Susan T. Nedorost - Generalized Dermatitis in Clinical Practice

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Susan T. Nedorost Generalized Dermatitis in Clinical Practice 2012 10.1007/978-1-4471-2897-7_1 Springer-Verlag London 2012

1. Introduction

Susan T. Nedorost 1

(1)

University Hospitals Case Medical Center UHMG Dermatology, Ohio, USA

Abstract

Some forms of dermatitis are very mild and self-limited, but for patients with generalized disease, the burden is great (Fig. 1.1).

Some forms of dermatitis are very mild and self-limited, but for patients with generalized disease, the burden is great (Fig. ).

Figure 1.1

Chronic severe generalized dermatitis

Quality of life suffers due to the symptom of itch interfering with sleep and concentration. Lost time from school and work and numerous topical and systemic therapies are costly.

Despite a burden of disease equal to many other common, chronic diseases, public awareness and research attention have been insufficient.

Generalized dermatitis is poorly characterized and imprecisely treated for several reasons.

Problems with the Definition

This is in part due to the inconsistent definition of dermatitis. Even among dermatologists, the term can be used to denote only atopic skin disease or a broader range of inflammatory skin disease []. Some even include papulosquamous diseases in the dermatitis category.

Definition of the term eczema is also imprecise. Some investigators prefer the term eczema because it is better recognized by patients, and patient perspective is an important part of outcomes research [].

In this work, dermatitis and eczema are used interchangeably to denote the entire spectrum of disease.

Problems with the Diagnosis and Treatment

Beyond the problem of the definition, dermatitis is almost always multi-factorial. Most patients have some irritant dermatitis in combination with either atopic, allergic contact, stasis, or systemic contact dermatitis. This greatly increases the difficulty of creating a similar cohort of patients for research (Fig. )

Figure 1.2

Clinical and basic science research requires clear definition of dermatitis cohorts

Treatment of chronic dermatitis requires attention to barrier repair, allergic triggers, and infection. Without concurrent management of each of these factors, solitary interventions usually fail.

The need to identify multiple diagnostic subtypes and to manage more than one therapeutic approach often overwhelms both physicians and patients. In North America, the most common, simplest form of acute generalized contact dermatitis results from skin exposure to poison ivy. This is appropriately treated with systemic corticosteroids for 23 weeks, and no other intervention is required. However, all other types of generalized dermatitis require multiple diagnostic and therapeutic interventions. Topical and systemic corticosteroids are never appropriate as mono-therapy for chronic dermatitis, but are commonly used in this fashion.

Problems with the Care Team

In the United States, patients with generalized dermatitis may seek care from primary care providers, urgent care or emergency settings, allergists, and/or dermatologists.

Government agencies also interface with dermatitis. For example, the Bureau of Workers Compensation is involved in occupational cases, and the Women Infants and Children nutrition program with selection of formulae for pediatric patients. There is usually poor communication between these providers and agencies which results in conflicting messages to patients.

An international Delphi exercise including patient perspective, clinicians, journal editors, and one regulatory agency outlined core measures to be included in outcomes research: physician scoring of physical exam (e.g. Severity Scoring of Atopic Dermatitis [SCORAD] or Eczema Area and Severity Index {EASI]), symptoms, and long-term control of flares. The type of eczema studied in this project appeared to be atopic eczema (dermatitis), but inclusion criteria for patient stakeholders other than belonging to an advocacy or support group was not specifically stated [].

Aim of This Work

Increased research focus and combined interdisciplinary attention to dermatitis will brighten the future for patients. This monograph utilizes scientific literature to guide classification and treatment of generalized dermatitis without losing site of the clinical reality that many of our most complicated patients have more than one inflammatory skin disease (Fig. ).

Figure 1.3

Generalized atopic dermatitis/systemic contact dermatitis (patch tests positive vanillin and eugenol, negative to Balsam of Peru)

Figure 1.4

Drug eruption in a patient with psoriasis. Note the underlying sharply demarcated (psoriatic) plaques. The superimposed papules represent a dermal hypersensitivity reaction to a medication, but the superimposed patterns mimic generalized dermatitis

Interdisciplinary communication depends on reducing specialty-specific jargon; a glossary of dermatological and immunological terms is included to this end.

References

Smith SM, Nedorost ST. Dermatitis defined. Dermatitis. 2010;21(5):24850. PubMed

Schmitt J, Flohr C, Williams HC. Outcome measures, case definition, and nomenclature are all important and distinct aspects of atopic eczema: a call for harmonization. J Invest Dermatol. 2012;132(2):4734. CrossRef

Hanifin JM. Atopic dermatitis nomenclature variants can impede harmonization. J Invest Dermatol. 2012;132(2):4723. PubMed CrossRef

Schmitt J, Langan S, Stamm T, Williams HC. Harmonizing Outcome Measurements in Eczema (HOME) Delphi panel. Core outcome domains for controlled trials and clinical recordkeeping in eczema: international multiperspective Delphi consensus process. J Invest Dermatol. 2011;131(3):62330. PubMed CrossRef

Susan T. Nedorost Generalized Dermatitis in Clinical Practice 2012 10.1007/978-1-4471-2897-7_2 Springer-Verlag London 2012

2. Generalized Dermatitis: The Basics

Susan T. Nedorost 1

(1)

University Hospitals Case Medical Center UHMG Dermatology, Ohio, USA

Key Concepts

• Dermatitis is multi-factorial
• Barrier dysfunction, infection, and immune response are key components
• Inter-disciplinary care including dermatology, allergy, and psychology and specialized nurse education best addresses patient needs

Introduction

This work focuses on generalized dermatitis; that is, dermatitis affecting several anatomical units. Chronic generalized dermatitis is more complex to diagnosis than localized dermatitis because the differential diagnosis includes mimics of dermatitis such as bullous pemphigoid and dermatomyositis. Asking the patient where dermatitis first appeared on the skin can help to direct history taking.

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