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Types of Eczema

   

Cheiropompholyx

A 19-year-old fireman developed itchy blisters, redness and swelling along the sides of his fingers and on the palms in the ten days before presenting to his doctor. He had never had any previous skin problem and was otherwise fit.

This pattern of dermatitis is sometimes known by the pretentious and confusing name of cheiropompholyx. It is quite often accompanied by the same type of vesicles occurring on the soles of the feet and around the toes. The cause is unknown but is considered to be constitutional in origin although it can be precipitated or aggravated by any stress, physical or emotional.

The patient was very keen to return to work and did not believe that his work was to blame. He was treated at home with wet dressings and weak corticosteroids for one week and given clean, dry work for another two weeks. He was then encouraged to return to

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Severe, acute. symmetrical hand dermatitis. The lesions began as small vesicles which wept; the area then became much more inflamed and swollen


This shows typical coalescing vesicles of pompholyx affecting the foot. The hadns and feet are frequently affected together in this type of dermatitic disease.

his normal duties after advice on care of the skin and avoidance of unnecessary injury. He remained well apart from one other episode just before he got married.

Wear and tear dermatitis

A 23-year-old mother of two noticed irritant rough scaling and sore cracked patches over the backs and sides of her fingers and on the palms. These had started three months

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Typical chronic hand dermatitis. The fissuring occurs because the abnormal stratum cornenum cracks when the hadn extends. This can be very painful and disablin this was due to peristent physical and mechanical trauma.


Example of chronic hand dermatitis, due to wear and teare in a motor mechanic.

previously in midwinter and had gradually worsened. Enquiry revealed that she had a part-time job as a domestic cleaner and received little help in the house from her husband.

The picture described was typical of what has come to be known as 'housewives' dermatitis'. It is better described as 'wear and tear' dermatitis as it is the result of persistent or repeated physical and chemical injury to the skin of the hands.

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Allergic contact dermatitis on the dorsum of the foot due to sensitivity to a component of a protective shoe worn at work

She was urged to wear household gloves (cotton gloves under rubber or rye gloves) while doing housework, to use a simple moisturizing cream, to ask her husband to help out at home as much as possible, and to take a rest from her part-time job. She did not follow this advice and developed an unpleasant infection in one of the cracks that developed on her palms. This solved the problem temporarily as she was admitted to hospital where, away from the traumas of everyday life, her hands healed quickly.

Some occupations at risk from 'wear and tear' dermatitis

  • Housewives
  • Hairdressers
  • Cleaners
  • Cooks
  • Barmaids
  • Mechanics and machinists
  • Carpenters
  • Nurses
  • Builders' laborers
  • Miners

Allergic contact dermatitis

A 35-year-old electronics technician developed an irritant red rash that occasionally blistered and wept on the fingers of the hands. When he was first examined it was noticed that the eruption was worse on the right hand and maximal at the tips of the thumb and index fingers. This man remarked that the rash improved at weekends and was almost clear on holidays. It was gradually worsening and beginning to spread up his arms and onto his face and neck. The distribution and nature of the rash and the occupational history was suggestive of an allergic contact dermatitis to one of the materials encountered at work. Patch testing at a later date did in fact reveal a strong positive to epoxy resin - the base material of the glues he was handling every day in the course of his work.

Specialist advice This is urgently required for this type of problem for two reasons. First, a definitive diagnosis is only possible after formal patch testing by someone with experience (see Chapters 34 and 38). Second, expert advice is necessary concerning what to avoid in future and what can be handled with impunity. It is not uncommon for such patients to resort to litigation (this one, in fact, did), and it is better to have an informed opinion early on in the march of events rather than later when all symptoms have abated and the history is hazy.

Treatment When there is a strong suspicion that occupational exposure is the cause of a rapidly worsening eruption, as in this case, it is foolhardy to permit the individual to return to work until the condition has completely subsided. The acute stage, when the rash is swollen, sore and blistering, should be treated by saline compresses or bathing in dilute potassium permanganate solution (1 :8000). A little later, bland emollient creams are useful. If no further exposure occurs the rash will often settle within three or four weeks, but it is quite common for it to flare up unexpectedly. Whether this is due to unmentioned or unknown exposure to the allergen, or whether this happens independently of further contact with the sensitizing agent, is not known.

Return to work After a few weeks the patient and the physician are often both bored with the problem. At this stage it is quite tempting to suggest a return to work. If arrangements can be made for the patient to do only clean, dry, non-manual work, well away from the sensitizer, then this may be the best plan. But make no mistake; even this sometimes provokes a fresh crop of spots.

Some occupations at risk from allergic contact dermatitis

  • Photographers
  • Nurses
  • Dental technicians
  • Chemical workers
  • Horticulturists
  • Rubber industry workers . Electroplating workers

There was no choice for the electronics technician but to try to change jobs. As far as the company was concerned he was no use to them unless he could handle the adhesive containing the epoxy resin, and anyway the atmosphere had been soured by the legal process resulting from the claim he had made. In times such as these, when employment is at a premium, such decisions are difficult, but this man's best option was to agree with the employers and try to find work elsewhere, well away from epoxy resin glues.

Atopic dermatitis

The last example concerns a 19-year-old nurse in her second year of training. She was referred to me by the occupational health service of the hospital, who said that she had developed 'an itchy skin problem' affecting the hands, arms, face and scattered patches elsewhere. It turned out that her father was asthmatic and that she suffered from hay fever and had always had an itchy dry skin and a few scaling itchy patches. Clearly she was suffering from a mild type of late-onset atopic dermatitis. Sometimes, as in this patient, the brunt of the disease does fall on the hands and then diagnosis can be quite difficult. Of course, patch tests were carried out just to be certain that she did not in fact have some type of allergic contact dermatitis to one of the drugs she often handled (such as penicillin). All patch tests were negative. She was a bright and keen young woman who was alarmed at the thought of being kept off work by a rash.

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Generalized otopic dermatitis. This patient was quite distressed by his persistently itching dermatitic rash. Scratch marks can be seen around the elbows and buttocks. This eruption would make it impossible to work in a hot, sweaty environment, such as on a hot factory floor

Return to work This type of problem can be quite difficult and there is no easy formula to apply. Each patient should be carefully evaluated to assess:

  • Their keenness for their present job.
  • The disability caused by the skin problem.
  • The role of the job in causing, precipitating or aggravating the rash.
  • The potential danger to workmates or the public by continuing to work with the rash.
  • The attitudes of the employers.

The nurse was keen and popular with patients and the nursing hierarchy. Although the job had obviously precipitated and then aggravated her constitutional dermatitis she could be given jobs that were less damaging to the skin than routine nursing duties. However, it had to be arranged that she did not assist at sterile procedures or dress wounds, because damaged, scaling skin can easily be colonized by pathogenic bacteria. Good nursing recruits were particularly difficult to find in the area. For all these reasons it was decided that she should continue her nursing studies. I am not sorry now that we made this decision, as she is now an excellent senior nurse involved in teaching!