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Overview of dermatitis (eczematous dermatoses)

Overview of dermatitis (eczematous dermatoses)
Author:
William Howe, MD
Section Editor:
Robert P Dellavalle, MD, PhD, MSPH
Deputy Editor:
Rosamaria Corona, MD, DSc
Literature review current through: Sep 2022. | This topic last updated: Apr 15, 2022.

INTRODUCTION — Eczematous dermatoses are common, representing approximately 10 to 30 percent of dermatologic consultations across different populations and ethnic groups [1-3]. Specific types of eczematous dermatitis are more common in some age groups. As an example, atopic dermatitis is far more common in children than in adults, whereas asteatotic eczema and nummular eczema are typically seen in older adults.

A brief overview of the clinical features of the most common types of eczematous dermatoses is provided here. Additional information on diagnosis and treatment of individual types of dermatitis is provided separately.

(See "Seborrheic dermatitis in adolescents and adults".)

(See "Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis".)

(See "Treatment of atopic dermatitis (eczema)".)

(See "Management of severe atopic dermatitis (eczema) in children".)

(See "Evaluation and management of severe refractory atopic dermatitis (eczema) in adults".)

(See "Seborrheic dermatitis in adolescents and adults".)

(See "Clinical features and diagnosis of allergic contact dermatitis".)

TERMINOLOGY — The terms "dermatitis" and "eczema" are frequently used interchangeably. When the term "eczema" is used alone, it usually refers to atopic dermatitis (atopic eczema). "Eczematous" also connotes some scaling, crusting, or serous oozing as opposed to mere erythema. The term "dermatitis" is typically used with qualifiers (eg, "contact dermatitis") to describe several different skin disorders.

SEBORRHEIC DERMATITIS — Seborrheic dermatitis is a common, relapsing skin disorder that affects approximately 1 to 3 percent of adults [4,5]. Dandruff of the scalp is a mild form of seborrheic dermatitis characterized by scaling with minimal inflammation (picture 1). (See "Seborrheic dermatitis in adolescents and adults".)

In infants, seborrheic dermatitis of the scalp is often called "cradle cap." (See "Cradle cap and seborrheic dermatitis in infants".)

Clinical features – Seborrheic dermatitis presents with erythematous, scaly patches located in areas with a high density of sebaceous glands (picture 2A-I):

Lateral sides of the nose and the nasolabial folds

Eyebrows and glabella

Retroauricular folds

Scalp

Less commonly involved are the chest (picture 2J), upper back, and axillae (picture 3).

Associated disorders:

HIV infection – Seborrheic dermatitis is common in human immunodeficiency virus (HIV) infection and can be a presenting finding. It is clinically atypical, however, with greater severity (picture 4) and characteristically distinct histologic findings [6]. Seborrheic dermatitis may also be a cutaneous manifestation of the immune reconstitution inflammatory syndrome in patients on antiretroviral therapy (ART) [7]. (See "Immune reconstitution inflammatory syndrome".)

Parkinson disease – Seborrheic dermatitis is a common finding in Parkinson disease and in neuroleptic-induced parkinsonism, although the pathogenetic mechanisms underlying these associations are unclear [8]. Other neurologic disorders, including mood disorders and tardive dyskinesia, are also frequently associated with seborrheic dermatitis [4,9]. (See "Clinical manifestations of Parkinson disease", section on 'Nonmotor symptoms' and "Diagnosis and differential diagnosis of Parkinson disease", section on 'Drug-induced parkinsonism'.)

ATOPIC DERMATITIS — Atopic dermatitis (eczema) is a chronic, pruritic, inflammatory skin disease that occurs most frequently in children but also affects adults. The hallmarks of atopic dermatitis are dry skin, severe pruritus, and cutaneous hyperreactivity to various environmental stimuli. The clinical presentation varies with age:

Infants and toddlers – In infants and toddlers (<2 years), atopic dermatitis presents with pruritic, red, weeping or scaly, and crusted lesions on the extensor surfaces of limbs and on the trunk, face, and scalp (picture 5A-G).

Older children and adolescents – In older children and adolescents, atopic dermatitis typically presents with lichenified plaques in a flexural distribution, especially of the antecubital and popliteal fossae, volar aspect of the wrists, ankles, and neck (picture 6A-D).

Adults – In adults, atopic dermatitis is usually more localized, with predominant lichenification (picture 7A-E), but exudative forms can also be seen (picture 8); chronic hand eczema, facial dermatitis, and eyelid eczema are also frequently seen in adults (picture 9A-D).

Patients with atopic dermatitis often present a variety of minor cutaneous findings, the so-called atopic stigmata, which include:

Keratosis pilaris (picture 10A-C)

Palmar hyperlinearity (picture 11A-B)

Pityriasis alba (picture 12A-B)

Periorbital darkening (picture 13)

Dennie-Morgan infraorbital folds (picture 14A-B)

Nipple eczema (picture 15)

The clinical manifestations, diagnosis, and management of atopic dermatitis are discussed separately.

(See "Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis".)

(See "Treatment of atopic dermatitis (eczema)".)

(See "Management of severe atopic dermatitis (eczema) in children".)

(See "Evaluation and management of severe refractory atopic dermatitis (eczema) in adults".)

CONTACT DERMATITIS — Contact dermatitis refers to any dermatitis arising from direct skin exposure to a substance. The dermatitis may either be allergic or irritant-induced; the latter accounts for 80 percent of cases of contact dermatitis. In allergic contact dermatitis (ACD), an allergen induces an immune response, while in irritant contact dermatitis (ICD), the trigger substance itself directly damages the skin.

Allergic contact dermatitis — Allergic contact dermatitis (ACD) occurs when contact with a particular substance elicits a delayed (type IV) hypersensitivity reaction:

Common sensitizers – The most common sensitizer in North America is the plant oleoresin urushiol found in poison ivy, poison oak, and poison sumac (figure 1 and picture 16A-C) (see "Poison ivy (Toxicodendron) dermatitis"). Ginkgo fruit and the skin of mangoes also contain urushiol and can produce ACD.

Other common sensitizers in the United States include metals (eg, nickel in jewelry), preservatives (eg, formaldehyde and quaternium-15 in cosmetics and personal care products), fragrances (perfumes, cosmetics), topical antibiotics, and paraphenylenediamine (commonly used in hair dyes) [10]. (See "Common allergens in allergic contact dermatitis".)

Clinical presentation – ACD usually presents a well-demarcated, intensely pruritic, eczematous eruption localized to the area of skin that comes in contact with the allergen, for example, cosmetics on the face (picture 17A-B), nickel where jewelry is worn (picture 18C) or metal buttons in garments that are in contact with the skin (picture 18D), rubber and latex where gloves are worn (picture 18E) or elastic bands that contact the skin (picture 18F), and points of shoe that contact the feet (picture 18A-B).

Allergens applied to the scalp, including hair dyes and shampoos, may elicit dermatitis in adjacent areas, such as the neck, retroauricular folds, or eyelids (picture 19A-B). A diffuse or patchy dermatitis of the trunk, often with accentuation in the axillary folds, may be caused by cloth dyes or textiles (picture 18G).

Poison ivy, poison oak, and poison sumac typically cause an acute, eczematous reaction, with linear lesions representing the areas of contact with the plant leaves or stems (picture 20A-B). However, lesions can occur at other body sites due to transfer of the plant resin by the hands (picture 21). (See "Poison ivy (Toxicodendron) dermatitis".)

ACD, most frequently induced by fragrances, lanolin, preservatives, and topical antibiotics, is common in patients with stasis dermatitis [11]. ACD should be suspected in patients with recalcitrant stasis dermatitis that fails to improve or worsens despite appropriate skin care and topical therapy. (See "Stasis dermatitis", section on 'Contact sensitization'.)

The diagnosis and treatment of ACD and poison ivy dermatitis are discussed separately. (See "Clinical features and diagnosis of allergic contact dermatitis" and "Management of allergic contact dermatitis" and "Poison ivy (Toxicodendron) dermatitis".)

Irritant contact dermatitis — Irritant contact dermatitis (ICD) is the most common form of contact dermatitis. It results from exposure to substances that cause physical, mechanical, or chemical irritation of the skin [12]. Common irritants include water and wet work, soaps and cleansers, bleach, solvents, acids and alkalis, plant parts, paper, and dust or soil.

ICD of the hands is the most common type of occupational dermatitis, particularly among food handlers, health care workers, mechanical industry workers, cleaners, and housekeepers (table 1). (See "Irritant contact dermatitis in adults" and "Contact dermatitis in children", section on 'Irritant contact dermatitis'.)

Acute ICD presents with erythema, edema, vesicles and bullae, and oozing (picture 22A-C). In chronic ICD, lichenification, hyperkeratosis, and fissuring predominate. Mild irritants produce erythema, chapped skin, dryness, and fissuring (picture 22C). Pruritus and pain are accompanying symptoms. The hands are the usual site for ICD; the web spaces of the fingers trap irritating substances and may be the first area of involvement.

Rubber, nitrile, and vinyl gloves may also induce an ICD, which is distinct from latex allergy. Friction, as well as irritation from repeated moisture build-up under gloves, and the drying after the removal of the gloves can be contributing factors.

JUVENILE PLANTAR DERMATOSIS — Juvenile plantar dermatosis (JPD), also called dermatitis plantaris sicca, is an eczematous disorder involving the soles that typically occurs in children aged 3 to 14 years, more often in those with an atopic diathesis [13,14]. Its pathogenesis is unknown, although irritation from synthetic shoe materials, synthetic fabrics, friction, and sweating are thought to have a role. Histologically, JPD is characterized by subacute or chronic, spongiotic dermatitis with the distinctive finding of a lymphocytic infiltrate surrounding the eccrine sweat ducts [15].

Clinical presentation and diagnosis — JPD presents with redness and soreness of the plantar surface of the foot, which assumes a shiny, glazed, and cracked appearance (picture 23A-C). The web spaces between the toes and the dorsal aspect of the feet are typically spared.

The diagnosis of JPD is usually clinical. Skin scraping for a potassium hydroxide (KOH) preparation and patch testing can be performed to rule out a fungal infection or allergic contact dermatitis (ACD) from leather shoe chemicals or rubber. (See "Office-based dermatologic diagnostic procedures", section on 'Potassium hydroxide preparation' and "Patch testing".)

Treatment — JPD is a self-limiting condition and usually resolves spontaneously over a few years. Avoidance of synthetic socks and occlusive shoes and frequent use of emollients are the mainstay of treatment [16].

STASIS DERMATITIS — Stasis dermatitis, or stasis eczema, is a common, inflammatory dermatosis of the lower extremities occurring in patients with chronic venous insufficiency. It typically presents with erythematous, scaling, and eczematous patches or plaques on chronically edematous legs (picture 24A-C). Acute forms may present with severely inflamed, weeping plaques, vesiculation, and crusting, often with bacterial superinfection (picture 25).

Allergic contact dermatitis (ACD) due to sensitization to topical preparations, dressings, and topical antibiotics is a frequent complication. Hyperpigmentation, due to dermal hemosiderin deposition, scaling, and potential development of lipodermatosclerosis occur in chronic forms (picture 26A-B). (See 'Allergic contact dermatitis' above.)

Lipodermatosclerosis is a chronic form of panniculitis resulting from chronic inflammation, fat degeneration, and fibrosis, resulting in a constriction of the ankle region that gives the legs the appearance of an inverted champagne bottle (picture 27). (See "Stasis dermatitis" and "Clinical manifestations of lower extremity chronic venous disease", section on 'Lipodermatosclerosis'.)

ASTEATOTIC ECZEMA — Asteatotic eczema, also called eczema craquelé, is a common type of pruritic dermatitis that typically occurs on the lower extremities of older individuals with dry skin. Its incidence peaks during cold winter months. Water loss from the stratum corneum due to age-related skin barrier impairment is believed to be a key pathogenetic factor. Low environmental humidity (eg, cold and dry weather, central heating) and exposure to harsh detergents or irritants are well-known exacerbating factors.

In the vast majority of cases, asteatotic eczema is an isolated finding. Rarely, it may occur in association with an underlying condition (eg, malnutrition, hypothyroidism, malignancy) or as an adverse effect of certain drugs (eg, retinoids, antineoplastic agents) [17-21].

Clinical features and diagnosis — Asteatotic eczema typically presents with scaling and superficial fissuring of the skin resulting in the so-called "dried river bed" appearance, with varying degrees of inflammation (picture 28A-C). In severe cases, the fissures can be hemorrhagic. Pruritus is usually present.

The upper and lower extremities are the sites most commonly involved. Generalized forms have been rarely described in patients with cancer [17-19].

The diagnosis of asteatotic eczema is usually clinical. If performed, a skin biopsy usually shows a subacute, eczematous pattern with acanthosis, hyperkeratosis, mild spongiosis, and a superficial, perivascular, lymphocytic infiltrate.

Treatment — Asteatotic eczema usually responds promptly to treatment with mid-potency topical corticosteroids (groups 3 and 4 (table 2)). Emollients should be used liberally multiple times per day to avoid recurrence.

DYSHIDROTIC ECZEMA — Dyshidrotic eczema, also called acute palmoplantar eczema, pompholyx, or dyshidrosis, is an intensely pruritic, chronic and recurrent, vesicular dermatitis of unknown etiology that typically involves the palms and soles and lateral aspects of the fingers [22]. It occurs most commonly in young adults.

The typical physical finding is the presence of multiple small, deep-seated vesicles on the palmar or plantar skin, especially along the lateral aspects of the fingers and toes (picture 29A-E). The vesicles may coalesce to form large bullae (picture 30) and may become superinfected (picture 31). Vesicles and bullae persist for several weeks, desiccate, and resolve with desquamation (picture 32A-B). Erythema, scale, and fissures can occur in older lesions.

The clinical manifestations, diagnosis, differential diagnosis, and treatment of dyshidrotic eczema are discussed in detail separately. (See "Acute palmoplantar eczema (dyshidrotic eczema)".)

NUMMULAR ECZEMA — Nummular eczema, also called nummular dermatitis or discoid eczema, is a chronic, relapsing, inflammatory skin disease characterized by multiple pruritic, coin-shaped, eczematous lesions involving the extremities and, less commonly, the trunk (picture 33A-E) [23]. It occurs more frequently in middle-aged individuals, although individuals of all ages can be affected.

The clinical manifestations, diagnosis, differential diagnosis, and treatment of nummular eczema are discussed separately. (See "Nummular eczema".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Contact dermatitis (The Basics)" and "Patient education: Seborrheic dermatitis (The Basics)")

Beyond the Basics topics (see "Patient education: Contact dermatitis (including latex dermatitis) (Beyond the Basics)" and "Patient education: Seborrheic dermatitis (including dandruff and cradle cap) (Beyond the Basics)" and "Patient education: Eczema (atopic dermatitis) (Beyond the Basics)")

SUMMARY

Seborrheic dermatitis – Seborrheic dermatitis is a common skin disorder characterized by erythematous, scaly patches on the scalp, face, and upper trunk (picture 2B-J). Dandruff of the scalp is a mild form of seborrheic dermatitis characterized by scaling with minimal inflammation (picture 1). Severe seborrheic dermatitis is common in HIV infection. (See "Seborrheic dermatitis in adolescents and adults".)

Atopic dermatitis – Atopic dermatitis (eczema) is a chronic, pruritic, inflammatory skin disease that occurs most frequently in children but also affects adults. The clinical presentation varies with age. The face, scalp, and extensor limb surfaces are involved in infant and toddlers (picture 5A-G); the flexural areas are involved in older children and adolescents (picture 6A-D), and the hands and face are involved in adults (picture 9A-D). (See "Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis" and "Treatment of atopic dermatitis (eczema)".)

Allergic contact dermatitis – Allergic contact dermatitis (ACD) is a delayed hypersensitivity reaction following topical exposure to an allergen. Patients typically present with a pruritic eruption at the site of exposure (picture 17A-B, 18A-G, 19A-B). Common allergens include the plant oleoresin urushiol found in poison ivy, metals (eg, nickel in jewelry), preservatives, fragrances, topical antibiotics, and paraphenylenediamine (commonly used in hair dyes). (See "Clinical features and diagnosis of allergic contact dermatitis" and "Management of allergic contact dermatitis".)

Irritant contact dermatitis – Irritant contact dermatitis (ICD) is the most common form of contact dermatitis. It results from exposure to substances that cause physical, mechanical, or chemical irritation of the skin. The hands are commonly affected, particularly among food handlers, health care workers, mechanical industry workers, cleaners, and housekeepers. Patients may present with erythema, dryness, and/or fissuring of the skin (picture 22A-C). (See "Irritant contact dermatitis in adults".)

Juvenile plantar dermatosis – Juvenile plantar dermatosis (JPD) is an eczematous disorder involving the soles typically occurring in children aged 3 to 14 years. It presents with redness and soreness of the plantar surface of the forefoot, which assumes a shiny, glazed, and cracked appearance (picture 23A-C). (See 'Juvenile plantar dermatosis' above.)

Stasis dermatitis – Stasis dermatitis, or stasis eczema, is a common, inflammatory dermatosis of the lower extremities occurring in patients with chronic venous insufficiency. It typically presents with erythematous, scaling, eczematous patches and hyperpigmentation on chronically edematous legs (picture 24A-C). (See "Stasis dermatitis" and "Clinical manifestations of lower extremity chronic venous disease".)

Asteatotic eczema – Asteatotic eczema, also called eczema craquelé, is a common type of pruritic dermatitis that typically occurs on the lower extremities of older individuals with dry skin, especially during cold winter months. It typically presents with scaling and superficial fissuring of the skin resulting in the so-called "dried river bed" appearance, with varying degrees of inflammation (picture 28A-C). (See 'Asteatotic eczema' above.)

Dyshidrotic eczema – Dyshidrotic eczema, also called pompholyx, is an intensely pruritic, chronic and recurrent, vesicular dermatitis that typically involves the palms and soles and lateral aspects of the fingers. It typically presents with multiple small, deep-seated, vesicles on the palmar or plantar skin, especially along the lateral aspects of the fingers and toes (picture 29A-E). Large bullae may also form (picture 30). Erythema, scale, and fissures can occur in older lesions (picture 32A-B).

Nummular eczema – Nummular eczema, also called discoid eczema, is characterized by pruritic, round, eczematous plaques, most frequently found on the trunk and lower extremities (picture 33A-E). (See "Nummular eczema".)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges William L Weston, MD, who contributed to an earlier version of this topic review.

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