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Lichen Simplex (Circumscribed Neurodermatitis)

  1. Definition
    1. Lichenification denotes a cutaneous response to repeated rubbing or scratching.
    2. It is characterized clinically by a thickened appearance of the skin, with accentuation of the surface markings so that the affected skin surface resembles tree bark.
    3. Lichen simplex is a circumscribed area of lichenification resulting from repeated rubbing and scratching occurring on some predilected sites.
    4. This term is used when there is no known predisposing skin disorder.
  2. Clinical Features
    1. Women are more common affected than men.
    2. Pruritus is the predominant symptom and is often out of proportion to the extent of the objective changes. During the early stages the skin is reddened and slightly oedematous, and the normal markings are exaggerated.
    3. The redness and oedema subsided and the central area becomes scaly and thickened and sometimes pigmented. Almost any sites are affected, but the commonest sites are those that are conveniently reached.
    4. The usual sites are the nape of the neck, the lower legs and ankles,. the sides of the necks, the scalp, the upper thighs, the vulva, pubis or scrotum and the extensor forearms.
  3. Management
    1. A search for a causation should be made before the lichenification is considered to be primary, then a careful psychological history should be taken and the patient given some assistance in reducing her tensions.
    2. Topical steroid is the treatment of choice, sometimes with occlusion to enhance absorption and prevent further scratching.
    3. Intralesional triamcinolone is useful for circumscribed chronic lesions.
H. Seborrhoeic Dermatitis
  1. Diagnostic feature
    Seborrhoeic dermatitis is characterized by a distinctive morphology (red, sharply marginated lesions covered with greasy looking scales) and a distinctive distribution (scalp, face and upper trunk) which are areas rich in sebaceous glands.
  2. Clinical patterns
    1. Adult (may be associated with Parkinsonism and HIV infection)
      1. Scalp Dandruff is usually the earliest manifestation. In chronic cases, there may be hair loss which is reversible when the inflammation is controlled. Ears are a common site of involvement.
      2. Face Medial sides of the eyebrows, glabella, nasolabial fold, are predilected sites . Blepharitis is a feature.
      3. Trunk Petaloid form is commoner than the pityriasiform. Follicular papules with greasy scale that may become confluent, and commonly found over the sternum and interscapular region.
    2. Infantile
      The eruptions in infants frequently first appear between the third and eighth weeks of life. It may start in the napkin area, the face and scalp, and occasionally on the trunk outside the napkin area. The rash comprises well-defined areas of erythema and scaling with tiny vesicles. Papular and lichenified lesions are not seen. Typically the infant is well and not irritable (c/w atopic dermatitis). The prognosis is usually good. Most uncomplicated cases clear in 3 to 4 weeks.




  1. Management
    1. Adults: Ketoconazole shampoo is very effective in removing dandruff. Shampoos that contain salicylic acid, selenium sulphide, zinc pyrithione and tar are alternatives. For thick scalp scale and crust, sulphur salicylic emulsion can be applied before bed and shampooed next morning. Steroid lotion applied twice daily provides symptomatic relief but may relapse.
    2. Lesions on face, chest can be treated by weak topical steroid and antiseborrhoeic shampoo. Washing the affected areas with soap can be a useful adjunct. 2% Ketoconazole cream once a day is highly effective in difficult cases. Scaling of blepharitis may be suppressed by frequent washing with zinc or tar containing antidandruff shampoos.
    3. Infants
      Cradle cap should be oiled regularly with warm olive oil and washed off few hours later with 5% cetrimide shampoo. Erythema and scaling on the body can be treated with weak topical corticosteroid cream +/- topical antibiotic if infection is present. Shampoo that contains salicylic acid or selenium.
      Sulphide should be avoided in neonates for the risk of systemic absorption.
Extra Edge:
Classification of topical steroids based on potency
Class 1 (Super potent)
Clobetasol propionate ointment and cream 0.5%
Betamethasone dipropionate ointment 0.05%
Halobetasol propionate ointment and cream 0.05%
Class 2 (Highly potent)
Mometasone furoate ointment 0.1 %
Class 3 (Potent)
Betamethasone dipropionate cream 0.05%
Fluticasone propionate ointment 0.05%
Class 4 (Moderately potent)
Fluocinolone acetonide ointment 0.025%
Fluticasone propionate cream 0.05%
Mometasone furoate cream 0.1 %
Class 5 (Moderately potent)
Betamethasone valerate cream 0.1 %
Hydrocortisone butyrate cream 0.1 %
Class 6 (Mildly potent)
Desonide cream 0.05%
Fluocinolone acetonide solution 0.05%
Class 7 (Least potent)
Dexamethasone cream 0.1 %
Hydrocortisone 1 %

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