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Nummular Eczema

  1. Clinical Presentation
    Nummular eczema (discoid eczema) is characterized by circular or oval plaques of eczema with a clearly demarcated margin . The typical lesions are coin-shaped, 1 to 5 cm in diameter itchy plaques. There are commonly distributed on the extremities and can become generalized. Acute lesions may be vesicular; chronic lesions may become scaly, cracked and confluent.
  2. Differential Diagnoses
    Allergic or irritant contact dermatitis have primary lesions conform to area exposing to allergens/irritants, and a contact history is often present. Ringworm infection presents as annular, scaly erythematous patches or plaques with central clearing. Psoriatic plaques are well marginated with prominent scales. Irritation is variable. Lesions of chronic superficial dermatitis are dry, indolent patches.
  3. Management
    Treatment is similar to other forms of eczema and depends on the stage of activity. A course of mild to potent topical corticosteroid combined with topical or systemic antibiotic is effective since infection is commonly associated;
  4. Asteatotic Eczema (Xerotic Eczema, Eczema Craquele)
    1. Diagnostic feature
      Lesions are mainly distributed over the hands and legs; and consist of minute, thin fissures, with minimal inflammation.
    2. Clinical presentation
      It commonly occurs in the elderly and people with dry skin especially in winter times when the humidity is low. The condition is thought to due to a reduction of in skin surface lipid. Distal parts of the extremities especially the legs are affected. The skin is dry, slightly scaly and criss-crossed on the surface to produce a reticulate pattern. The borders of this reticulation can become erythematous and slightly raised, and finally eczematous. The patient feels itchy, sting and burnt.
    3. Management
      The mainstay of treatment is to reduce moisture loss and to maintain the surface lipid layer. Reducing the bathing frequency to an acceptable level; avoiding hot bath, restricting soap are good measures. Ordinary soaps should be replaced by soap substitute and emollients should be used as frequently as appropriate. Inflammation can be controlled by application of mid potency topical steroid ointment.
  5. Stasis Dermatitis (Gravitational Eczema, Varicose Eczema, Venous Eczema)
    1. Diagnostic feature
      A history of preceding non-inflammatory swelling, distributed over the ankles and association with varicose veins.
    2. Clinical presentation
      Acute inflammation is characterized by a red, superficial, itchy plaque with weeping and crusting on the lower limbs especially the medial side of lower legs, ankles and calves. This is due to a combination of eczematous changes and cellulitis. A vesicular eruption (id reaction) on the palms, trunk, extremities sometimes accompanies this acute inflammation. In subacute and chronic stages, an increased hydrostatic pressure lead to extravasation of red blood cells from the leg veins. Disintegration of these red blood cells lead to haemosiderin deposition (Lipodermato sclerosis). The skin looks dry, scaly, hyperpigmented and accompanied with white atrophic changes ('atrophie blanche'). Ulceration is common in the late stage and is a serious consequence.
    3. Aetiology
      Venous insufficiency is a major factor Allergic response to an epidermal protein antigen created through increased venous pressure, susceptibility to minor trauma and irritation are the contributing factors.
    4. Management
      The dry eczematous inflammation can be managed with lubricants and topical corticosteroids. Moist exudative inflammation and moist ulcers respond to tepid wet compress of KMnO4 solution several times a day. Any infection should be identified and treated promptly. Oral antibiotic appropriate to the organism is more preferable than topical antibiotic which should be avoided. Physiotherapy, elevation of legs and compression stocking are helpful. Patients with varicose veins should be referred to the vascular surgeons for early assessment and prompt treatment.

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