Eczema

Eczema is an allergic disease accompanied by an inflammatory and dystrophic reaction of the skin, developing against the background of changes in the body's reactivity, prone to chronic relapsing course, characterized by polymorphism of elements, among which bubbles predominate.

[1], [2], [3], [4], [5], [6]

Causes and pathogenesis of eczema

The cause of eczema is not well understood. In the occurrence of the disease, both exogenous (chemical, medicinal, food and bacterial antigens) and endogenous (antigen determinants of microorganisms from foci of chronic infection, intermediate metabolic factors) play an important role. In the pathogenesis of the disease, the leading role is played by immune inflammation of the skin, which develops against the background of the appearance of cellular and humoral immunity, non-specific resistance of hereditary genesis. The hereditary nature of the disease has been proven by the frequent detection of histocompatible HLA-B22 and HLA-Cwl antigens.

Diseases of the nervous and endocrine systems, the gastrointestinal tract, etc. Are also of great importance.

According to modern concepts, development is associated with a genetic predisposition, which is confirmed by the positive association of histocompatibility system antigens.

A characteristic feature of the disease are disorders in patients with the activity of the immune and central nervous system. The basis of immune disorders is increased production of prostaglandins. The latter, on the one hand, activate the production of histamine and serotonin, on the other hand, they suppress the reactions of cellular immunity, first of all, the activity of T-suppressors. This contributes to the development of an inflammatory allergic reaction, accompanied by an increase in the permeability of the vessels of the dermis and intercellular edema, to spongiosis in the epidermis.

Changes in the activity of the nervous system lead to a deepening of immune disorders, as well as changes in the trophism of the skin. In patients, the sensitivity of the skin to the action of various exo- and endogenous factors is increased, which is realized by the type of viscerocutaneous, kutano-kutanny pathological reflexes.

Reduced immunity in combination with trophic disorders leads to a decrease in the protective function of the skin to various antigens and microorganisms. Tone sensitization that develops at the onset of the disease, as it progresses, is replaced by a polyvalent characteristic of eczema.

[7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17]

Symptoms of eczema

During the course of true eczema, it is customary to distinguish three phases: acute, subacute, chronic.

For an acute eczematous process, an evolutionary polymorphism of lesions is characteristic, when different morphological elements are simultaneously encountered. On the erythematous, slightly edematous, background, there are rashes of the smallest nodular elements and vesicles, pinpoint erosion - eczematous wells, like dew, serous exudate (weeping), small petioles, small crusts, subsiding hyperemia.

The acute stage of the disease is characterized by the appearance of erythema on the skin, edema of various sizes and shapes with clear boundaries. The primary morphological element is micro-vesicles, prone to grouping, but not to merge. Bubbles quickly open to form point erosions that separate a clear, opalescent fluid (Devery's “serous wells”), which dries to form serous crusts. Subsequently, the number of newly formed bubbles decreases. After the resolution of the process, fine-plate peeling remains for some time. Sometimes, due to the addition of a secondary infection, the contents of the vesicles become purulent, pustules and purulent crusts are formed. A characteristic feature is the true polymorphism of elements: microvesicles, microerosion, microcori.

In the subacute form of the disease, the change of stages can occur in the same way as in the acute, but the process proceeds with less pronounced weeping, hyperemia and subjective sensations.

For the chronic form of the presence of increasing infiltration and lichenification in the lesions. The process is wave-like, remissions are replaced by relapses. The intensity of itching varies, but itching is almost constant. Moisture is observed during exacerbation of a chronic type of the disease. Despite the long course, after treatment, the skin becomes normal. Chronic eczema, as well as acute, occurs on any areas of the skin, but more often localized on the face and upper extremities. A disease occurs at any age, somewhat more often in women.

A true eczematous process occurs at any age and is characterized by a chronic course with frequent exacerbations. Rashes are located on symmetrical areas of the skin, capturing the face, upper and lower extremities.

One of the most common forms is chronic, lichened eczema, which is characterized by infiltration and lichenification of the skin. Frequent localization on the neck and limbs resembles a limited atopic dermatitis.

The dyshydrotic eczematous process is localized on the palms and soles and is represented by sago-like dense bubbles, erosive patches and scraps of bubble tires along the periphery of the lesion. It is often complicated by secondary pococcal infection (impetiginization), which in turn can lead to the development of lymphangitis and lymphadenitis.

For coin-like disease, along with infiltration and lichenification, there is a sharp limitation of lesions. The process is localized mainly in the upper extremities and is represented by round-shaped foci. Pustulization is relatively rare. Exacerbations are observed more often in the cold season.

In its clinical manifestations, the priest form resembles pruritus, but is distinguished by a later onset and a tendency to exoserosis in isolated sites. Dermographism in most patients - red.

The varicose type is one of the manifestations of the varicose symptom complex, is localized in most cases on the legs and is very similar to paratraumatic eczema. Clinical features include significant sclerosis of the skin around the varicose veins.

The rarer varieties of the chronic form of the disease include winter eczema. Although it is believed that the occurrence of the disease is associated with a decrease in the level of superficial lipids of the skin, the pathogenesis remains unclear. The majority of patients showed a decrease in the amino acid content in the skin, in patients with a severe course of the disease, a decrease in lipid levels leads to a loss of the liquid part of the skin by 75% or more and thus to a decrease in the elasticity and dryness of the skin. A dry climate, cold, hormonal disorders contribute to the occurrence of this pathology.

The winter form of the eczematous process often accompanies diseases such as myxedema, enteropathic acrodermatitis, and occurs when taking cimetidine, irrational use of local corticosteroids. The disease most often occurs at the age of 50-60 years.

In patients suffering from a winter-looking pathology, the skin is dry and slightly flaky. The skin-pathological process is often located on the extensor surface of the limbs. The fingertips are dry, have small cracks and resemble parchment paper. On the legs, the pathological process is deeper, the cracks often bleed. The focus of the outbreak is uneven, erythematous and slightly elevated. In the future, patients are subjectively worried about itching or pain due to cracks.

The flow is unpredictable. Remission may occur in a few months, with the beginning of the summer. Relapses mainly occur in winter. Sometimes, regardless of the season, the process lasts a long time. In severe cases, itching, scratching and irritation on contact lead to a rash of diffuse vesiculo-squamous rash and the development of a true or numular form of eczema. However, the relationship between the winter form of pathology and these two species remains unclear until the end.

In the case of a cracked form of the disease, the unsharply limited red background of the skin is covered with translucent thin and at the same time broad whitish-gray scales of polygonal outlines. This peculiar picture gives the impression of cracked skin. Localized almost exclusively on the legs. Subjectively marked itching, burning, feeling of tightening of the skin.

Horny look localized on the palms and less often - on the soles. The clinical picture is dominated by hyperkeratosis phenomena with deep painful cracks. The boundaries of foci are indistinct. More sore than an itch. Moisture is extremely rare (during the exacerbation).

The contact form of pathology (eczematous dermatitis, occupational eczema) occurs under the influence of an exogenous allergen in a sensitized organism and usually has a limited, localized nature. Most often located on the rear of the brushes, the skin of the face, neck, in men - on the genitals. Polymorphism is less pronounced. Quickly treatable by eliminating contact with a sensitizing agent. Very often, the contact form is caused by professional allergens.

The microbial (posttraumatic, paratraumatic, varicose, mycotic) eczematous process is distinguished by an asymmetric location of the lesions, mainly on the skin of the lower and upper extremities. A characteristic sign is the presence of infiltrated background, along with areas of soak, pustular rash, purulent and hemorrhagic crusts.

The foci are bordered by a border of exfoliated zpidermis on their periphery, you can see pustular elements, impetiginous crusts. The patchy (monet-like) form is characterized by a symmetrical generalized nature of the lesion in the form of slightly infiltrated spots with a slight weeping and sharp boundaries.

Seborrheic eczema is characterized by the appearance of a process on the scalp with subsequent transition to the neck, auricles, chest, back and upper limbs. The disease usually occurs on the background of oily or dry seborrhea, in both cases - on the scalp. Further, weeping may occur with subsequent accumulation of a large number of crusts on the surface of the skin. The skin behind the auricles is hyperemic, swollen, covered with cracks. Patients complain of itching, soreness, burning. Possible temporary hair loss.

Lesions may also be localized on the skin of the trunk, face and limbs. Dotted follicular nodules appear yellowish-pink in color, covered with greasy greyish yellow scales. Merging, they form plaques with scalloped outlines. Many dermatologists call this disease "seboroids".

Microbial eczematous process in the clinic is close to seborrheic; it also has lesions with sharp edges, often covered with dense, greenish-yellow, and sometimes bloody crusts and scales; more or less pus is usually found beneath them. After peeling, the surface is glossy, bluish-red, weeping and bleeding in places. This type of disease is characterized by a tendency of lesions to peripheral growth and the presence of a corolla of flaking epidermis around the periphery. Around them are the so-called screenings (small follicular pustules or conflict). Itching increases at the time of exacerbation. Localized disease most often on the legs, mammary glands in women, sometimes on the hands. It occurs in most cases at the site of the chronic Pococcal process and is distinguished by asymmetry.

Microbial eczema should be distinguished from the impetiginous secondary pyococcal infection arising from the complication of the eczematous process.

Yeast eczema is a chronic type of candidiasis (candidosis, monidiasis) caused by Candida albicans, tropicalis, crusei. Increased humidity and repeated maceration of the skin of a mechanical and chemical nature, weakening of the immunobiological resistance of the body, impaired carbohydrate metabolism, avitaminosis, diseases of the gastrointestinal tract, prolonged contact with products that contain yeast and other factors contribute to the formation of yeast skin lesions.

Candidiasis of the skin with a subsequent yeast eczematous process is observed mainly in the natural folds (in the groin, around the anus, genitals), around the mouth, on the fingers. On the hyperemic skin, flat, flaccid vesicles, pustules appear, which quickly burst and erode. Dark red erosions with brilliant liquid, edema, polycyclic outlines, sharp boundaries and a corolla underwent macerated epidermis. By merging erosion, large areas with a garland shape are formed. There are new rashes around. In some patients, the elements have the appearance of solid, slightly moist erythematous foci. Candidiasis can affect the interdigital folds of the hands (usually the third interval), the head of the penis and the skin of the preputial sac, palms and soles, field rollers and nails, lips, etc., in isolation.

According to the clinical course, the mycotic type of pathology is similar to dyshydrotic and microbial. It occurs in persons suffering from long-term mycosis of the feet. Characterized by the appearance of multiple bubbles, mainly on the lateral surfaces of the toes, palms and soles. Bubbles can merge and form multi-chamber cavities and large bubbles. After opening the bubbles, wet surfaces appear, and as a result of drying, crusts form. The disease is accompanied by swelling of the extremities, itching of varying severity, often joined by a pyococcal infection.

[18], [19], [20], [21]

Eczema classification

There is no single universally accepted classification of eczema. Rational division is true, contact; microbial (mycotic) forms.

[22], [23], [24]

Differential diagnosis

Eczema must be differentiated from diffuse neurodermatitis, dyshidrosis, and allergic dermatitis.

Dyshidrosis usually occurs in spring and summer against the background of vegetative-vascular dystonia and is characterized by the localization of the bubbles on the palms. Bubbles are sized with a pinhead and a tight tire, transparent contents. After a few days, the bubbles either shrink or open to form erosions, and then regress.

Allergic dermatitis occurs when repeated contacts with various household and professional chemical agents (cosmetics, medicines, washing powders, varnishes, paints, chromium, cobalt, nickel salts, plants, etc.) due to sensitization to them.

According to the clinical picture, the process resembles acute eczema, but on the background of hyperemia and edema, not microvesicles appear, but larger bubbles. The course is more favorable, the manifestations disappear after eliminating contact with the allergen.

[25], [26], [27], [28], [29], [30], [31], [32]

Eczema treatment

The general treatment is to prescribe sedatives (bromine, valerian, camphor, novocaine, etc.), antidepressants in small doses (depres, lyudiomil, etc.), desensitizing drugs (calcium chloride or calcium gluconate, sodium thiosulfate, etc.), antihistamine drugs (tavegil, loratal, analergin, fenistil, etc.), vitamins (B1, PP, rutin, etc.), diuretics (hypothiazide, uregit, fonurit, furosemide, etc.). In the absence of the effect of therapy, corticosteroid drugs are prescribed orally. The dose depends on the severity of the course, usually prescribed 20-40 mg per day.

Local treatment depends on the period of the disease. When soaking, lotions are prescribed (resorcinol 1%, zinc 0.25-0.5%, Sol. Argenti nitrici 0.25%, furatsillin, rivanol), in the subacute form - pastes (naphthalan, ichthyol 2-5% - and in chronic eczema - boron-tar paste, ointment with ASD 5-10% (B fraction), hormonal ointments, etc.

From antipruritic remedies, fenistil-gel has a good effect when it is topically applied 3 times a day.

The literature data show that elidel has a high therapeutic effect, reducing the duration of treatment. The effectiveness of therapy is enhanced by the combination of elidel with local glucocorticosteroids.

[33], [34], [35], [36], [37]

The basic principles of treatment

• It is necessary to prescribe a diet with reduced consumption of table salt, carbohydrates, with the exception of nitrogenous extracts, food allergens, including citrus, with the inclusion in the diet of vegetables, fruits, lactic acid products, cottage cheese.
• For the purpose of desensitization, it is recommended to take calcium salts, sodium thiosulfate, antihistamines (diphenhydramine, diprazine, suprastin, tavegil, etc.).
• The use of sedatives (bromides, tinctures of valerian, motherwort, tazepam, seduxen, etc.).
• The use of vitamins A, C, PP, and group B as stimulants.
• The choice of dosage form for external use depends on the severity of the inflammatory response, the depth of infiltration and other manifestations of the disease. In the acute stage, in the presence of microvesicles, erosion, exudation, lotions and wet-drying dressings are shown with a c1-2% tannin solution, 1% resorcinol solution, in a subacute - oil suspensions with norsulfazol or dermatol, paste (5% boric naphthalan. 1-5 % tar, 5% ASD 3-I fraction), in the chronic stage - ointment (tar, dermatol, boron-naphthalan, etc.).
• Physiotherapeutic methods: ultrasound, hydrotherapy, suberythemal doses of ultraviolet rays (in the recovery phase), etc.

Eczema relapse prevention

• In-depth examination of patients in order to identify comorbidities, the appointment of corrective therapy
• Rational employment: vocational guidance of sick adolescents.
• Dieting.
• Clinical examination of patients.

The frequency of observation by a dermatologist 4-6 times a year, a therapist and a neurologist - 1-2 times a year, a dentist - 2 times a year.

Examination volume: clinical blood and urine tests; analysis of feces on the eggs of worms (2 times a year); biochemical studies (blood for sugar, protein fractions, etc.); allergological studies characterizing the state of cellular and humoral immunity.

• Spa treatment.

[38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48]