Eczema (overview) L30.9

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 19.12.2020

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Synonym(s)

Eccema

Definition
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The term eczema is increasingly losing its meaning in international literature. In this respect, this article refers to the definition and classification commonly used up to now. The substitute, non-prejudicial term "dermatitis" is used synonymously.

Until now, "eczema" has been defined as an acute to chronic, non-infectious inflammatory reaction of the epidermis and dermis, caused by a variety of exogenous noxae and endogenous reaction factors with typical clinical symptoms (itching, erythema, papules, seropapules, vesicles, scaling, crusting, lichenification) and characteristic histological appearance (spongiosis, acanthosis, parakeratosis, lymphocytic infiltration). In Anglo-American usage, the term eczema is usually replaced by the term dermatitis, which leads to considerable nomenclatural problems.

Classification
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The eczema group can be classified according to various criteria, with a rough division into "atopic eczema, toxic and allergic contact dermatitis" covering a large part of the diseases of the eczema group.

A more detailed classification (n. P. Fritsch) takes into account not only the pathogenesis but also topographical and endogenous influences on the basic eczematous reaction and thus does more subtle justice to the variety of reaction patterns and the different therapy modalities that are necessary as a result.

Histology
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Acanthosis of varying severity, lengthening of the reticulum, hyperkeratosis with parakeratotic parts, perivascular, partly also diffuse, predominantly lymphocytic infiltrate in the upper dermis with slight to distinct dermal fibrosis (depending on the duration of the eczema reaction). Mostly proliferation of capillaries in the infiltrate zone. Focally very differently pronounced epidermotropy with spongiosis (up to intraepidermal spongiotic blistering) of varying severity (depending on the degree of acuteity of the eczema reaction).

Therapy
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  • Switching off the triggering noxae, phase-specific eczema therapy, according to the prevailing clinical findings. In particular, in the case of chronic eczema, test ointment tolerance as quickly as possible ( epicutaneous test, quadrant test). Selection of suitable or, if possible, indifferent bases (e.g. aqueous solutions, vaselinum alb.). Especially no wool waxes and wool wax alcohols!
  • Acute eczema

    :Note!

    Basic principle: The more acute and weeping the eczema, the more watery the ointment base!
    • Acute vesicular to bullous stage (weeping)
      : short-term glucocorticoids of medium to strong potency such as 0.1% triamcinolone acetonide, 0.25% prednicarbate (e.g. Dermatop cream/ointment), 0.1% mometasone (e.g. Ecural ointment) or 0.05% clobetasol(e.g.
      R054, Dermoxin cream/ointment) depending on the clinic and localisation. No isolated application of fatty bases, but better solutions or hydrophilic creams like Ungt. emulsif. aq. (e.g. R054, Dermatop cream, Ecural Lsg.). If greasing basis, then in combination with moist compresses. Moist compresses are also indicated in combination with hydrophilic creams. Envelopes with e.g. Ringer's solution for superinfection with antiseptic additives like quinolinol (e.g. Chinosol 1:1000), quinolinol sulfate monohydrate solution 0.1% or potassium permanganate - light pink).
      In the vesicular stage also fat-moist with glucocorticoid like 1% hydrocortisone in lipophilic base like Vaselinum alb. (hydrocortisone ointment 1%), a dressing moistened over it (e.g. Ringer's solution) or possibly a cotton glove. Caution! Restrained use of glucocorticoids on sensitive skin areas such as face, neck, intertriginous areas (submammary, groin region, ano-genital area)!
    • Crusty or squamous stage: Hydrophilic creams with the highest possible oil content for the regeneration of the skin (e.g. base cream (DAC), Linola cream, Ash base cream, Excipial cream, Dermatop base cream). If necessary also with wound healing additives like dexpanthenol (e.g. R064, Bepanthen ointment).
      After treatment: Nourishing and moisturizing topicals in a compatible base such as Vaselinum alb., Linola fat, Ash Base Ointment, Excipial Almond Oil Ointment) possibly with addition of 2-10% urea (e.g. R102 R107, Basodexan Cream, Excipial U Lipolotio).
  • Chronic eczema

    :Remember!

    Basic principle: The more chronic the eczema, the more oily the ointment base!
    • Short-term glucocorticoids of medium to high potency see above in a fatty base (e.g. Ecural fat cream, Dermatop ointment). Subsequently antiphlogistic topicals such as Pix lithanthracis. On a trial basis Pix lithanthracis 2% in zinc oil(coal tar-zinc oil 2-5%) or coal distillate containing or shale oil sulphonate containing topicals (e.g. ichthosin, ichthoderm, tar-linola fat). Soaps and detergents should be omitted, instead oil-containing baths (e.g. Balneum Hermal, Balneum Hermal Plus, Balmandol, Linola Fat-Oil Bath, Liquedin Bath Oil). If necessary also tar-containing oil baths such as Ichtho bath.
    • In chronic, hyperkeratotic and highly scaly plaquelike eczema foci (see also eczema, hyperkeratotic-rhagadiform eczema of the hands and feet), strongly potent glucocorticoids, possibly under occlusion, e.g. clobetasol propionate (e.g. dermoxin). Caution! Cautious use of glucocorticoids in children! No treatment under occlusion!
    • From the subacute stage of eczema onwards, the combination of external therapy with UV therapy is recommended. Cave! No phototherapy for phototoxic and photoallergic eczema! A high-dose UVA1 treatment has proven to be effective in eczema therapy as well as the combination of brine baths with subsequent UVB irradiation. In case of therapy failure, PUVA bath therapy (if necessary locally) is recommended. Aftercare as above.

Internal therapy
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  • In the case of highly acute eczema, glucocorticoids (e.g. Solu Decortin H) i.v. in a dosage of 100-150 mg i.v. in rapidly balancing doses. Switch to oral therapy such as prednisone (e.g. Decortin) or cloprednol (e.g. Syntestan) and quickly balance out within one week. For pruritus antihistamines such as desloratadine (e.g. Aerius) 1-2 doses/day or levocetirizine (e.g. Xusal) 1-2 doses/day, if necessary antihistamines with sedative effect such as dimetinden (e.g. Fenistil) 3 times 1-2 doses/day.
  • In case of a pronounced superinfection with systemic reaction (such as fever, BSG acceleration, leukocyte increase) antibiotics internally with a broad spectrum of action such as cephalosporins.

Note(s)
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The term " dermatitis" includes the term eczema. The term "dermatitis" is much broader than the term "eczema" because it also includes diseases (e.g. hypereosinophilic dermatitis, dermatitis herpetiformis, etc.) which do not correspond to the much narrower definition of the term "eczema".

Also in histopathological (descriptive) language the term "dermatitis" claims a wide field for very different inflammatory patterns of the dermis (e.g. neutrophilic dermatitis, granulomatous dermatitis, etc.).

In international literature the term "eczema" is increasingly losing importance. The group of diseases traditionally referred to as "eczema diseases" such as "atopic eczema, contact allergic eczema, microbial eczema, seborrheic eczema etc. are internationally listed under the term "dermatitis": atopic dermatitis, seborrheic dermatitis, contact dermatitis etc. German-speaking dermatology will not be able to escape this trend. In this respect, the term "eczema" is replaced by the internationally used term dermatitis in this online encyclopaedia.

Literature
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  1. Breuer K et al (2003) The impact of food allergy in patients with atopic dermatitis. dermatologist 54: 121-129
  2. Dittmar HC et al (2001) UVA1 phototherapy. Pilot study of dose finding in acute exacerbated atopic dermatitis. dermatologist 52: 423-427
  3. Fritsch P (1998) Dermatology and Venereology, Textbook and Atlas. Springer, Berlin Heidelberg New York, S. 161-164
  4. Hafeez ZH (2003) Perioral dermatitis: an update. Int J Dermatol 42: 514-517
  5. Mehta SS, Reddy BS (2003) Cosmetic dermatitis - current perspectives. Int J Dermatol 42: 533-542
  6. Meurer M, Wozel G (2003) The treatment of atopic dermatitis in adults with topical calcineurin inhibitors. dermatologist 54: 424-431
  7. Nicolas ME et al (2003) Dermatitis herpetiformis. Int J Dermatol 42: 588-600
  8. Schempp CM et al (2002) Plant-induced toxic and allergic dermatitis (phytodermatitis). Dermatologist 53: 93-97
  9. Urbatsch AJ et al (2002) Extrafacial and generalized granulomatous periorificial dermatitis. Arch Dermatol 138: 1354-1358
  10. Wildemore JK et al (2003) Evaluation of the histologic characteristics of patch test confirmed allergic contact dermatitis. J Am Acad Dermatol 49: 243-248

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Last updated on: 19.12.2020