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Dermatitis and Eczema Treatment

Definition

Atopic dermatitis: An acute, subacute, usually chronic and pruritic, relapsing inflammation of epidermis and dermis. Commonly occurs in individuals with a family history of asthma, hayfever, allergic rhinitis, or atopic dermatitis. All are referred to as atopy.

Contact dermatitis: Acute, subacute, or chronic inflammation of the skin due to external agents that exhibits a delayed immune response. Pruritis,inflammation, and burning occur on first and subsequent exposures of primary irritant contact.

Dyshidrotic eczema (pomphylox): Chronic, recurrent, vesicular scaling dermatitis of the hands and feet.

Lichen simplex chronicus: Chronic dermatitis caused by frequent and repeated rubbing or scratching.

Nummular eczema: Chronic, pruritic, coin-shaped sized, plaque dermatitis with papules, vesicles, and scales on a red-skin base. Occurs on the extremities.

Seborrheic dermatitis: Chronic, inflammatory, scaling eruption of a characteristic distribution in sebaceous gland areas.

History

Symptoms

Atopic dermatitis: Pruritis is the hallmark symptom on red patches of the skin. Associated with papules, blisters, plaques, oozing, thickening on the head, and extensor surfaces of infants and young children, on flexor surfaces, especially behind knees and elbows of older children and adults, and on the neck and face. Occasionally occur on the hands and feet.

Contact dermatitis: Burning and/or itching in reddened skin. Very local or widespread. May be acute illness syndromeincluding fever, in acute severe allergic contact.

Dyshidrotic eczema (pomphylox): Itchy, small blisters, initially on hands and/or feet. Later dry, flaking and cracking with itchy, burning pain.

Lichen simplex chronicus: Local isolated areas of intense itch that become pleasureable to scratch. Night-time rub and scratch. Rough, red thickening of skin.

Nummular eczema: Pruritis which is mild to intense. Dry, rough, or bumpy small and large spots on the legs and arms; occasionally is more generalized.

Seborrheic dermatitis: Fine, white, dry scale or thick, yellowish often greasy scales of the scalp, face, chest, and/or body folds. Variable itch.

Age

Atopic dermatitis: Infant to adult. Sixty percent of patients develop the dermatitis in the first year of life.

Contact dermatitis: Any.

Dyshidrotic eczema (pomphylox): Usually 20-to 40-year-olds.

Lichen simplex chronicus: Over 20 years.

Nummular eczema: Fifty years and older in males, 20 to 40 years or more in females and in infants is association with atopic dermatitis.

Seborrheic dermatitis: In infants is known as cradle cap or a severe form of an exfoliative erythroderma. May occur in puberty but the majority of cases occur at 20 to 60 years or older. More common in males.

Onset

Atopic dermatitis: Acute in first 2 years, more chronic onset in adults. Males affected more than females.

Contact dermatitis: Acute and sudden or delayed.

Dyshidrotic eczema (pomphylox): Sudden.

Lichen simplex chronicus: Gradual with increasing pruritis.

Nummular eczema: Slow to sudden, single or numerous lesiom regions or clusters on legs, arms, hands, thighs, or back.

Seborrheic dermatitis: Gradual, slow, or steady increase.

Duration

Atopic dermatitis: Indefinite with chronic relapses. Sometimes dirr ishes by adolescence or adulthood if of infantile onset. Sometimes lasts a lifetime but is common to last 20 years.

Contact dermatitis: Acute contact: Days to weeks. Chronic contact:, Months to years.

Dyshidrotic eczema (pomphylox): Recurrent attacks with intervals days to months, or for months to years.

Lichen simplex chronicus: As long as irritation is present, itch-scratch cycle.

Nummular eczema: Weeks and longer, with waxing and waning periods.

Seborrheic dermatitis: Recurrences and remissions, especially on the scalp. Infantile form disappears and adolescent lesions disappear with time.

Intensity

Atopic dermatitis: Erythematous spot or patches with erosions, papules Small to involvement of the entire head, causing hair loss. Occur on the arms and legs of infants, or the entire body in children and adults.

Contact dermatitis: Isolated and localized to generalized. Random characteristic depending on the nature of the exposure (e.g., airborne irritants only involve exposed surfaces).

Dyshidrotic eczema (pomphylox): Isolated patch lesions or generalized lesions over one or both hands and/or one or both feet.

Lichen simplex chronicus: Single isolated lesion to several scattered small or large plaques.

Nummular eczema: A few regional clusters to generalized. Arms and legs are the most common site.

Seborrheic dermatitis: A small scalp scale occurring on one or more of the following areas (singly or together): ears, brow, eyelids, sides of nose (especially nasolabial folds), chin, chest, body folds, and trunk.

Aggravating Factors

Atopic dermatitis: Temperature changes, stress, wool contact, food allergen ingestion, aeroallergen contacts. Other infections (skin and systemic).

Contact dermatitis: Scratching or rubbing; continued contact with allergen or irritant.

Dyshidrotic eczema (pomphylox): Emotional stress, hot water contact, chemical contacts, dryness and denaturing dyes, detergents, sanitizers (e.g., lanolin and fragrance), hyperhidrosis, and Nickel ingestion.

Lichen simplex chronicus: Scratch and rub, even in sleep. Nummular eczema: Dryness, scratching, strong soap, hot water, and emotional stress.

Seborrheic dermatitis: None.

Alleviating Factors

Atopic dermatitis: Removing allergens, hydrating skin, summer sun.

Contact dermatitis: Removal of offending contactants.

Dyshidrotic eczema (pomphylox): Rehydration, bland occlusives, stress alleviation.

Lichen simplex chronicus: Anything that interrupts itch-scratch cycle. Long term barrier.

Nummular eczema: Skin hydration.

Seborrheic dermatitis: Time, in infantile and adolescent forms.

Associated Factors

Atopic dermatitis: Up to 50 percent exhibit other allergic conditions (e.g., hay fever, asthma).

Contact dermatitis: Numerous possible home and workplace contactants.

Dyshidrotic eczema (pomphylox): Found in both sexes, often other family members have the condition, patient may be a type A person, and/or have an atopic background.

Lichen simplex chronicus: Somewhat more common in females and Asians.

Nummular eczema: Older men in dry climates. Wool and mechanical irritants.

Seborrheic dermatitis: Genetic diathesis, diet, alcohol, and stress probably play some role. Greater predilection in males.

Physical Examination

Skin

Atopic dermatitis: Acute: In infants and in childhood. Red skin with erosive areas, and/or small vesicles, crusts vary from dry weeping, scaling, and cracking. Occur on the scalp, face, and extremities (on extensor or flexor surfaces) and sometimes upper trunk and neck. Tends to spare perioral area. Subacute: Excoriated, lichenified papules, plaques, erosions, and crusts mainly seen on antecubital fossa, knee bends , necks, and face.

Contact dermatitis: Erthematous patches with superimposed close spaced nonumbilicated vesicles, punctate erosions, weeping serum, and crusts or dry scales on mildly reddened patches. Exhibit superficial desquamation or small red round or pointed firm papules, or lichenified patches (dry, thickened skin with exaggerated skin lines) with rounded or fiat topped small satellite papules, excoriation, and pigmentation. Sometimes very linear with artificial patterns. Isolated lesions or regional localization are common (e.g., just top of feet, just on the eyelids, back of hands, or exposed surfaces). Occur in covered areas only or randomly.

Dyshidrotic eczema (pomphylox): Initial presentation of pruritic, deep grouped, tiny (1 mm) vesicles (tapioca) on the sides of the finger, or palms and soles. Sometimes blisters or bullae are present, especially on the feet. Later exhibit scaling, flaking, fissuring, and lichenification with painful erosion. Occasionally will have erythema, tenderness, and crusting of secondary infection.

Lichen simplex chronicus: Well-circumscribed patch, papule, or plaque of lichenified skin in round, ovoid, or linear scratch/rub pattern. Single or multiple lesions occur on the nape of neck, scalp, ankles, lower legs, thighs (medial or lateral), outer arms, vulva, pubis, scrotum, or perianal area.

Nummular eczema: Coalescence of small grouped vesicles and papules that form discoid or coin-shaped plaque patch lesions. Occur mostly on the legs and arms but may become generalized. Common on the hands of young women. Become lichenified, dry, scaly-crusty plaques. All phases on erythematous base and lesions are dull red.

Seborrheic dermatitis: White or yellowish, dry or greasy, and scaling on discreet red macules. Diffuse on the scalp. Weeping and fissuring is common with external ear and scalp involvement. Polycyclic or annular on the trunk. Predilection for scalp, beard, face (especially brow and nasolobial folds), center chest, and body folds.

Pathophysiology

Atopic dermatitis: Immunoglobulin E (lgE)-mediated response to allergen contacts. Basophils-mast cell release of histamine responsive to hypersensitive IgE reactivity and chemical effects. Dermal infiltrate of monocytes, lymphocytes, mast cells, and a few eosinophils.

Contact dermatitis: Cellular, cell mediated, or delayed hypersensitivity reaction caused by T-cells after antigen contact. Tissue damage is caused by T-cells and/or release of lymphokines. Antigen processing is by Langerhans cells. Spongiosis and lymphocytic infiltrates evident. Increased polymorphonuclear lymphocytes in superficial vesicles suggest a pure irritant basis.

Dyshidrotic eczema (pomphylox): No real eccrine or apocrine pathogenesis. There is epidermal eczematous inflammation or spongiosis and intraepidermal edema with subcorneal vesicles. Definitive cause unknown.

Lichen simplex chronicus: Epidermal hyperplasia results as response to repeat physical trauma, causing a nerve proliferation and increased touch sensation.

Nummular eczema: Eczematous reaction pattern often with colonization of Staphylococci. Frequently occurring in asteatotic skin.

Seborrheic dermatitis: No known cause. No organism proved, but increases of P. ovale fungus and bacteria are common. Neutrophilic stratum corneum and lymphohistiocytic perivascular infiltrate with nonspecific inflammation of dermis, parakeratosis, acanthosis, and spongiosis is also present.

Diagnostic Studies

Laboratory

Atopic dermatitis: None needed as the condition is clinically apparent.Corroboration attained by serum eosinophilia and elevated IgE in 80 percent of atopics.

Contact dermatitis: Not applicable.

Dyshidrotic eczema (pomphylox): None however a negative fungal culture may help with some cases.

Lichen simplex chronicus: None. Clinical alone.

Nummular eczema: Culture more to clarify differential.

Seborrheic dermatitis: Not applicable.

Radiology: Not applicable.

Other

Atopic dermatitis: Skin testing: Eighty percent positive immediate hypersensitivity skin testing. Radioallergosorbent test (RAST) in infants may illicit fish, milk, eggs, mites, grasses, or mold as causation factor.

Contact dermatitis: Patch testing: May lead to identification of offending allergens, but only if skin is clear of sensitization in area of testing for at least 2 to 3 weeks.

Dyshidrotic eczema (pomphylox): Biopsy to differentiate pustular psoriasis.

Lichen simplex chronicus: Not applicable. Nummular eczema: Biopsy to clarify differential.

Seborrheic dermatitis: Biopsy might help differentiate for resistant condition or disease.

Differential Diagnosis

Traumatic

Atopic dermatitis: Contact dermatitis may be difficult to differentiate so if it becomes refractory to treatment, consider contact dermatitis. Usually it is in a wider range of local distributions.

Contact dermatitis: Anything traumatic is a contact dermatitis.

Dyshidrotic eczema (pomphylox)/lichen simplex chronicus/Nummular eczema/Seborrheic dermatitis: Not applicable.

Infectious

Atopic dermatitis: Dermatophyte more typical on hands and feet if scaly erythema. Positive for hyphae on KOH preparation. Unusual in infants. Sometimes the two are superimposed.

Norwegian scabies: Multiple cases in institutional setting with generalized eczematization, mite may be demonstrated in black-dot scraping.

Contact dermatitis: Dermatophytosis: More common in noncontact area (e.g., under toes and feet, in groin and axillae, and under skin folds). More commonly unilateral at onset. Body lesions are typically ring lesions, round and annular with clearing, smoothing centers. Same areas for yeast.

Yeasts-candidiasis: Affect the same areas as dermatophytois, but are beefy red, solid patches with red, small, satellite maculopapules surrounding larger lesions. Sometimes have a slight whitish exudate in intertriginous area.

Dyshidrotic eczema (pomphylox): Dermatophytosis: Usually more discrete patch lesions with typical border. More inflamed, but difficult and may require culture for fungus. Consider Id reaction for hands where feet are positive for fungus.

Lichen simplex chronicus: Not applicable.

Nummular eczema: Dermatophytosis: Positive KOH preparation and/or culture for fungus.

Herpes simplex: Have larger vesicles and less nummular, coin patch like.

Seborrheic dermatitis: Dermatophytosis and candidiasis will have positive KOH preparations and cultures. Usually more circumscribed lesions with less scale, mostly on borders.

Metabolic

Atopic dermatitis: Acrodermatitis enteropathica: Gluten-sensitive enteropathy, seen with histidine mia, phenylketonuria, and immunologic disorders. Wiskott-Aldrich syndrome, agammaglobulinemia, hyper IgE syndrome, and selective Immunoglobulin A (IgA) deficiency: All rare but hard to differentiate so if treatment fails or becomes refractory, consider these conditions.

Contact dermatitis: Stasis dermatitis: Slow, chronic onset and asymptomatic, usually without contact history.

Dyshidrotic eczema (pomphylox): Pustular psoriasis: Less pruritic and more rapid progression to pustules.

Lichen simplex chronicus: Mycosis fungoides: More bizarre shapes, more scale possible, older ages typically, long term lesions, various shades of red, and less lichenification.

Nummular eczema: Psoriasis: Generally thicker plaques with typical silver-white heavy scale. Seen on dorsal and exterior surfaces.

Seborrheic dermatitis: Histiocytosis X: In infants is distinguished by its petechial component and extracutaneous and histologic features.

Neoplastic

Atopic dermatitis: Letterer-Siwe disease and histiocytosis X in children, and mycosis fungoides and Sezary syndrome in adults: Plaques become hemorrhagic and indurated. A biopsy is required.

Lichen simplex chronicus: Mycosis fungoides: More bizarre shapes, more scale possible, older ages typically, long term lesions, various shades of red, and less lichenification.

Nummular eczema: Mycosis fungoides: Biopsy may be helpful. May be more annular and less coin like.

Contact dermatitis/Dyshidrotic eczema (pomphylox)/Seborrheic dermatitis: Not applicable.

Vascular: Not applicable

Congenital

Atopic dermatitis: Rare to be born with atopic dermatitis.

Dyshidrotic eczema (pomphylox): Rare prepubertally.

Lichen simplex chronicus: None, rare before 20-years-old.

Seborrheic dermatitis: Atopic dermatitis: More dry and rough with lichenification later. Also mostly in flexural areas arms, legs, less often groin or axillae.

Contact dermatitis/Nummular eczema: Not applicable.

Acquired

Atopic dermatitis: Seborrheic dermatitis: Often involves axillae or groin in infants as well as scalp; no positive RAST tests.

Contact dermatitis: Atopic dermatitis: Difficult, but usually in typical flexural distribution. If poor treatment response, consider contact.

Contact urticaria: Acute red dish wheal flare with resolution in 24 hours or so. Dyshidrotic eczema (pomphylox):Atopic dermatitis: Usually has involvement of other locations (e.g., arms, neck, legs, trunk). Drug eruption: More widespread and inflammed.

Lichen simplex chronicus: Psoriasis: Usually white or silver scale and plaques, with more rounded borders and less obvious lichenification markings. May be less pruritic, sharper margins.

Lichen planus: Different distribution (e.g., wrists, hands, intraoral). Small plaques with Wickham striae, not lichenification. Surface smooth. Chronic contact dermatitis: Hard to differentiate and may lead to lichen simplex.

Nummular eczema: Contact Dermatitis: Usually has a positive contact history and localization.

Seborrheic dermatitis: Psoriasis: Nearly indistinguishable if only scalp is involved, but psoriasis usually has more discrete circumscribed plaques especially of the scalp. Thicker white scale. Other considerations might include zinc deficiency, erythrasma, acrodermatitis enteropathica, drug eruption, or contact dermatitis.

Treatment

Atopic dermatitis: Aimed chiefly at hydrating the skin by using mild moisturizing soaps, frequent emollient creams, lotions, and body/bath oils. Avoidance of known irritants and allergens. Must stop the itch-scratch cycles. Antihistamines can be helpful such as:

Diphenhydramine 25 to 50 mg every 6 to 8 hr. as required for itching for adults. Children 12.5mg/5 ml solution V2 to 3 tsp pending weight every 6 to 8 hr. Hydroxyzine HCL 10 to 50 mg every 6 to 8 hr. depending on weight and side-effects, for adults. A liquid form is made for pediatrics and should be dosed according to weight schedule.

Other HI antihistamines from other classes may be added or tried (e.g., chlorpheniramine, trimeprazine, cyproheptadine, and the tricyclic antidepressant doxepin). All of the above may have a sedative side-effect.

Astemizole and loratadine twice a day have shown Some usefulness and are nonsedating. The mainstay of significantly erupted dry, lichenified skin is the topical corticosteroids. Choose a medium to high potency ointment (ointments more effective in this dry condition) except for the thin-skin areas (e.g., face, axillae, groin). For these areas, use a low to medium, nonfluorinated ointment such as hydrocortisone 1 percent, Desonide .05 percent or Aclovate, Locoid or Westcort. Medium to high potency include triamcinolone 0.1 percent to clobetasol .05 percent. These topicals should be used twice daily and are best after shower or bath. For chronic and/or severe disease parenteral corticoids may be necessary (e.g., triamcinolone, betamethasone inject able or prednisone tablets). Doses may vary by patient weight, condition, and severity of the condition. For the excoriated, weepy, crusty secondarily infected cases an antibiotic is important. Erythomycin is the first choice, but may necessitate theophylline monitoring in asthmatics. Dose in adults 500 mg 3 or 4 times daily for 2 to 4 weeks. If resistant, then dicloxacillin may be used, with note as to increased risk of allergy in these patients. Clindamycin 300 mg twice a day is another alternative.Ultraviolet (UV) radiation may be helpful from increased planned sun exposure short of burning or treatments in UVB or UV A cabinets under professional supervision, adding oral or topical psoralens or PUVA.No astemizole, loratadine, or terfenadine should be used with erythromycin.

Contact dermatitis: Primarily avoidance of contactants and/or barrier protection. Boro compresses: Domeboro, blueboro or pediaboro solution, two powder packets or tablets per quart of water and compressed or soaked 20 to 30 minutes 2 to 4 times daily, especially if vesicles, weeping, or crusting; continue until smoothing and dry.

Topical corticosteroid: Triamcinolone 0.1 percent ointment or cream if preferred (ointments more efficacious but sometimes less cosmetic) to involved body areas twice a day. Hydrocortisone 1 to 21/2 percent, Westcort, Desowen, Locoid, or Aclovate to facial, and genital areas twice a day or Desowen hydrocortisones, Elocon, or fluocinolides in liquid form for hairy areas, 1 to 2 times daily.

For extensive dermatitis, oral prednisone or equivalent 40 to 60 mg every day (divided dose OK) for 2 to 3 weeks, tapering 5 to 10 mg a day after first 7 to 10 days. Antihistamines may help in doses as listed in section on treatment for atopic dermatitis.

Dyshidrotic eczema (pomphylox): Avoid contactants! Diprolene ointment twice a day short-term graduating to medium potency (e.g., triamcinolone 0.1 percent 2 to 3 times daily).

Celestone 1 ml intramuscularly for acute, severe conditions.Triamcinolone acetonide 40 mg intramuscularly or prednisone 40 to 60 mg every day with slow taper, sometimes maintenance with 20 to 40 mg Q.O.D. Liberal use of occlusives (e.g., Eucerin, Nivea). Systemicantibiotics for infectious signs and symptoms. See bacterial infections medications and doses.

Lichen simplex chronicus: Elimination of the rub/scratch-itch cycling. Diprolene, temovate, or psorcon cream or ointment twice a day for 2 weeks, but not in anogenital area or on face. Triamcinolone 0.1 percent cm or ointment with plastic wrap or other occlusion for 12 to 24 hours. Triamcinolone acetonide 1.0 to 1.5 mg/ml intralesionally into dermis monthly X 3, 1 cm between injection sites. Reduce corticosteroid potency as control and maintenance are reached. Oral antihistamines may be helpful adjunctive treatment.

Nummular eczema: Dicloxacillin or erythromycin 250 to 500 mg four times a day for any signs of infection (e.g., inflammation, vesicles, crusting).

Topical corticosteroids:

Triamcinolone ointment or cream 0.1 percent three times a day or Betamethasone diproprionate .05 percent mg or cream twice a day or other mid to higher potency, tapering to medium and low potency steroids as condition clears and controls. Hydration of skin with oils and emollients 2 to 4 times daily.

Seborrheic dermatitis: Shampooing every day or two with tar, zinc, salicylic acid, or selenium sulfide shampoos is the mainstay of treatment for the scalp, which is the most common site. May also need mild to moderate to potent, pending severity, topical steroid lotion.

A Hydrocortisone 1 percent lotion Q.h.s. or Elocon lotion .05 percent Q.h.s. or Synalar solution .01 percent Q.h.s. or Lidex solution .05 percent Q.h.s. or Diprolene or temovate lotion Q.h.s. For face and intertriginous areas, 1 to 21/2 percent hydrocortisone cream or ointment 2 to 3 times a day or Westcort, Desowen, Aclovate, Locoid, cream or ointment 2 to 3 times a day or Elocon cream 1 to 2 tImes a day for severe conditions. For the trunk and extremities, a short course of medium potency steroid cream or ointment is the most helpful. Triamcinolone 0.1 percent 2 to 3 times daily or for stubborn conditions. Consider Elocon ointment 1 to 2 times daily after Improvement and move to lower potency topical steroids as mentioned above for more delicate skin areas. If condition remains resistant, try 2 percent ketoconaczole 1 to 2 times daily. In chronic disease, tar and sulfur PreparatIons are safe and effective, but very messy.

Pediatric Considerations

Atopic dermatitis: Common in pediatrics.

Contact dermatitis: Same as adult but pediatric dosing.

Dyshidrotic eczema (pomphylox): Not applicable.

Lichen simplex chronicus: None.

Nummular eczema: Same as adult but rare and treat with pediatric doses.

Seborrheic dermatitis: Avoid irritating substances, they might get rubbed into eyes, Le., tars. Usually respond well to low potency steroid creams/ointments.

Atopic dermatitis: Atopic dermatitis (eczema) is a commonly encountered skin disorder in the pediatric population. It affects 3 to 5 percent of children before the age of 5. Sixty percent of children affected will develop atopic dermatitis in the first year and 90 percent within the first 5 years. Approximately 75 percent of affected individuals will outgrow the disorder by adolescence. There are three distinct clinical phases recognized: infantile, childhood, and adult. The infantile stage begins between 2 and 6 months and typically involves the cheeks, forehead, and extensor surfaces of the extremities. It is characterized by pruritus, erythema, papules, vesicles, oozing, and crusting.

It will frequently resolve by age 5. The childhood stage develops between 4 and 10 years and affects the flexor surfaces, popliteal and antecubital fossae, wrists, and ankles. It is characterized by chronically dry, papular eruptions which are extremely pruritic. Skin lichenification is common. The most common complication is secondary infection with S. aureus.

Treatment is directed at controlling the dryness, inflammation, and pruritus. Topical steroids should be used cautiously in children due to the potential of system absorption and adrenal suppression. Fluornated steroids should not be used on the face.

Seborrheic dermatitis: In the pediatric age group, seborrheic dermatitis is most commonly seen in infants and adolescents. It may begin within the first month. Cradle cap may be the initial and sometimes only manifestation. Most infants with dermatitis, especially if the trunk and extremities along with the face and scalp are involved, will eventually demonstrate features consistent with atopic dermatitis. Seborrheic dermatitis with petechiae are often seen in Letterer-Siwe disease, a type of histiocytosis X. During adolescence seborrheic dermatitis is more localized and may occur on the scalp, mid-face, chest, or in the nasolabial folds or postauricular area. Seborrheic dermatitis is a common cutaneous manifestation of acquired immunodeficiency syndrome among young adults. Antiseborrheic shampoos (selenium sulfide, tar) may be used daily if necessary. Topical steroids of low potency will often clear the dermatitis.

Contact dermatitis: The most common form of contact dermatitis seen in pediatrics is diaper dermatitis, the result of prolonged contact of urine and feces with the perineal skin. Secondary infection with Candidaalbicans is common. Conservative treatment consists of frequent diaper changes, air drying, topical barriercreams (zinc oxide) and, if appropriate, light application of 0.5 to I percent hydrocortisone cream. Other forms of irritant contact dermatitis common in childhood may result from prolonged contact with saliva (drooling infants and children who are habitual lip-lickers), bubble bath, detergents, soaps, proprietary lotions and creams, and sweat and moisture resulting from the wearing of occlusive shoes. Allergic contact and rhus dermatitis (poison ivy, poison sumac, poison oak) are commonly seen in childhood.

Obstetrical Considerations

Potent topical steroids should be avoided; use only if expected benefit justifies potential fetal risk. Do not apply over extensive areas, in large amounts, or for prolonged periods.

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   Polymorphous Light Eruption
   Porphyria Cutanea Tarda
   Port-Wine Stain
   Premalignant and Malignant Skin Tumors
   Pressure Ulcers
   Pruritic Urticarial Papules
   Pseudoxanthoma Elasticum
   Pyogenic Granuloma
   Radiation Dermatitis
   Raynaud's Disease
   Reiter's Syndrome
   Rocky Mountain Spotted Fevers
   Rosacea
   Rubella
   Xanthelasma
   Xanthomas
   X-Linked Hyper-IgM Syndrome
   Xeroderma Pigmentosum
   Yaws
   Yellow Fever
   Yellow Nail Syndrome
   Zygomycete
   Zinc Deficiency

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