Hands & Feet
Richard Ashton, Barbara Leppard in Differential Diagnosis in Dermatology, 2021
Eczema here can be due to: Atopic eczema. Eczema affecting the dorsum of the big toe in a child aged 7–10 years is one of the patterns of atopic eczema. Note tinea pedis affects the fourth and fifth toes not the big toe.Allergic contact dermatitis. A rash up to the level of the shoe and sparing the toe webs is usually due to an allergic contact dermatitis to chrome in the leather of the shoe uppers, or azo dyes in nylon socks/stockings. A rash at the site of contact with flip flops is due to mercaptobenzothiazole (MTB), a rubber additive.Endogeneous eczema. Symmetrical eczema on the dorsum of the foot can be due to endogeneous eczema. Patch testing is negative.Discoid eczema presents as a well-defined round or oval red scaly plaque with obvious vesiculation and crusting (see p. 175).
Differential diagnoses of psoriasis
M. Alan Menter, Caitriona Ryan in Psoriasis, 2017
Discoid eczema (nummular eczema) is characterized by circular or oval plaques with a clearly demarcated edge (Figure 12.10), although the demarcation between involved and uninvolved skin may not be as sharply defined as in a classic psoriasis plaque (Figure 12.11).9 Some cases are associated with Staphylococcus aureus infection.10 Discoid eczema can affect children and adults but predominantly affects adults with a peak incidence of 50–65 years of age.10 It is slightly more prevalent in males than in females.9 It can be seen in elderly people, often with dry skin exacerbated by low humidity and central heating.9 The pathogenesis is unknown; most patients do not have a history of atopy, and immunoglobulin E (IgE) levels are often within the normal range.9 The clinical presentation is of well-demarcated coin-shaped annular plaques (Figure 12.12) with coalescing papules and papulovesicles on an erythematous base.9 Pinpoint oozing and crusting are distinctive.9 Scaling is usually less marked than in psoriasis. These lesions arise quite rapidly, ranging in size from 1 to 3 cm.9 The surrounding skin is generally normal but may be xerotic.9 In the acute phase, the lesions are dull red, very exudative or crusted (Figure 12.13), and highly pruritic.9 They progress toward a less vesicular and more scaly stage, often with central clearing, and peripheral extension, causing ring-shaped or annular lesions.9 Distribution is usually on the extensor surface of the extremities more than the trunk but can become widespread.9 Females tend to have more involvement of the upper extremities compared with the lower extremities in men (Figure 12.14).10 The clinical course tends to be chronic with relapses and most are worse during the colder months of the year.10 Some cases clear within 1 year and others may persist for many years. Histopathology shows a subacute dermatitis indistinguishable from other forms of eczema, with spongiotic vesicles and a predominantly lymphocytic infiltrate.9 Parakeratosis containing plasma cells and neutrophils and psoriasiform epidermal hyperplasia with spongiosis are present, with a superficial dermal perivascular infiltrate of lymphocytes, macrophages, and eosinophils.10 In psoriasis, the lesions are dry with more prominent silver scaling and less itch.
Eosinophilic Granulomatosis with Polyangiitis Presenting as Unilateral Acute Anterior Ischaemic Optic Neuropathy
Published in Neuro-Ophthalmology, 2021
Anthony Fong, Shahzada Ahmed, Satheesh Ramalingam, Rachel M. Brown, Lorraine Harper, Susan P. Mollan
On examination, the visual acuity in her right eye (OD) was 6/5 and left eye (OS) was 6/6. She could see 16/17 OD and 15/17 OS of the Ishihara colour plates. She had a mild left relative afferent pupillary defect. Slit lamp examination showed a nodular episcleral injection of the right eye temporally. No intraocular inflammation was present. Fundus examination was normal on the right but there was marked optic disc swelling on the left with cotton wool spots overlying the disc but no haemorrhages (Figure 1). The peripheral retina and vessels were otherwise normal. Optical coherence tomography (OCT) of her peripapillary retinal nerve fibre layer (RNFL) likewise was normal in the right eye, but markedly swollen on the left in a diffuse pattern with a mean thickness of 337 µm (Figure 2a). Her Goldmann visual field in the right eye was normal but in the left showed an enlarged blind spot with an inferior arcuate scotoma (Figure 2c). There were no other orbital signs present. Her other cranial nerves were normal. Examination of her areas of rash on the face showed small <1 cm patches of nummular dermatitis consistent with eczema, while the occipital scalp lesion was larger (6–7 cm) with scaly hyperkeratosis reminiscent of psoriasis. No erythema nodosum or areas of necrosis were evident.
Real-life experience on effectiveness and safety of dupilumab in adult patients with moderate-to-severe atopic dermatitis
Published in Journal of Dermatological Treatment, 2021
M. C. Fargnoli, M. Esposito, S. Ferrucci, G. Girolomoni, A. Offidani, A. Patrizi, K. Peris, A. Costanzo, G. Malara, G. Pellacani, M. Romanelli, P. Amerio, A. Cristaudo, M. L. Flori, A. Motolese, P. Betto, C. Patruno, P. Pigatto, R. Sirna, G. Stinco, I. Zalaudek, L. Bianchi, V. Boccaletti, S. P. Cannavò, F. Cusano, S. Lembo, R. Mozzillo, R. Gallo, C. Potenza, F. Rongioletti, R. Tiberio, T. Grieco, G. Micali, S. Persechino, M. Pettinato, S. Pucci, E. Savi, L. Stingeni, A. Romano, G. Argenziano
A total of 109 (71 M/38F) patients, with a mean age of 37.9 years (SD 14.7, range 19–80) was included in the study. Demographic and clinical baseline characteristics of patients are summarized in Table 1. Mean age at disease onset was 14.2 years (range 0–77, SD 17.8), mean BMI was 23.9 (range 17–34.6, SD 3.4) and the pattern of AD was persistent in 59/109 (54.1%) patients, relapsing in 27/109 (24.8%) patients and late-onset in 23/109 (21.1%). The most frequent AD phenotype was the classic adult-type with lichenified/exudative flexural dermatitis, often associated with head/neck eczema and/or hand/feet eczema, observed in 79/109 (72.5%) patients, followed by erythrodermic in 13/109 (13%), prurigo in 9/109 (8.2%) and nummular dermatitis in 8/109 (7.3%). Face was affected in 83/109 (76.1%) patients, hands in 67/109 (61.5%) and genitals in 25/109 (22.9%). Allergic comorbidities were mostly represented by allergic rhinitis (44.9%), asthma (38.5%), conjunctivitis (33.0%) and food allergy (15.6%). Other comorbidities including psychiatric or psychological conditions (11%), hypertension and cardiovascular disorders (9.1%) and obesity (6.4%) were less frequent. The majority of patients had been treated with cyclosporine (88.9%), followed by oral corticosteroids (88.1%), phototherapy (UVB) (45.8%), methotrexate (24.7%), azathioprine (16.5%), omalizumab (7.3%) and mycophenolate mofetil (0.9%).
Mindfulness-Based Cognitive Hypnotherapy and Skin Disorders
Published in American Journal of Clinical Hypnosis, 2018
Hypnosis has been used to assist in improving a wide variety of skin disorders. These include acne excoriée, alopecia areata, atopic dermatitis, congenital ichthyosiform erythroderma, dyshidrotic dermatitis, erythromelalgia, furuncles, glossodynia, herpes simplex, hyperhidrosis, ichthyosis vulgaris, lichen planus, neurodermatitis, nummular dermatitis, postherpetic neuralgia, pruritus, psoriasis, rosacea, trichotillomania, urticaria, verruca vulgaris, and vitiligo (Shenefelt, 2000). Behavioral medicine approaches using hypnosis for skin disorders such as acne, eczema, herpes, neurodermatitis, pruritus, psoriasis, and warts have been successful (Brown & Fromm, 1987, pp. 126–134). When hypnotic suggestion proves insufficient, such as for resistant warts, prurigo nodularis, or erythema nodosum, psychosomatic hypnoanalysis can often produce improvement or resolution (Shenefelt, 2007). Psychosomatic hypnoanalysis has also been reported effective in specific cases for herpes simplex, neurodermatiits, urticaria from chocolate, and persistent warts resistant to ordinary hypnotic suggestion (Ewin & Eimer, 2006, pp. 73–92). The affect bridge technique or the somatic bridge technique is often employed. Cheek and LeCron’s seven key factors can be recalled by the mnemonic C.O.M.P.A.S.S. for Conflict, Organ language (skin), Motivation or secondary gain, Past traumatic experiences, Active identification with a significant person, Self-punishment, and Suggestion or imprint (Shenefelt, 2010). If there is still no response, where appropriate spiritual aspects can be explored and if spiritual blockages are present they can be removed to allow healing to proceed (Shenefelt & Shenefelt, 2014). Spiritual experiences often involve trance and can be explored through hypnosis. Hypnotic relaxation for dermatologic procedures and surgeries has been shown to significantly reduce anxiety associated with the procedures (Shenefelt, 2013).
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