DermatitisDermatitisDermatitisDermatitis

• Definisi:Definisi:• Peradangan kulit (epidermis, dermis)

sebagai respons terhadap pengaruh faktorsebagai respons terhadap pengaruh faktor eksogen dan atau faktor endogen. Menimbulkan kelainan polimorfik (eritemaMenimbulkan kelainan polimorfik (eritema, edema, papul, vesikel, skuama, likenifikasi)likenifikasi)

EtiologiEtiologiEtiologiEtiologi

Faktor eksogen: bahan kimiafi ik (SUV)fisik (SUV)

Faktor endogen: Dermatitis Atopik

KlinisKlinisKlinisKlinis

Keluhan gatalKeluhan gatalKelainan kulit bergantung pada stadium• Akut : eritema edema vesikel/ bula erosiAkut : eritema, edema, vesikel/ bula, erosi,

eksudasi• Subakut: eritema ber ( ) eksudat kering krusta• Subakut: eritema ber (-), eksudat kering krusta• Kronis : lesi kering, skuama, papul, likenifikasi,

erosi ekskoriasierosi, ekskoriasi

Tatanama/KlasifikasiTatanama/KlasifikasiTatanama/KlasifikasiTatanama/Klasifikasi

• Belum seragamBelum seragam• Ada yg berdasarkan:

ti l i (DK D M dik t )etiologi (DK, D. Medikamentosa)morfologi (papulosa, eksfoliativa)bentuk (D. Nummularis)lokalisasi (D intertrigenous)lokalisasi (D. intertrigenous)

DERMATITIS

Eczema Contact Dermatitis

Non AllergicContactAllergic ContactNon AtopicAtopic Dermatitis

(Eczema / ContactDermatitisDermatitisDermatitis(Eczema /

Atopic Eczema)

DERMATITISDERMATITIS1. Nonspecific Eczemaous1. Nonspecific Eczemaous

DermatitisDermatitisDermatitisDermatitis2. Atopic Dermatitis2. Atopic Dermatitis3. Contact Dermatitis3. Contact Dermatitis4 Seborrheic Dermatitis4 Seborrheic Dermatitis4. Seborrheic Dermatitis4. Seborrheic Dermatitis5. Stasis Dermatitis5. Stasis Dermatitis6 Li h Si l Ch i6 Li h Si l Ch i6. Lichen Simplex Chronicus6. Lichen Simplex Chronicus

Histological DermatitisHistological DermatitisHistological DermatitisHistological Dermatitis

Histological: gIntercellular edema (spongiosis)inflammatory infiltrate in dermisy

- Acute dermatitis: erythema, edema, spongiosis causing vesicular

- Subacute dermatitis: less spongiosis, juicy papules

- Chronic dermatitis: thickened epidermis (lichenification)/acanthotic, slight spongiosis, scalling

The hallmarks of Eczematous The hallmarks of Eczematous D titiD titiDermatitisDermatitis

• 1 Marked pruritus1. Marked pruritus• 2. Indistinct border

3 E id l h b i l j i• 3. Epidermal changes by vesicles, juicy papules/lichenification

• 4. Localized/ diffuse• 5 Idiopathic/ cause by specific ethiology5. Idiopathic/ cause by specific ethiology

Regional DermatitisRegional DermatitisRegional DermatitisRegional Dermatitis• Ear Eczema• Eyelid dermatitis• Breast Eczema

H d E I it t h d d titi• Hand Eczema Irritant hand dermatitis• Vesicobullous Hand Eczema (Pompholyx, Dyshydrosis)• Chronic vesicobullous hand eczemaChronic vesicobullous hand eczema• Hyperkeratotic Dermatitis of the palms• Autosensitization Dermatitis• Xerotic Eczema• Nummular Eczema

Nummular eczemaNummular eczemaNummular eczemaNummular eczema

• Nummular dermatitisNummular dermatitis• Predominantly a disease of adulthood (50-

65 years) rare in infancy childhood65 years), rare in infancy, childhood• Man>Women• Characteristic: Oval patches with

crusted papulovesiclesLocalisation: Trunk

ExtremitiesExtremities

Nummular EczemaNummular EczemaNummular EczemaNummular Eczema• Also known as discoid eczema• A chronic disorder of unknown etiology• Papules and papulo vesicles cialescencePapules and papulo vesicles cialescence

to form nummular plazues with oozing, crust and scalecrust and scale

• Commone sites: upper extremities, dorsal hands in women lower extremities in manhands in women lower extremities in man

• Pathology acute, subacute, chronic eczema

Etiology and PathogenesisEtiology and PathogenesisEtiology and PathogenesisEtiology and Pathogenesis

• Pathog Is unknownPathog. Is unknown• Family history atopy (-)

H d ti f th ki i d d• Hydration of the skin is decreased• Role of infection• Role of invironmental allergen: HDM,

Cand

Clinical ManifestationClinical ManifestationClinical ManifestationClinical Manifestation

• Well demarcated coin-shape plaquesWell demarcated, coin shape plaques from coalescing papules and papulovesiclespapulovesicles

• Pinpoint oozing, crusted entire surfacePl 1 3 i i• Plaque 1-3 cm in size

• Surrounding skin is normal/ xerotic• Pruritus• Central resolution annular formCentral resolution annular form

Clinical ManifestationClinical ManifestationClinical ManifestationClinical Manifestation

• Chronic plaque are dry scaly and• Chronic plaque are dry, scaly and lichenifiedL b t t t t h t t b f l i• Laboratory test: patch test maybe seful in chronic recalcitrant– rule out

i d CDsuperimposed CD

Dermatitis NumularisDermatitis NumularisDermatitis NumularisDermatitis Numularis

Differential DiagnosisDifferential DiagnosisDifferential DiagnosisDifferential Diagnosis

Acute vesico papular dermatitis:Acute vesico papular dermatitis:Contact dermatitisInfections: Dermatophyte HS virusInfections: Dermatophyte, HS virus,

Varicella Zoster, BacteriaCh i i l d titiChronic vesico papular dermatitis:

Chronic CD, psoriasis, drug eruption,fungal infect

TherapyTherapyTherapyTherapy1. Corticosteroid:

- topically (under occlution)- injectable intralesional

sistemic- sistemic2. Calceneurin inhibitors: tacrolimus,

pimecrolimus3. Wide spread acute/ subacute eczematous:

prednisone/ triamcinolone 40 mg/i mwet dressing/bath: acute dermatitiswet dressing/bath: acute dermatitis

4. Chronic: baths containing oil moisturizers/emmolient5. Itching: hydroxyzine/ diphenhydramineg y y p y

Atopic Dermatitis in ChildAtopic Dermatitis in Child

Lichen Simplex ChronicusLichen Simplex ChronicusLichen Simplex ChronicusLichen Simplex Chronicus• Also known as neurodermatitis

i i t / i ib dcircumcripta/ circumscribed neurodermatitis

• Chronic, severely pruritic characterized by one or more lichenified plaques the skin is thickend

• Most common sites: scalp, nape of neck, p, p ,extensor aspects of extremities, ankles,

• Anogenital regionAnogenital region

Etiology and PathogenesisEtiology and PathogenesisEtiology and PathogenesisEtiology and Pathogenesis

• Induced by rubbing and scratchingInduced by rubbing and scratching secondary to itch

• Environmental factors inducing itch• Environmental factors inducing itch• ( heat, sweat, irritation)• Emotional/ psychological factors

(depression, anxiety)

Clinical FindingClinical FindingClinical FindingClinical Finding

• Severe itching (the hallmark of LSC)Severe itching (the hallmark of LSC)• Paroxysmal, continous/ sporadic

R bbi d t hi• Rubbing and scratching• Itch severity is worse with sweating, heat/

irritation from clothing/ psychological distress

Cutaneous LesionsCutaneous LesionsCutaneous LesionsCutaneous Lesions• Repeating rubbing and

t h li h ifi d (thik d ki ithscratch lichenified (thikened skin with accentuated skin marking)

• Scally plaque with excoriations• Hyper and hypopigmentation chronicityyp yp p g y• One plaque or more• Sites: scalp the nape of neck (women)• Sites: scalp, the nape of neck (women)

ankles, extensor aspect o/t extremities, it lanogenital

Pathology LSCPathology LSCPathology LSCPathology LSC

• Hyperkeratosis, hypergranulosis, psoriasisform epidermal hyperplasiapsoriasisform epidermal hyperplasia, thickened papillary dermal collagen

Liken Simplek Kronikus/ Liken Simplek Kronikus/ N d titiN d titiNeurodermatitisNeurodermatitis

TherapyTherapy

DifficultT ili d ti d tTranquilizer and anti depressantsTopical steroid and intralesional steroid

Xerotic EczemaXerotic EczemaXerotic EczemaXerotic Eczema

• Is the results of low humidity and dry skin

• Clinis: dry fissure skin trunk, extremities(lower leg)

Autosensitization/Id eruptionAutosensitization/Id eruptionAutosensitization/Id eruptionAutosensitization/Id eruption

• - generalized sub acute dermatitisf t/h d• - feet/hands

• - Hypersensitivity reaction to substance produced by the acute dermatitis

Dyshidrotic EczemaDyshidrotic EczemaDyshidrotic EczemaDyshidrotic Eczema

• -Characteristic: deep seated vesicles ( hi h bl th l i t i(which resemble the pearls in tapioca pudding)

• -Palm, soles, side of fingers• -Bilaterally symmetricallyBilaterally, symmetrically

CONTACT DERMATITISCONTACT DERMATITIS

An inflammatory reaction ofAn inflammatory reaction ofAn inflammatory reaction of An inflammatory reaction of the skin precipitated by an the skin precipitated by an

exogenous chemicalexogenous chemical

Contact DermatitisContact Dermatitis1.1. Irritant CD: produced by Irritant CD: produced by

substance that has direct toxic substance that has direct toxic effect on the skineffect on the skin

2.2. Allergic: trigger an Allergic: trigger an immunologic reactionimmunologic reaction tissue tissue gginflammationinflammation

PathogenesisPathogenesisPathogenesisPathogenesis

• Irritant CD: nonspecific inflammatoryIrritant CD: nonspecific inflammatory reactions due toxic injury of the skin

• Allergic CD: Cell mediated immunity/• Allergic CD: Cell mediated immunity/ type IV

A. Sensitization phaseB. Elicitation Phase

Sensitization: hapten + protein LCs Th1

type IV

antigens

T

inflammatorymediators lymphokines

activated macrophage

IrritantsIrritantsIrritantsIrritants

Subtances direct toxic effect of the skin• AcidsAcids• Alkalis• Solvents• Solvents• Detergents

AllergensAllergensAllergensAllergens

Triggers immunologic reaction tissueTriggers immunologic reaction tissue inflammation

• Metals• Plants• Rubber chemicalsRubber chemicals• Medicines

Incidence:Incidence:

-- Frequent problemFrequent problem-- 50% occupational illness50% occupational illness

HistoryHistoryHistoryHistory

First determine: ACD/ICDFirst determine: ACD/ICD• Strong irritant several hours skin damage• Weaker irritants multiple application & daysWeaker irritants multiple application & days

dermatitis• Allergic Contact Dermatitis:Allergic Contact Dermatitis:

– Requires 24-48 hours– Often exposure Clinical diseasep– Occasionally dermatitis (8-12 hours) up to 4-7 hours– Detailed history of occupation, hygiene habits, hobbies

The most common SensitizersThe most common Sensitizers

• Poison Ivyy• Para phenylenediamine• Nickel• Rubber compounds• EthylenediamineEthylenediamine• Poison ivy: in the summer

– Allergen: pentadecylcatechol (oleoresin of the plant)Allergen: pentadecylcatechol (oleoresin of the plant)

PPDPPDPPDPPD

• Permanent coloring of hair• Cross reaction : Azo, aniline dye,

Benzocaine procaineBenzocaine, procaine, HydrochlorothiazineSulfonamides

When completely oxidized (fur coat), PPD not allergenic

NickelNickelNickelNickel

• Most commonly in womanMost commonly in woman• Ear piercing

I ll t l• In all metals• “Hypoallergenic” earring: one cannot be

certain that they are free of nickel• Stainless steel: nickel bound so tightlyg y

ACD (-)

Rubber compoundRubber compoundRubber compoundRubber compound

• Shoes ACD on dorsa of the feetAll M t b thi l• Allergen: Mercaptobenzothiazole

Thiurams

EthylenediamineEthylenediamineEthylenediamineEthylenediamine

Preservative in Mycolog cream, ointment (-)Dyes, insecticides, Rubber accelerators, Synthetic waxes, y ,In aminophyllin

Sensitive individual generalizedSensitive individual generalized eczematous dermatitis

Physical ExaminationPhysical ExaminationPhysical ExaminationPhysical Examination

• Acute/chronic• Depend upon the nature of the exposure

patches/plaque, angular corner, geometric on p p q , g , glines, sharp margin

• Localization: Head& neck: cosmetics, hair dyes, permanent waves, shampoosEyelid: eye cosmetic nail polishEyelid: eye cosmetic, nail polishPhoto allergic: produce by a photoreaction between SUV & allergen of the neck armsbetween SUV & allergen, of the neck, arms

Physical ExaminationPhysical ExaminationPhysical ExaminationPhysical Examination

• The dorsum of the hands: industrialThe dorsum of the hands: industrial chemicals (irritants): petroleum, solvents

• The dorsum of the feet: shoes (rubber• The dorsum of the feet: shoes (rubber, leather tanning agents)G i d b tt k i i f t Di• Groins and buttocks in infants: Diaper dermatitis: moisture and feces

DiagnosisDiagnosisDiagnosisDiagnosis

• Patch test: The test material, in different vehiclesPatch test: The test material, in different vehicles (commonly white petrolatum)

• Is applied to the skin under a metal disc, called a pp ,Finn chamber

• A test battery of 20-24 allergens is used as y gstandard allergens

• The sheet is placed on the upper back, scaled with adhesive tape

• The patch is removed after 48 hours read

TherapyTherapyTherapyTherapy

• PreventionPrevention• Avoidance of irritant/allergen change in life

style & occupationy p• Protective clothing• Occupational: protective barrier cream littleOccupational: protective, barrier cream little

benefit• SubstitutedSubst tuted• Topical steroid• AntihistamineAntihistamine

Dermatitis Kontak IritanDermatitis Kontak Iritan

DKI pd tangan & ujungDKI pd tangan & ujung--ujung jari akibat asamujung jari akibat asam

Dermatitis Kontak AlergiDermatitis Kontak AlergiDermatitis Kontak AlergiDermatitis Kontak Alergi

DKA akibat kalung nikelDKA akibat kalung nikel DKA akibat semenDKA akibat semengg

Fotoalergi Fotoalergi (D titi B l )(D titi B l )(Dermatitis Berloque)(Dermatitis Berloque)

Seborrheic Dermatitis/ Morbus Seborrheic Dermatitis/ Morbus UUUnnaUnna

• Definition: a chronic, superficial, inflammatory process affecting the hairy regions of the body

/• Etiology: unknown/ Pityrosporum ovale

D d ff i li f th l ith tDandruff is scaling of the scalp without inflammation

• Incidence: a common problem 2-5%• Incidence: a common problem, 2-5%adult 18-40 years, baby (cradle cap), children 6-10 years woman> manchildren 6 10 years, woman> man

Seborrheic DermatitisSeborrheic Dermatitis• Predilection hairy

region: scalp eyebrowregion: scalp, eyebrow• eyelid• Nasolabial creases• Nasolabial creases,

ears, chest

HistoryHistoryHistoryHistory

• The occurrence of SeborrheicD titi ll l th i dDermatitis parallels the increased sebaceous gland activity occurring in i f t ft b t itinfant, after puberty, pruritus

Physical examinationPhysical examinationPhysical examinationPhysical examination

• Predilection for the hairy regions where there y gare numerous sebaceous gland: scalp, eyebrows, eyelids, nasolabial creases, ears, chest intertriginous area: axilla groin buttockschest, intertriginous area: axilla, groin, buttocks, infra mammary folds

• Bilateral and symmetricallyBilateral and symmetrically• Most mild form, dandruff, fine whittis scaling

without erythema.• Patch/plaque: indistinct margin, erythema,

yellowish, greasy scaling, uncommon hair loss

Physical examination S.DPhysical examination S.DPhysical examination S.DPhysical examination S.D

• Mild form: dandruff fine whitish scalingMild form: dandruff fine whitish scaling without erythema / Pityriasis sica

• Mild Moderate: erythema yellowish• Mild Moderate: erythema, yellowish greasy scaling

DDDDDDDD1. A.D (infantile eczema)

if i f t L di & illif infant Loc: diaper area & axilladiagnosis S.DIf l i f hi ADIf lesion: forearms, shins AD

2. Psoriasis: scalp, groin, other areapapilosquamous patches &papilosquamous patches & plaque

3 T capitis: hair loss urban black3. T. capitis: hair loss, urban blackBiopsy : non diagnostic

Therapy S.DTherapy S.DTherapy S.DTherapy S.D

• Anti seborrheic shampoos (sulfur salicylicAnti seborrheic shampoos (sulfur, salicylic acid, selenium sulfide, zinc pyrithione)

• Shampoos must be rubbed in to the• Shampoos must be rubbed in to the scalp 5-10 minutesI fl S b h i• Inflam. Seborrrheic:

• topical steroid lot/gel in hairy area; hydrocortisone cream non hairy skin

STASIS DERMATITISSTASIS DERMATITISSTASIS DERMATITISSTASIS DERMATITIS

D fi tiD fi tiDefination:Defination:

An eczematous eruption of the An eczematous eruption of the lower leglower leg secondary to peripheralsecondary to peripherallower leglower leg secondary to peripheral secondary to peripheral venous diseasevenous disease

STASIS DERMATITISSTASIS DERMATITIS

Venous incompetenceVenous incompetence hydrostatichydrostaticVenous incompetence Venous incompetence hydrostatic hydrostatic pressure, capillary damagepressure, capillary damage extravasation of extravasation of red blood cell & serumred blood cell & serum inflammatoryinflammatoryred blood cell & serumred blood cell & serum inflammatory inflammatory eczematous processeczematous process

IncidenceIncidence

• Adults (middle age old age)

• History: Chronicpruritic eruptionpruritic eruptionprecede by edema & swelling

Patients with Stasis dermatitis have oftenPatients with Stasis dermatitis have often had thrombophlebitis

Physical examinationPhysical examination

Varicose vein are prominent1. Edema2. Brown pigmentationg3. Petechiae4. Sub acute and chronic dermatitis5. Thickened skin, scaling and /or weeping6. Any portion of the leg prominent site is6. Any portion of the leg prominent site is

above the medial malleolus

TherapyTherapyTherapyTherapy

- Prevention of venous stasis and edemaPrevention of venous stasis and edema use of supportive hose

- Standing should be restrictedg- Patients who are obese weight reduction- If this fails bed rest with elevation of legsIf this fails bed rest with elevation of legs- Topical steroid- Wet compresses if there is oozing or- Wet compresses if there is oozing or

crusting

HistoryHistory

-- Patient may have history of emotional or Patient may have history of emotional or psychiatric problempsychiatric problem

Physical ExaminationsPhysical ExaminationsPhysical ExaminationsPhysical Examinations

• Patients: anxiousLi h ifi d l t hi ( )• Lichenified plaque, scratching (+)

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