to address these psychosocial aspects? A holistic approach is key:

1. Screening for mental health issues and referring to mental health professionals when needed
2. Discussing the emotional impact of the condition during visits
3. Providing resources for support groups and patient advocacy organizations
4. Considering quality of life measures in treatment decision-making
5. Collaborating with other specialists (e.g., sleep medicine, pain management) for comprehensive care

Special Considerations in Pediatric Eczematous Dermatoses

How does the management of eczematous conditions differ in children? Pediatric patients present unique challenges and considerations:

• Age-appropriate treatment selection: Balancing efficacy and safety
• Growth and development concerns: Monitoring for potential treatment effects
• School and social impacts: Addressing bullying and self-esteem issues
• Family dynamics: Involving caregivers in treatment plans
• Long-term prognosis: Discussing the potential for outgrowing certain eczemas

What strategies can help improve adherence in pediatric patients?

1. Simplified treatment regimens when possible
2. Age-appropriate education materials (e.g., picture books, apps)
3. Involving children in their care through games or reward systems
4. Addressing caregiver concerns and providing support
5. Regular follow-up to adjust treatments as the child grows

By tailoring approaches to the unique needs of children and their families, clinicians can improve outcomes and quality of life for young patients with eczematous conditions.

Occupational Considerations in Eczematous Dermatoses

How do occupational factors influence the development and management of eczematous conditions? Certain professions carry a higher risk of developing or exacerbating eczematous dermatoses, particularly contact dermatitis:

• Healthcare workers: Frequent hand washing and glove use
• Hairdressers: Exposure to various chemicals and wet work
• Construction workers: Contact with irritants and allergens
• Food service workers: Exposure to water, detergents, and food allergens
• Mechanics: Contact with oils, solvents, and other chemicals

What strategies can be employed to manage occupational eczematous conditions?

1. Identifying and minimizing exposure to workplace triggers
2. Implementing proper protective measures (e.g., gloves, barrier creams)
3. Educating employers and coworkers about the condition
4. Considering job modifications or reassignment in severe cases
5. Collaborating with occupational health specialists for comprehensive management

How can healthcare providers support patients in navigating workplace challenges related to their eczematous conditions? Open communication and a collaborative approach are key:

• Providing detailed documentation for workplace accommodations
• Offering guidance on discussing the condition with employers
• Recommending occupational health evaluations when appropriate
• Staying informed about relevant workplace regulations and patient rights
• Considering the impact of treatments on work performance and safety

The Role of Allergy in Eczematous Dermatoses

How significant is the connection between allergies and eczematous conditions? The relationship is complex and varies depending on the specific type of eczema:

• Atopic dermatitis: Strong association with other atopic conditions (asthma, allergic rhinitis)
• Allergic contact dermatitis: Direct result of type IV hypersensitivity reactions
• Other eczemas: May be exacerbated by allergens but not primarily allergic in nature

What diagnostic tools are available to assess the role of allergies in eczematous conditions?

1. Patch testing: Gold standard for identifying allergens in contact dermatitis
2. Skin prick testing: Can identify IgE-mediated allergies that may exacerbate atopic dermatitis
3. Serum IgE levels: May be elevated in atopic individuals
4. Allergen-specific IgE testing: Can identify specific environmental or food allergies
5. Elimination diets: May be used to identify food triggers in select cases

How should clinicians approach allergy management in patients with eczematous conditions?

• Collaborate with allergists for comprehensive evaluation and management
• Consider allergen immunotherapy for select patients with atopic dermatitis
• Educate patients on allergen avoidance strategies
• Address both skin-directed treatments and systemic allergy management
• Monitor for the development of new allergies over time

By understanding and addressing the allergic components of eczematous conditions, clinicians can provide more targeted and effective treatment approaches.

Eczematous Dermatitis? | JAMA Dermatology

Eczematous Dermatitis? | JAMA Dermatology | JAMA Network










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Article

September 1996

Elizabeth F. Sherertz, MD^{; Bhavik P. Soni, MD}

Author Affiliations

Department of Dermatology Bowman Gray School of Medicine Winston-Salem, NC 27157

Arch Dermatol. 1996;132(9):1130. doi:10.1001/archderm.1996.03890330146030

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Abstract

The title of the article in the December 1995 issue of the Archives about the antipruritic effect of doxepin hydrochloride certainly drew our attention.¹ What is eczematous dermatitis? We were taught that neither eczema nor dermatitis is a specific diagnosis. Also, although some authors use eczema for diseases with a chronic course and dermatitis for diseases with an acute course, most dermatologists use the 2 words interchangeably. Thus, to lump cutaneous eruptions under an umbrella diagnosis of eczematous dermatitis is at least a redundancy similar to making a diagnosis of aphthous ulcer (given that aphtha means ulcer). The use of imprecise, redundant terms such as eczematous dermatitis is propagated by their inclusion in major textbooks of dermatology.²

Ackerman has already commented on the lack of a clear definition of the term eczema.³ Rather, eczema is a nonspecific term describing skin inflammation involving epidermal change. The study further characterizes the patients as having lichen simplex

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Eczematous Dermatoses | SpringerLink

Eczema dermatosis | PsorMak

August 5, 2019

Eczema is a ubiquitous, more often acute, less often chronic, recurrent skin disease that occurs at any age, characterized by polymorphism of the morphological elements of the rash. Eczema accounts for 30-40% of all skin diseases [Studnitsin A. A., Skripkin Yu. K., 1979]. The name of this dermatosis is explained by the property of eczematous vesicles to quickly open, like bubbles of boiling water (eczeo in Greek – to boil). An important sign of acute eczema is the presence of numerous grouped and quickly opening with the formation of serous “wells” of small bubbles, which have some resemblance to bubbles on the surface of boiling water.

The term “eczema” was used as early as the 2nd century BC. e., but only to refer to various acutely occurring dermatoses. Only in the first half of the 18th century, Willen (1808), Bateman (1813), Reye (1823) and other scientists singled out eczema as a separate nosological form.

Etiology and pathogenesis

Eczema is formed as a result of a complex complex of etiological and pathogenetic factors. Since the predominant value of certain endogenous and exogenous influences remains controversial, eczema is considered to be a polyetiological disease.

At different stages of the development of the doctrine of eczema, the nervous system (neurogenic theory), the role of the endocrine glands, the allergic state of the body (allergic theory), hereditary factors were of particular importance in the etiology and pathogenesis of the disease. It should be recognized that the etiology and even pathogenesis of eczema are extremely complex, not always the same, and in many of their aspects remain unexplored.

In recent years, most authors believe that the eczematous process develops as a result of the complex effects of neuroallergic, endocrine, metabolic and exogenous factors [Shakhtmeister I. Ya., 1970; Skripkin Yu. K. et al., 1975; Antoniev A. A. et al., 1978; Kubanova A. A., 1986].
Exogenous irritants can be chemical, biological agents, bacterial allergens, physical factors, medicines, foods, cosmetics.

Allergic reactivity at the onset of the disease is sometimes monovalent. With the further course of dermatosis, the diseased organism qualitatively and quantitatively begins to respond to a variety of irritants and allergens, which indicates the development of polyvalent sensitization characteristic of eczema. An eczematous reaction is a delayed-type allergic reaction. However, in some patients, as a result of the use of medications (penicillin, novocaine, B vitamins, etc. ), reactions of an immediately-delayed type (anaphylactic reaction) may develop.

The reaction between antigens and antibodies occurs in a specific humoral environment. Changes in homeostasis also have a significant impact on the mechanisms of formation of allergic phenomena (disturbances in the activity of the endocrine, nervous, immune systems that are in constant interaction). At the present stage of development of the doctrine of eczema, the main importance is attached to the pathogenetic role of various immune shifts, changes in the state of prostaglandins and cyclic nucleotides. When studying the immune status of patients with eczema, A. A. Kubanova (1986) established significant disorders of the cellular link of immunity and nonspecific defense factors, manifested in severe lymphocytopenia, a decrease in the functional activity and content of the T-lymphocyte pool, a sharp suppression of the functional activity of T-suppressors and a decrease in the number of T-helpers. The revealed violations were directly dependent on the duration of the disease, the decrease in the severity of clinical manifestations and changed with age. The highest indicators, reflecting the state of the immune status, were found in the age groups from 16 to 20 years and from 20 to 30 years, and the lowest in the age group over 50 years. The dependence of changes in the immune status on gender has not been established.

Violations of non-specific defense factors are manifested in a decrease in the functional activity of neutrophils (phagocytosis percentage, phagocytic number, absolute phagocytic index), the ability to spontaneous and complementary rosette formation of neutrophilic leukocytes, in a decrease in the number of their cytoplasmic granules (cytoplasmic granules of neutrophils are a morphological indicator of their digesting ability , reflecting the fourth stage of phagocytosis). These disorders, perhaps, explain the often observed complications of the eczematous process by secondary streptostaphyloderma, which aggravates the course of the disease and leads to additional sensitization of the body. Indicators of humoral immunity (total number of B-lymphocytes, immunoglobulins A, M, G) in patients with eczema do not change significantly.

Patients with true eczema have a positive association of histocompatibility system antigens (HLA) B22 and CW1 [Kubanova AA, 1986]. The indicated association of antigens was noted in persons of the Slavic race, predominantly of Russian nationality, which allows us to consider these antigens as genetic markers of eczema for persons of the Slavic race. The information obtained deepens the understanding of the mechanisms of implementation of the genetic predisposition to the development of immunopathological conditions. The dependence of indicators of the suppressor function of T-lymphocytes and the content of T-helper cells on the HLA phenotype was revealed, as evidenced by a decrease in suppressor function and the number of T-helper cells in patients with eczema markers HLA-B22 and CW1 [KubanovaA. A., 1986].

A significant role in the pathogenesis of eczema is played by changes in the state of prostaglandins and cyclic nucleotides, which occupy a central place in intracellular regulatory mechanisms, mediate neuroendocrine information, turn it into a specific cell response and implement normal and pathological reactions of the body [Fedorov N. A., 1979]. Prostaglandins E1 and F201, cyclic adenosine monophosphate and guanosine monophosphate have a regulatory effect on the development of allergic and inflammatory reactions, the functional activity of the body’s immune system. Antagonistic relationships exist between prostaglandins E1 (PGE1, cyclic adenosine monophosphate (cAMP) and prostaglandins F2a cyclic guanosine monophosphate (cGMP). PGE1 stimulates the synthesis of cAMP, which suppresses the production of histamine, serotonin and other mediators of allergic reactions. PFG2a stimulates the synthesis of cGMP, which activates the production of allergy mediators, thereby contributing to the development of allergic and inflammatory reactions.In patients with eczema, an increase in the concentration of PGE1 and PGF2a in the blood plasma was found, but a more significant increase in PGFa, which leads to a change in the ratio of PGE1/PGF2 (PGF2a predominates) and the formation of a kind of PGE1 deficiency.0006

Established biochemical and immune disorders made it possible to develop a new concept of the pathogenesis of eczema [Kubanova AA, 1986]. In individuals with a hereditary predisposition, confirmed by a positive association of antigens of the histocompatibility system (B22 and Cw1), the synthesis of prostaglandin F2a increases, which causes increased stimulation of the synthesis of cyclic guanosine monophosphate, which activates the production of histamine, serotonin and other mediators of allergy, contributes to the development of allergic and inflammatory reactions, increased vascular permeability. Simultaneously with the increase in the formation of prostaglandin F2a, the synthesis of prostaglandin E1 increases, but its concentration is significantly reduced in relation to the increasing concentration of prostaglandin F201. The lack of content of prostaglandin E1, the violation of its ratio with the content of prostaglandin F2a leads to insufficient stimulation of the synthesis of cyclic adenosine monophosphate, which suppresses the formation of allergic and inflammatory reactions, the production of allergy mediators. Thus, in patients with eczema, as a result of an increase in the content of F2a and a violation of the ratio of PGE1 / PGF2a and cAMP / cGMP, prostaglandin F2a and cyclic guanosine monophosphate predominate, which is one of the causes of the development of the disease. In the peripheral blood platelets of patients with eczema, an increase in the synthesis and excretion of serotonin into the bloodstream was found. The platelet release reaction that releases serotonin into the blood is regulated by prostaglandins. Prostaglandin E1 suppresses it, and prostaglandin F2a provokes it. The predominance of prostaglandin F2a causes an increase in the content of serotonin in the blood, which exacerbates allergic reactions. The thyroid hormone thyrocalcitonin stimulates the activity of adenylate cyclase, an enzyme that catalyzes the synthesis of cyclic adenosine monophosphate from ATP. An increase in the content of thyrocalcitonin in patients with eczema may be a manifestation of the protective-compensatory reactions of the body.

Prostaglandins and cyclic nucleotides are one of the factors of the multicomponent system of immune response regulation. An increase in their synthesis leads to changes in immunological reactivity and causes profound immunological disorders, manifested in the suppression of cellular immunity (decrease in the content of T-ROK, quantitative and functional indicators of T-helpers and T-suppressors, suppression of the suppressor activity of T-lymphocytes) and nonspecific protective factors ( decrease in the number of spontaneous and complementary neutrophils, the content of cytoplasmic granules of neutrophilic leukocytes, the percentage of phagocytosis, the absolute phagocytic index and phagocytic number). Changes in the immune status contribute to an increase in allergic reactivity and, along with prostaglandins and cyclic nucleotides, lead to the formation of an eczematous process. The degree of severity of the established imbalance of prostaglandins, cyclic nucleotides and immunological reactivity is reflected in the severity of clinical manifestations and the course of the process.

Simultaneously with the state of immune deficiency in patients with eczema, there are functional changes in the activity of the central nervous system, the predominance of the activity of unconditioned reflexes over the activity of conditioned reflexes, imbalance between the activity of the sympathetic and parasympathetic divisions of the autonomic nervous system, changes in the functional state of skin receptors in the form of dissociation of skin sensitivity. Thus, inhibition of immune reactivity in patients with eczema does not develop in isolation, not only on the basis of a genetic predisposition, but also as a result of complex neuroendocrine-humoral changes that change tissue trophism.

The predominance of parasympathetic mediators in the skin, humoral insufficiency of the pituitary-adrenal system [Sharapova G. Ya., 1965; Shakhtmeister I. Ya., 1970, etc.] lead to a sharp increase in the permeability of the walls of blood vessels and increased sensitivity of smooth muscle cells to the action of endo- and exogenous resolving factors, including bacterial antigens. Weakness of immunity in the presence of infectious antigenic stimuli is manifested by the persistence of microbial and bacterial antigens, the formation of chronic recurrent inflammation in the epidermis and dermis. In this case, pathological immune complexes arise that damage their own microstructures and create autoantigens that form autoaggressive antibodies.

Inflammatory chronic process in the epidermis and dermis occurs as a result of the complex pathological functioning of various systems of the macroorganism. Most clearly in patients with eczema, neurodermatitis and other allergic dermatosis, violations of the functional state of the gastrointestinal tract, nervous, endocrine systems, and metabolic processes are revealed [Toropova NP et al. , 1986].

The formation of eczema due to a genetic predisposition, which depends on the presence of an immune response gene in lymphocytes, creates the prerequisites for its inheritance in subsequent generations. The development of eczema in children of the first year of life contributes to the complicated course of pregnancy in the mother [Toropova N. P. et al., 1986]. When studying the anamnesis of sick children, it was revealed that toxicosis and nutritional errors during pregnancy, concomitant diseases in the mother (nephropathy, diabetes mellitus, cardiovascular insufficiency, chronic hepatocholecystitis) contribute to the onset of the disease. According to F. A. Zverkova (1975), in 30% of mothers, pregnancy was accompanied by toxicosis, severe vomiting. Artificial feeding from the first days of a child’s life, early introduction of complementary foods, especially whole cow’s milk, semolina porridge with whole or condensed milk, concentrates, meat and fish broths, create conditions for the occurrence of exudative diathesis and severe dermatoses, most often children’s eczema.

In the development of eczema in children, polygenic multifactorial inheritance takes place with pronounced gene expression and penetrance. Yu. K. Skripkin (1979) reports that with an allergic disease of one of the parents (mainly the mother), the chance of developing eczema in a child is approximately 40%, and if both parents are affected, the risk increases to 50-60%. The formation of immediate-delayed type hypersensitivity, manifested by eczematous rashes, is promoted by foci of chronic infection, gastrointestinal disorders, dysfunction of the liver, pancreas, etc. Clinical and pathogenetic features of eczema allow us to identify several of the most common forms.

Classification

There is currently no generally accepted unified classification of eczema. Some scientists [L. N. Mashkilleyson, 1965; Smelov N. S. et al., 1973] distinguish the following forms of eczema:

• acute (Eczema acutum),
• subacute (Eczema subacutum),
• chronic (Eczema chronicum),
• seborrheic (Eczema seborrhoeicum),
• children’s (Eczema infantum)
• varicose (Eczema varicosum) forms.