Eczema Complications series – Erythroderma

Erythroderma Eczema Complications

Pictures taken from dermnetnz.org without specific permission granted, click on image for click to Dermnet NZ Erythroderma page

This is a 4-topic series focused on complications from eczema and mainly inspired because my daughter recently had impetigo. Moreover, the potential complications from bacterial, viral and fungal infection are not very often emphasized yet a child with eczema is often vulnerable to infections. So let’s explore!

Erythroderma and its Causes

Erythroderma refers to generalized redness of skin due to skin inflammation. It is a complication associated with severe eczema, psoriasis and other skin inflammatory diseases. It can also be caused by drug reaction or even without a known cause (idiopathic erythroderma). Other possible causes are:

  • Other forms of dermatitis, apart from eczema, such as contact dermatitis, stasis dermatitis (skin inflammation from blood pooling in leg veins, common for women above 50) and seborrheic dermatitis
  • Staphylococcal scalded skin syndrome, with fever, skin tenderness and irritability (staph bacteria infection causing blisters, aka scalded skin appearance, affecting kids below age 5)
  • Pityriasis rubra pilaris, appears as reddish-orange scaling patches, more common in adults
  • Pemphigus vulgaris and bullous pemphigiod, which refers to autoimmune blistering skin disease
  • Lymphoma of the cutaneous T-cells, also known as Sezary syndrome
  • Leukemia
  • Malignant rectum, lung, colon and fallopian tubes
  • Graft vs Host disease
  • HIV infection and other immune-deficiency conditions

The common drugs causing erythroderma in children are sulfonamides, antimalarials, penicillins, isoniazid, thioacetazone, streptomycin, nonsteroidal anti-inflammatory drugs (NSAIDS), topical tar, homeopathic and ayurvedic medicines. For general population, drugs such as allopurinol, arsenicals, aspirin, carbamazepine, captopril, gold, hydantoins, mercurials, penicillin, phenothiazines, phenylbutazone, quinacrine, sulfonamides, homeopathic and ayurvedic medication as well.

Symptoms of Erythroderma

The onset of erythroderma can be sudden and spread quickly. Apart from skin redness, it is often seen with:

  1. Skin exfoliation, also known as exfoliative dermatitis where about 90% of skin peel off in scales or layers
  2. Swelling (oedema)
  3. Oozing skin
  4. Itch
  5. Thickening of palms or soles or nails (even shedding nails)
  6. Erythroderma of the scalp may result in hair loss
  7. Erythoroderma of the eyelid may result in ectropian, which is rolling outwards of the inner eyelid (may also have conjunctivitis)
  8. Measle-like eruptions if due to drug reaction

Treatment of Erythroderma

The underlying cause has to be treated, with the following general treatment steps:

  • Wet wrap for skin moisture retention, with moisturizer and mild steroids
  • Maintain hydration, fluid and electrolyte balance
  • Antihistamines for itch
  • Stop unnecessary medication, in case erythroderma is drug-induced

Bacterial skin infection commonly accompanies erythroderma, and therefore antibiotics may be prescribed. Where fluids have to be given intravenously, hospitalization is required.

Complications of Erythroderma

Most important to watch out in erythroderma is compensating for the loss of skin’s ability to temperature control and maintain fluids. Complications include:

  • Pigment changes in skin to brown and white patch
  • Secondary infection with the oozing and crust
  • Swollen lymph nodes
  • Dehydration, from fluid loss through skin from higher metabolism
  • Heart failure from increased heart rate (usually in elderly)
  • Hypothermia, from abnormal temperature regulation, thus hydration and temperature control are important
  • Malnutrition, from protein loss and higher metabolism (to compensate for heat loss)

As I researched on erythroderma, I felt really sad for those suffering with it. As to why some people with inflammatory skin condition have an onset of erythroderma, it is not clear. I do hope though that keeping the underlying skin condition under control will forever keep erythroderma at bay. Anyone has experience with this?

Other parts of this series:

Eye and Eyelid Complications

Folliculitis

Molluscum Contagiosm

Eczema Complications series – Eye and Eyelid

Eczema eyelid complications eyeThis is a 4-topic series focused on complications from eczema and mainly inspired because my daughter recently had impetigo. Moreover, the potential complications from bacterial, viral and fungal infection are not very often emphasized yet a child with eczema is often vulnerable to infections. So let’s explore!

Eyelid Functions and Skin

The eyelid very often present a very tricky and difficult to treat skin area for eczema sufferers. Moreover, the constant rubbing and scratching of the eczema at the eyelid can also lead to complications. Before we go into the complications, let’s first understand the basics of eyelid functions and the skin at this delicate area.

Functions of the Eyelid

  1. Protection from injury
  2. Regulation of light
  3. Maintenance and distribution of tear film/ flow

Eyelid Skin

The skin of the eyelid is characterized by:

  1. Thinnest skin are of our body – total less than 1mm, with both the epidermis and dermis being the thinnest
  2. Smoother skin due to finer hairs
  3. Oilier skin due to more oil glands

Common Eyelid Conditions

Being thinner oilier skin and on the face predispose the eyelid to various health conditions, such as:

  1. Atopic dermatitis (eczema), more common from adolescent age (read more from dermatologist Dr Lynn Chiam)
  2. Contact dermatitis, due to contact with chemicals used on the face/eyes and hair
  3. Seborrheic dermatitis, typically on the eyelid and eyebrow (read here for more on seborrheic dermatitis)
  4. Blepharitis, also known as eyelid inflammation
  5. Conjunctivitis – this refers to inflammation of the eyelid lining, accompanied by itching and eye watering
  6. Ptosis, known as droopy eyelids from prolonged contact lens use or aging
  7. Dermatochalasis, baggy eyes from aging
  8. Ectropion, eyelids that roll outwards usually from ageing or sun-damaged facial skin
  9. Entropion, eyelids that roll inwards, may also be complication of blepharitis
  10. Malignant eyelid tumors
  11. Chalazion, eyelid cyst swelling from obstruction of the meibomian (tear) gland, may also be complication of blepharitis
  12. Hordeolum, also known as a stye, lump from infection of the meibomian gland, may also be complication of blepharitis

Eczema and Eyelid Complications

Apart from atopic, contact and seborrheic dermatitis of the eyelid, there are also complications from having eczema at the eyelid. Complications usually occur in patients with severe atopic dermatitis where repeated scratching and rubbing, inflammation and infection of the eyelid cause other conditions. Let’s take a closer look at some of these eczema eyelid complications:

Blepharitis

This refers to inflammation of the eyelid, being accompanied by redness, sore eyes, itch, flakiness, burning, swelling, eye watering and mucous discharge. The eyelid margin may appear crusty, waxy or greasy. Blepharitis can be due to many reasons, including allergy, irritation and bacteria infection that causes the eyelids to become itchy. Blepharitis is associated with eczema, rosacea and acne patients.

Relation of Blepharitis to eczema as follow:

a)     Staphylococcal blepharitis – patients with eczema have higher chance of staphylococcus bacteria colonization, leading to staph bacteria infection

b)    Seborrheic blepharitis – due to the malfunction of oil glands at the eyelid, affecting patients with seborrheic dermatitis. The excess oil production may be due to stress, hormonal changes or diet. A characteristic of seborrhea blepharitis is redness at the eyelid throughout the day and crusting at eyelid in the morning.

c)     Other eczema complications – Complications of eczema such as from herpes simplex or varicella zoster virus or molluscum contagiosum can also cause blepharitis.

Dennie-Morgan fold

This refers to a fold under the lower eyelid, typically due to excessive scratching/rubbing of the eye. The eyelid may also hyper-pigment or become red and swollen.

Allergic Contact Dermatitis

Ophthalmic corticosteroids may also product allergic contact dermatitis, due to allergy from certain ingredients of the corticosteroids.

Eyelid Erythema

This refers to redness of the eyelids and can be caused by eczema, contact dermatitis and blepharitis.

Cellulitis

This refers to bacterial infection of the eyelid and can also be caused by insect bite/ other skin injury. Preseptal cellulitis affects the eyelid and skin around the eye, but not the eye socket. Orbital Cellulitis is much more severe and affects the back of the eye, causing eye protrusion and double vision. The common bacteria causing cellulitis are Haemophilus influenzae, Staphylococcus and Streptococcus.

Neurodermatitis

Also known as lichen simplex chronicus, this refers to skin thickening, lichenification of the skin of the eyelid from habitual scratching.

Eczema and Eye Complications

There are also complications involving the eye, typically for prolonged eczema at the eyelid.

Keratoconus – This refers to the degeneration of cornea which pushes the eye outward, resulting in a cone shaped eyeball. There will be visual disturbance with this condition. This may be due to hard rubbing of the eye from the itch.

Scarring – This refers to scarring of the eye, mostly due to scratching or excessive rubbing.

Cataract – There is association between cataract and severe and chronic atopic dermatitis of more than 10 years, possibly due to overtime absorption of steroid cream applied on thin eyelid. One feature of cataracts associated with eczema is that the cataract affects both eyes.

Retinal detachment – This is very rare and associated with severe atopic dermatitis.

Complications from prescription creams seeping into the eyes, resulting in glaucoma

Certain eye-related conditions are not directly related to eczema, but related to allergy. For instance, conjunctival irritation

General Care for the Eyelid (Hygiene)

Top tips for general care of the eyelid:
1. Refrain from eye make-up
2. If wearing contact lens, always clean with disinfectant solution; in certain cases, refrain from using contact lens.
3. Apply warm (not hot) compress 4 times a day to clean and reduce discomfort (for blepharitis)
4. Clean eyelid with cotton swab with mild diluted baby shampoo/wash (read dermatologist Dr Jessica Krant’s tips for baby’s eyelid here)
5. Use artificial tears as blepharitis commonly occurs alongside dry eyes
6. An omega-3 supplement may be recommended to patients with blepharitis as small-scale study suggested anti-inflammatory effect of omega 3 benefit blepharitis patients. More on omega 3 and eczema here.

As you can see, there are quite a lot of health conditions affecting the eyelid and a few relating to eczema. Most of it has to do with bacteria and scratching, thus it is important to practice eyelid hygiene and treating conditions that create itch at the eye promptly.

note: if you’ve reached this far to the post, thank you! Took me a long time to do up a comprehensive post on eyelid complications from eczema and if you have any to share, kindly comment, will make my day!

Eczema Complications series – Folliculitis

Folliculitis_Eczema

Taken from http://health.howstuffworks.com (no direct permission obtained for use, but duly credited)
Link of picture directed to HowStuffWorks website

This is a 4-topic series focused on complications from eczema and mainly inspired because my daughter recently had impetigo. Moreover, the potential complications from bacterial, viral and fungal infection are not very often emphasized yet a child with eczema is often vulnerable to infections. So let’s explore!

Bacterial Infection

Last week, we covered viral infections – eczema herpeticum previously covered in this blog (here and here) and molluscum contagiosum. This week, our focus is on bacterial infection. The most common bacteria that colonizes eczema skin is staphylococcus aureus bacteria, which is the cause of common children skin infections like impetigo and folliculitis. Apart from impetigo and folliculitis, S. aureus also causes other secondary infection with presence of pus, fever, swollen lymph nodes and in severe cases, staphylococcal scalded skin syndrome, where the lesions rupture to give scalded appearance (see this interview with Dr Clay Cockerell on symptoms of S.aureus infection).

Other bacterial infection include boils and ecthyma, also from S. aureus. The other common bacteria that causes infection is streptococcus pyogenes, which can cause cellulitis and erysipelas. Untreated bacterial infection can cause fatal systemic toxaemia or septicaemia, which is blood poisoning. If strep infection is a topic you’re interested, comment/email me and I may start a series on it!

Folliculitis

Folliculitis is an inflammation at the hair follicle that can be due to numerous causes – a common one being from staph bacteria. A word about staph bacteria is that even if it doesn’t trigger secondary infection, its presence impedes the recovery of eczema rash via (i) toxins (enterotoxin) from the bacteria that can trigger hypersensitivity and (ii) existing inflammation from bacteria makes it harder to treat the eczema (more on staph bacteria here).

So back to folliculitis – It appears as a small localized pus (on surface or deep) at the hair follicle, followed by red bump when the pus dried with surrounding inflamed skin that may itch. If the infection runs deep into the hair follicle, it can cause a boil which can be painful. The hair follicles on the chest, back, legs, face, neck, thighs and buttocks are more vulnerable to folliculitis. Folliculitis will not affect part of the body with no hair follicle such as the eye, mouth, palm and sole.

Multiple Causes of Folliculitis

Bacteria, from staphylococcus aureus is the most common cause.

Virus – Herpes simplex virus (that cause eczema herpeticum), herpes zoster (that cause shingles, read here of my daughter’s shingles experience) and molluscum contagiosum (covered last week) may also cause folliculitis.

Yeast – Folliculitis may also be from the yeast, Pityrosporum ovale (Malassezia) when it proliferates, usually on the trunk of young adults.

Fungi – Fungi such as tinea capitis (ringworm), Microsporum canis and Trichophyton tonsurans can cause folliculitis particularly on the scalp.

Parasite – Hair follicle mite (demodex) can affect the face or scalp of adults with compromised immune system or that of elderly. This is known as demodicosis. Scabies is another parasite that can trigger folliculitis.

Steroid – Systemically administered or topically applied steroids could result in facial folliculitis (perioral dermatitis) or steroid acne due to adverse reactions to long and significant doses of steroid.

Occlusion – Clothes with sweat, friction, thicker emollients, like paraffin-based ointment and adhesive plastic can break the skin and/or increase the penetration of bacteria into the hair follicle.

Chemicals – Some chemical like coal tar may cause irritant folliculitis.

Razor-burn folliculitis – This is due to frequent razor cuts creating opening on skin’s surface that allow bacteria to enter and cause inflammation at the hair follicle.  It is more common on women’s leg and men’s face and neck. Excessive close shaving creates trapped hair in the follicle, increasing inflammation.

Spa pool/ Hot tub folliculitis –  This is infection from inadequately chlorinated warm water, allowing the bacteria Pseudomonas aeruginosa to thrive. It is more common on the back and to prevent this, rinse/shower after a spa or hot tub.

Who is a Higher Risk of Folliculitis?

Skin conditions, such as acne, eczema and psoriasis patients

Diabetic patients

Obesity

Patients with lower immunity such as cancer, HIV, hepatitis or even chronic eczema patients who are on immunosuppressants may get eosinophilic folliculitis.

Occupations – Those that come into often contact with oil, tar or grease and sweat.

Warm and humid climate

Treatment of Folliculitis

The treatment will depend on the cause, as follow:

Bacteria – Antibacterial wash such as benzoyl peroxide, chlorhexidine or in certain case, antibiotics to kill the bacteria and clear the skin. There are increasing instances of methicillin-resistant Staph aureus bacteria, thus making it more difficult to treat such MRSA bacterial infection. Oral flucloxacillin is often prescribed and if there is penicillin resistance, erythromycin is prescribed. More on MRSA here.

Fungus and Yeast – Both fungus and yeast causing folliculitis can be treated using an antifungal shampoo or body wash such as ketoconazole (Nizoral shampoo) twice daily. Topical antifungal cream such as miconazole (Lotrimin) or terbinafine (Lamisil) and an antifungal medicine fluconazole (Diflucan) may be prescribed for more severe case.

Virus – Medication for virus, such as acyclovir for herpes simplex virus will help to resolve the folliculitis.

Razor folliculitis – Treatment includes antibacterial wash and topical antibiotics if not resolved on its own. Stopping to shave and using alternative hair removal techniques may help prevent future folliculitis from shaving repeatedly. Using a new razor and shaving in the direction of hair growth will help to prevent cuts. For men, antibacterial benzoyl peroxide shaving gel can be used. Permanent hair removal can also be attempted.

As the most likely factor is from bacterial infection, good hygiene measures such as hand-washing, not sharing towels/razors and showering after contact with likely bacteria surfaces helps prevent folliculitis. Not touching parts of body that have high staph bacteria such as the nose, armpit and perineum (area between anus and vulva/scrotum) can limit the spread of the bacteria to other parts of the body.

Folliculitis and Eczema

Children with eczema have a few factors to their disadvantage which make them more likely to get folliculitis. Of the causes of folliculitis, the one that most affect eczema patients is bacterial infection from staph bacteria.

  1. Eczema skin already have higher likelihood of bacterial colonization, of more than 50% chance.
  2. Most skin with staph bacteria won’t be harmed, however eczema skin is defective in its barrier protection, either from dry skin, ‘open’ skin from scratching and more permeable.
  3. Eczema patients are suspected to be less able to fight common bacteria, fungus, virus and yeast.
  4. The dry skin on eczema children is a more conducive environment for bacterial growth, compared to normal skin with natural oils.
  5. The toxin produced by Staph aureus bacteria worsens the eczema with triggering more hypersensitive reaction/inflammation.

It once again points to keeping bacteria count low, proper hygiene, keeping our children fresh and cool as preventive measures for our children. What is your experience? Do share in the comment!

Eczema Complications series – Molluscum Contagiosum

molluscum contagiosum eczema

Taken from cdc.gov (no direct permission obtained for use, but duly credited)
Link of picture directed to CDC website

This is a 4-topic series focused on complications from eczema and mainly inspired because my daughter recently had impetigo. Moreover, the potential complications from bacterial, viral and fungal infection are not very often emphasized yet a child with eczema is often vulnerable to infections. So let’s explore!

Molluscum Contagiosum (Virus)

Apart from molluscum contagiosum, the other common viral infection is eczema herpeticum. This eczema complications series will not include herpeticum because it has been covered in April 2012 post: Eczema Herpeticum – What is it and is it Dangerous? Eczema herpeticum is caused by the herpes simplex virus and eczema children’s skin (being defective) is more vulnerable to the penetration of the virus.

The other common viral infection in children is molluscum contagiosum, caused by the molluscum contagiosum virus, a family of the pox virus. It appears in clusters of small bumps (papules) in places such as armpit, face, neck, abdomen, groin, joints which are warm and moist. The papules may be pink, white or brown but often with a center hole and waxy/shiny look. The papules will later turn inflamed, crusted or into scabs. The extent of the molluscum varies – from mild with a few papules in most healthy children to extensive and last longer for children with eczema (study here) or low immunity (for instance, larger and more papules in HIV patients). In healthy children, the virus will stay on the skin and not circulate in the body therefore the virus leave the body with full resolution of the papules.

Spreading of Molluscum Contagiosum

Molluscum Contagiosum is spread by skin contact, for instance, taking shower or swim together (not clear whether the water spread the virus or contact with towels, surfaces at pool spread the virus). It can also be spread via bedding, toys, towels and clothes. In adults, it can be spread by sexual intercourse. Children (age 1-4, some reports show up to 12) living in tropical climate (warm, humid, crowded) have a higher risk of molluscum contatgiosum. The incubation period ranges from weeks to months. The recovery period on its own can take from 6 months to few years. It follows that if you are infected, to limit sharing of towels, toys and touching surfaces (bandaged the papules).

Treatment of Molluscum Contagiosum

Treatment can be hastened by pinching/ squeezing the molluscum lesions to express the soft white core. This is best done a few lesions at a time for children as it can be painful. The base is then treated with silver nitrate or mild sclerosing agent. Various medical treatment may include electrocautery, cryotherapy (freezing), curettage (cutting), laser, cantharidine, imiquimod cream or wart cream containing salicylic acid. There is no drug/ vaccine that kill the virus. Consultation for treatment should be about 3-4 weeks apart as certain molluscum may have been in incubation stage.

Although both the molluscum contagiosum and small pox are pox virus, they are distinctively different to our immune system and thus a smallpox vaccination does not prevent molluscum contagiosum.

Relationship with Eczema

It is almost like a double-whammy – children with eczema with defective skin barrier are more susceptible to molluscum contagiosum and after getting molluscum contagiosum, the eczema worsened PLUS the molluscum at the eczema area healed slower. Furthermore, molluscum contagiosum is likely to be more extensive in eczema children due to the scratching of the papules, followed by touching the rest of the body. There is also linkage between molluscum contagiosum and long-term use of glucocorticoids which are steroids such as prednisone, dexamethasone and hydrocortisone. Use of non-steroid cream such as topical immune-modulators (tacrolimus and pimecrolimus) have also been associated with molluscum contagiosum (here).

My take – a lot of the complications are possibly going to be linked to scratching, where infection and bacteria/virus spread from one part to another. Therefore, it always make sense to treat eczema and take steps to improve the skin barrier.

Have your child had molluscum contagiosum before? Share your experience and it may help another family, thanks!

 

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