Chapter 053. Eczema and Dermatitis (Part 5)

Stasis dermatitis. An example of stasis dermatitis showing erythematous, scaly, and oozing patches over the lower leg. Several stasis ulcers are also seen in this patient.Stasis Dermatitis and Stasis Ulceration: Treatment Patients with stasis dermatitis and stasis ulceration benefit greatly from leg elevation and the routine use of compression stockings with a gradient of at least 30–40 mmHg. Stockings providing less compression, such as antiembolism hose, are poor substitutes. Use of emollients and/or midpotency topical glucocorticoids and avoidance of irritants are also helpful in treating stasis dermatitis. Protecting the legs from injury, including scratching, and control of chronic edema...
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Chapter 053. Eczema and Dermatitis (Part 5) Chapter 053. Eczema and Dermatitis (Part 5) Stasis dermatitis. An example of stasis dermatitis showing erythematous,scaly, and oozing patches over the lower leg. Several stasis ulcers are also seen inthis patient. Stasis Dermatitis and Stasis Ulceration: Treatment Patients with stasis dermatitis and stasis ulceration benefit greatly from legelevation and the routine use of compression stockings with a gradient of at least30–40 mmHg. Stockings providing less compression, such as antiembolism hose,are poor substitutes. Use of emollients and/or midpotency topical glucocorticoidsand avoidance of irritants are also helpful in treating stasis dermatitis. Protectingthe legs from injury, including scratching, and control of chronic edema areessential to prevent ulcers. Diuretics may be required to adequately control chronicedema. Stasis ulcers are difficult to treat, and resolution is slow. It is extremelyimportant to elevate the affected limb as much as possible. The ulcer should bekept clear of necrotic material by gentle debridement and covered with asemipermeable dressing and a compression dressing or compression stocking.Glucocorticoids should not be applied to ulcers, since they may retard healing;however, they may be applied to the surrounding skin to control itching,scratching, and additional trauma. Secondarily infected lesions should be treatedwith appropriate oral antibiotics, but it should be noted that all ulcers will becomecolonized with bacteria, and the purpose of antibiotic therapy should not be toclear all bacterial growth. Care must be taken to exclude treatable causes of legulcers (hypercoagulation, vasculitis) before beginning the chronic managementoutlined above. Seborrheic Dermatitis Seborrheic dermatitis is a common, chronic disorder, characterized bygreasy scales overlying erythematous patches or plaques. Induration and scale aregenerally less prominent than in psoriasis, but clinical overlap exists between thesediseases—sebopsoriasis. The most common location is in the scalp where it maybe recognized as severe dandruff. On the face, seborrheic dermatitis affects theeyebrows, eyelids, glabella, and nasolabial folds (Fig. 53-4). Scaling of theexternal auditory canal is common in seborrheic dermatitis. Additionally, thepostauricular areas often become macerated and tender. Seborrheic dermatitis mayalso develop in the central chest, axilla, groin, submammary folds, and glutealcleft. Rarely, it may cause a widespread generalized dermatitis. Pruritus isvariable. Figure 53-4 Seborrheic dermatitis. Central facial erythema with overlying greasy,yellowish scale is seen in this patient. (Courtesy of Jean Bolognia, MD; withpermission.) Seborrheic dermatitis may be evident within the first few weeks of life, andwithin this context it occurs in the scalp (cradle cap), face, or groin. It is rarelyseen in children beyond infancy but becomes evident again during adult life.Although it is frequently seen in patients with Parkinsons disease, in those whohave had cerebrovascular accidents, and in those with HIV infection, theoverwhelming majority of individuals with seborrheic dermatitis have nounderlying disorder. Seborrheic Dermatitis: Treatment Treatment with low-potency topical glucocorticoids in conjunction with atopical antifungal agent, such as ketoconazole cream or ciclopirox cream, is ofteneffective. The scalp and beard areas may benefit from anti-dandruff shampoos,which should be left in place 3–5 min before rinsing. High-potency topicalglucocorticoid solutions (betamethasone or clobetasol) are effective for control ofsevere scalp involvement. High potency glucocorticoids should not be used on theface since this is often associated with steroid-induced rosacea or atrophy.Tacrolimus and pimecrolimus are alternatives to topical glucocorticoids,especially when seborrheic dermatitis involves eyelids, although they are notFDA-approved for these indications.