ECZEMATOUS DISORDERS Eczema is not a specific disease .

Dermatitis and Eczema are terms that may be used interchangeably to describe a group of disorders with a characteristic clinical appearance. Some types of eczema or dermatitis are,

Contact eczema: a localized reaction that includes redness, itching, and burning where the skin has come into contact with an allergen (an allergy-causing substance) or with an irritant such as an irritating acid, a cleaning agent, or other chemical. Allergic contact eczema: a red, itchy, weepy reaction where the skin has come into contact with a substance that the immune system recognizes as foreign, such as poison ivy or certain preservatives in creams and lotions like Neosporin or Bacitracin. Seborrheic eczema (also called seborrheic dermatitis or seborrhea): is a very common form of mild skin inflammation of unknown cause that presents as yellowish, oily, scaly patches of skin on the scalp, face, ears, and occasionally other parts of the body. Often this is also called dandruff in adults or "cradle cap" in infants. Nummular eczema: coin-shaped (round), isolated patches of irritated skin -- most commonly on the arms, back, buttocks, and lower legs -- that may be crusted, scaling, and extremely itchy Neurodermatitis: a very particular type of dermatitis where the person frequently picks at their skin, causing rashes.The underlying cause may be a sensitivity or irritation which sets off a cascade of repeated itching and scratching cycles. It may be seen as scratch marks and pick marks on the skin. Stasis dermatitis: a skin irritation on the lower legs, generally related to circulatory problems and congestion of the leg veins. It may have a darker pigmentation, lightbrown, or purplish-red discoloration from the congestion and back up of the blood in the leg veins. It's sometimes seen more in legs with varicose veins Dyshidrotic eczema: irritation of the skin on the palms of hands (mostly) and less commonly soles of the feet characterized by clear, very deep-seated blisters that itch and burn. It's sometimes described as a "tapioca pudding"-like rash on the palms. Atopic dermatitis:it is a common,chronic,relapsing,pruritic type of eczema. The word atopic refers to a group of three associated allergic disorders, asthma,allergic rhinitis(hay fever), and eczema.

STAGES OF ECZEMA Acute dermatitis: it is characterized by extensive erosions with serous exudate or by intensely pruritic,erythematous papules and vesicles on a background of erythema. Subacute dermatitis: it is characterized by erythematous,excoriated,scaling papules or plaques that are either grouped or scattered over erythematous skin. Chronic dermatitis: it is characterized by thickened skin and increased skin marking secondary to rubbing and scratching.

ATOPIC DERMATITIS Atopic dermatitis is a very common, often chronic (long-lasting) skin disease that affects a large percentage of the world's population. Most commonly, it may be thought of as a type of skin allergy or sensitivity. The atopic dermatitis triad includes asthma, allergies (hay fever), and eczema. There is a known hereditary component of the disease, and it is seen more in some families. The hallmarks of the disease include skin rashes and itching. The word "dermatitis" means inflammation of the skin. "Atopic" refers to diseases that are hereditary, tend to run in families, and often occur together. MEANING "Atopic dermatitis is an inflammatory, chronically relapsing, non-contagious and pruritic skin disorder. Atopic dermatitis is a skin disease characterized by areas of severe itching, redness, scaling, and loss of the surface of the skin (excoriation). INCIDENCE Atopic dermatitis is very common worldwide and increasing in prevalence. It affects males and females equally and accounts for 10%-20 % of all referrals to dermatologists (doctors who specialize in the care and treatment of skin diseases). Atopic dermatitis occurs most often in infants and children, and its onset decreases substantially with age. Scientists estimate that 65% of patients develop symptoms in the first year of life, and 90% develop symptoms before the age of 5. Onset after age 30 is less common and often occurs after exposure of the skin to harsh conditions. People who live in urban areas and in climates with low humidity seem to be at an increased risk for developing atopic dermatitis. CAUSES Epidermal Barrier Dysfunction More recently, a theory involving the role of Epidermal Barrier Dysfunction has been proposed as an explanation on the physiopathology of atopic dermatitis. Changes in at least 3 groups of genes encoding structural proteins, epidermal proteases and protease inhibitors predispose to a defective epidermal barrier and increase the risk of developing atopic dermatitis. Allergy Although it is an inherited disease, eczema is primarily aggravated by contact with or intake of allergens. It can also be influenced by other factors that affects the immune system such as stress or fatigue.

Microwave radiation Exposure to microwave radiation from a cell phone can worsen existing allergies to house dust mite and Japanese Cryptomeria pollen.Exposure to a cell phone that was actively transmitting increased allergen specific IgE production, whereas sham exposure did not. The use of a microwave oven at home has been associated with an increased risk of eczema as well.[13] Mast cell activation is seen in children suffering from eczema.[14] Electrohypersensitive individuals suffer from increased levels of mast cells in their skin.[15] Food allergy While no cause of atopic dermatitis, food allergy is often present in atopic children, and children with food allergy often present with skin dermatitis indistinguishable from atopic dermatitis. Common food allergen causing eczematous dermatitis include peanuts, tree nuts, shellfish, fish, milk, and egg. While food allergy induced eczematous dermatitis might present independent of atopic dermatitis, some children with atopic dermatitis also have concurrent food allergies. Histamine intolerance For a subset of people afflicted with atopic dermatitis are affected by exogenous sources of histamine,[16] meaning histamine from outside the body. About one-third (33%) of atopic eczematics significantly improve their symptoms after following a histamine-free diet. This diet excludes various foods high in histamine content including cheeses, hard cured sausages, alcohol, and other fermented foods.[16] Other histamine-free diets also exclude fish, shellfish, tomatoes, spinach, and eggplant as well. Fish is known to succumb to bacterial degradation quickly thus forming high amounts of histamine in the fish which can cause Scombroid poisoning. Certain vegetables like tomatoes, spinach and eggplant naturally contain histamine. Histamine intolerance is related to an inability for the body to degrade the histamine. This decreased ability to breakdown histamine may be related to a deficiency in an enzyme called diamine oxidase (DAO). It is unknow whether a deficiency in DAO or another mechanism is responsible for the impaired histamine processing. Biological Twin studies have consistently shown that the disease has a higher rate of concordance in identical as compared to fraternal twins, which also indicates that genetics plays a role in its development. Genomic research into the cause of multigenic diseases is still in its infancy: few genes have ever been identified that contribute to multigenic human disorders. Itching and rash can be triggered by a variety of factors, including:Exposure to allergens, such as pollen, animal dander, or molds. Dust mites may be an allergen, although experts don't know whether they affect atopic dermatitis.

Exposure to irritants, such as using soaps, rubbing the skin, and wearing wool. Exposure to workplace irritants, such as fumes and chemicals. Climate factors, especially winter weather and low humidity. Cold air does not contain much moisture, which can result in drier skin and increased itchiness. Temperature changes. Sudden changes in temperature can result in increased itchiness. A suddenly higher temperature may bring on sweating, which can cause itching. Lying under blankets, entering a warm room, or going from a warm shower into colder air can all promote itching. Emotional stress. Emotions such as frustration or embarrassment may lead to increased itchiness and scratching. Exposure to certain foods, typically eggs, peanuts, milk, soy, or wheat products. Up to 40% of children with moderate to severe atopic dermatitis also have some type of food allergy. But experts do not agree on whether foods can cause atopic dermatitis.

Symptoms of Atopic Dermatitis Common symptoms of atopic dermatitis include dry, itchy skin; small, rough bumps on the face, upper arms, and thighs; and a red, scaly rash. Itching can make symptoms worse, especially at night, when conscious itching cannot be controlled.

Scratching and rubbing in response to itching will:

Irritate the skin Increase inflammation Increase itchiness.

Itching is a particular problem during sleep, when conscious control of scratching is lost. Skin that is affected by atopic dermatitis may appear:

Red and scaly Thick and leathery Covered in small, raised bumps To leak fluid Crusty and infected.

Other Symptoms of Atopic Dermatitis Other symptoms of atopic dermatitis include:

An extra fold of skin that develops under the eye Inflammation of the skin on and around the lips Increased number of skin creases on the palms

Eyelids that have become darker in color from inflammation or hay fever Dry, rectangular scales on the skin Small, rough bumps, generally on the face, upper arms, and thighs Thick, leathery skin resulting from constant scratching and rubbing Small, raised bumps that may open when scratched and become crusty and infected

Hives (red, raised bumps) that may occur after exposure to an allergen, at the beginning of flareups, or after exercise or a hot bath Factors that worsen atopic dermatitis

Dry skin Long, hot baths or showers Stress Sweating Rapid changes in temperature Low humidity Solvents, cleaners, soaps or detergents Wool or man-made fabrics or clothing Dust or sand Cigarette smoke Living in cities where pollution is high Certain foods, such as eggs, milk, fish, soy or wheat

Diagnostic Features of Atopic Dermatitis* CRITERIA FOR DIAGNOSING AD Major features Pruritus Chronic or relapsing dermatitis Personal or family history of atopic disease Typical distribution and morphology of atopic dermatitis rash: Facial and extensor surfaces in infants and young children Flexure lichenification in older children and adults Minor features Eyes Cataracts (anterior subcapsular) Keratoconus Infraorbital folds affected Facial pallor Palmar hyperlinearity Xerosis

Pityriasis alba White dermatographism Ichthyosis Keratosis pilaris Nonspecific dermatitis of the hands and feet Nipple eczema Positive type I hypersensitivity skin tests Propensity for cutaneous infections Elevated serum IgE level Food intolerance Impaired cell-mediated immunity Erythroderma Early age of onset --The diagnosis of atopic dermatitis should be suspected if three major criteria and three minor criteria are present. Prevention Since there is no cure for atopic eczema, treatment should mainly involve discovering the Striggers of allergic reactions and learning to avoid them. Diet Many common food allergens can trigger an allergic reaction: such as milk, nuts, cheese, tomatoes, wheat, yeast, soy, and corn. Many of these allergens are common ingredients in grocery store products (especially corn syrup, which is a sugar substitute). It has also been established that about a third of people afflicted with atopic dermatitis may have histamine intolerance[16] and benefit from a histamine-free diet. Various foods commonly associated with allergies also happen have high histamine content. Foods such as cheeses, yogurt, alcohol, fish, shellfish, tomatoes, and fermented foods (soy, yeast, etc.) all have high histamine content. Other histamine foods include spinach, and eggplant, hard-cured sausages, and other processed meats. Various food additives including benzoates and food coloring have also been shown to release endogenous histamine.[22] Avoiding high histamine foods and processed foods may be beneficial in improving symptoms. Breastfeeding has been demonstrated to help prevent the development of allergic disease, but if that is unavailable, then hydrolyzed formulas are preferred to cow's milk.[23] The use of organic dairy products by children and breastfeeding or pregnant mothers reduces the risk of atopic dermatitis in young children.

Environment and lifestyle : Since dust is a very common allergen and irritant, adults with atopic eczema should avoid smoking, as well as the inhalation of dust in general. The dander from the fur of dogs and cats may also trigger an inflammatory response. It is a common misconception that simply removing an animal from a room will prevent an allergic reaction from occurring. A room must be completely free of animal dander in order to prevent an allergic reaction. Anger, stress, and lack of sleep are also factors that are known to aggravate eczema. Excessive heat (especially with humidity) and coldness are known to provoke outbreaks, as well as sudden and extreme temperature swings. Allergen/Irritant Evasion An allergy skin-patch or "scratch" test, given by an allergist, can often pinpoint the triggers of allergic reactions. Once the causes of the allergic reactions are discovered, the allergens should be eliminated from the diet, lifestyle, and/or environment. If the eczema is severe, it may take some time (days to weeks depending on the severity) for the body's immune system to begin to settle down after the irritants are withdrawn. MANAGEMENT Maintaining the skin barrier The primary treatment involves prevention, includes avoiding or minimizing contact with (or intake of) known allergens. Once that has been established, topical treatments can be used.Topical treatments focus on reducing both the dryness and inflammation of the skin. USE OF MOISTURIZERS 1.petroleum jelly To combat the severe dryness associated with atopic dermatitis, a high-quality, dermatologistapproved moisturizer should be used daily. Moisturizers should not have any ingredients that may further aggravate the condition. Moisturizers are especially effective if applied 510 minutes after bathing. As a rule of thumb the thicker the moisturizer the better it is at retaining moisture. Petroleum jelly is considered one of the most effective moisturizers by reducing transepidermal water loss by up to 98%.

2.ceramite based creams Atopic dermatitis has also been linked to a ceramide deficiency. Ceramide is one of the three key lipids that comprise the skin barrier.[27] The "stratum corneum ceramide deficiency" is possibly "the putative cause of the barrier abnormality"[28] in atopic dermatitis. There are various ceramide based creams available including the prescription drug Epiceram as well as other non-prescription options like Cerave and Aveeno for Eczema. 3. lotion of sodium hyaluronate A doctor might prescribe lotion containing sodium hyaluronate to improve skin dryness. One brand of sodium hyaluronate lotion is Hylira. Most commercial soaps wash away all the oils produced by the skin that normally serve to prevent drying. Using a soap substitute such as aqueous cream helps keep the skin moisturized. A non-soap cleanser can be purchased usually at a local drug store. Showers should be kept short and at a lukewarm/moderate temperature. PRESCRIPTION DRUGS 1. topical corticosteroids. If moisturizers on their own don't help and the eczema is severe, a doctor may prescribe topical corticosteroid ointments, creams, or injections. Corticosteroids have traditionally been considered the most effective method of treating severe eczema. If the eczema is especially severe, a doctor may prescribe prednisone or administer a shot of cortisone or triamcinolone. 2.antibiotics If complications include infections (often of Staphylococcus aureus), antibiotics may be employed. 3.immunosuppresants. a.topical The immunosuppressants tacrolimus and pimecrolimus can be used as a topical preparation in the treatment of severe atopic dermatitis. b.oral In severe cases that do not respond to other treatments, oral immunosuppressant medications are sometimes prescribed, such as ciclosporin, azothioprine and methotrexate. However, these treatments require patients to take regular blood tests as they can have significant side effects on the kidneys and liver.

Light (UV) therapy A more novel form of treatment involves exposure to broad or narrow-band ultraviolet light. UV radiation exposure has been found to have a localized immunomodulatory effect on affected tissues and may be used to decrease the severity and frequency of flares. The usage of UVA1 is more effective in treating acute flares, whereas narrow-band UVB is more effective in long-term management scenarios. However, UV radiation has also been implicated in various types of skin cancer, and thus UV treatment is not without risk. If ultraviolet light therapy is employed, initial exposure should be no longer than 510 minutes, depending on skin type. UV therapy should only be moderate, and special care should be taken to avoid sunburn (sunburn will only aggravate the eczema). It does not necessarily have to be administered in a hospital; it can be done at a tanning salon or in natural sunlight, as long as it's done under the direction and supervision of a dermatologist. NURSING MANAGEMENT NURSING ASSESSMENT Collect a detailed history. Perform a physical examination. Assess for Bathing habits Use of moisturizers. Medication regimen. Exposure to allergens. Environmental exposure.

Check for laboratory values- esinophil count. NURSING DIAGNOSIS 1. Impaired skin integrity related to skin dryness, lesions. 2. Body image disturbance related to skin lesions and response of significant others to appearance. 3. Isolation related to repeated itching sensation, skin dryness lesions. 4. Ineffective therapeutic management related to chronic symptoms and management of the disorder. 5. Anxiety related to management, prognosis of the disease. 6. Risk for infection related to skin excoriation and decreased resistance to cutaneous organisms. 7. Deficient knowledge regarding disease process and its management.