White : Diseases of the Skin - Eczema and Related Disorders

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Gary M. White & Neil H. Cox

Diseases of the Skin

6	Eczema and Related Disorders

RELATED CONDITIONS
Intertrigo
Etiology and pathogenesis
The term intertrigo describes an inflammation of the skin that results from chronic wetness and maceration. Almost any skin at a body fold may be affected, although the groin and inframammary areas are most typically involved.

Clinical
The skin of a body fold becomes red and scaly. Itching is typical. In severe cases, the skin may become macerated. Obese women with large breasts exposed to hot humid climates, or men whose groin stays hot and sweaty, are typical patients. Secondary infection by candida is very common, and its presence is indicated by satellite pustules.

Differential diagnosis
Differential diagnoses are as follows (see also Table 2.4, pic 6. 24).

•	Candidiasis of flexures, especially inframammary, may mimic intertrigo or occur as a secondary event. Satellite lesions, sometimes pustular, should suggest this possibility.
•	Bacterial infection (staphylococcal or streptococcal) in flexures may occur secondary to intertrigo and should be considered, as it may be misdiagnosed and erroneously treated as a simple 'flare' of known intertrigo.
•	Erythrasma will affect the flexures but is red-brown in color, with less inflammation. A Wood's light examination may be performed to exclude erythrasma.
•	Tinea cruris contains scale and a raised, scaly border, and concurrent tinea pedis is almost always present.

Treatment
Patients must be educated on the cause of the rash. Specifically, they must understand that any skin does best if kept cool and dry. Typical discussion points include the following. Does the affected skin stay hot and sweaty? What can be done to keep the affected skin cool and dry? What is the patient's profession? (Prolonged sitting on plastic seats, for example, creates a hot sticky environment.) How hot does the patient get during the day? Does the patient have air conditioning at work? At home? What sort of underclothes are worn? Would boxers be better than briefs?
    Initially, a topical steroid cream or solution is needed to reduce the inflammation. Cool soaks b.i.d. may help dry a moist, oozing eruption. A steroid cream with added nystatin is helpful in areas where Candida is common, for example the inframammary area or the corners of the mouth. Long term, to prevent recurrences, the area must be kept dry. A superabsorbant powder (e.g. Zeasorb) two or three times daily is helpful. Some of these products have miconazole or other antifungal powders included. In extreme cases, a strip of an old white sheet or other cloth may be placed in the folds to absorb moisture.
    For maintenance therapy, have patients shower every day, use a blow-dryer to completely dry the area, and then apply a roll-on antiperspirant.
    Some athletes can get an irritation in the groin from the friction that occurs with exercise. Olive or other oil applied before workouts to decrease friction may be tried.

Practice point
• For the patient with intertrigo, recommend for maintenance the use of a
blow-dryer followed by an antiperspirant daily.

Grover disease
Etiology and pathogenesis
Grover disease, also known as transient acantholytic dermatosis, is of unknown etiology. Some view it as a type of heat rash, as it is often associated with increased sweating. Women may develop it at menopause as a result of hot flushes. It may occur in the winter (e.g. after Christmas in a patient given flannel pajamas and a new comforter). The patient should always be asked about increased sweating, particularly at night. A Grover disease-like rash has resulted from interleukin-4 administration.

Clinical
Discrete, truncal pruritic papules and papulovesicles in a middle-aged or elderly person are characteristic (Fig.6.80). The rash is usually symmetric across the chest, with an increased involvement just below the breasts in both men and women. Although originally described as a transient phenomenon (weeks to months), the disease may last years.

Differential diagnosis
This may include the following.

•	Acne:an acneiform condition may occur acutely and diffusely on the trunk, but the lesions are follicular with scattered pustules.
•	Miliaria:lesions are smaller, clear or red, and very transient.
•	Seborrheic keratoses:tiny lesions of this type may resemble the brownish scaling that occurs in established lesions of Grover disease.
•	Itchy red bump disease:a condition of unknown etiology, very itchy, that also tends to affect the trunk in older men mainly.
•	Eczemas:the lesions of nummular or of asteatotic eczema are larger.

Treatment
Patients should avoid heat, as it may contribute to an outbreak. Air conditioning or a ceiling fan may help, as may emollients or topical steroids. Dapsone, PUVA, and isotretinoin have been useful but are usually not needed.

Papuloerythroderma of Ofuji
Etiology and pathogenesis
Papuloerythroderma of Ofuji is a term used to describe a rash with a characteristic sparing of folds known as the 'deckchair' sign (Fig.6.81). It has been argued that this disease is not a single entity but instead a pattern of expression of, or association with, various inflammatory dermatoses, including lymphoma, hypereosinophilic syndrome, cancers, AD, pityriasis versicolor, and drug reactions. The work-up should include the exclusion of the above-mentioned entities, especially lymphoma. Localized or abortive forms have been described.

Clinical
There is diffuse, papular erythroderma that spares the skin folds, creating the deckchair sign. This condition typically occurs in older patients, many of whom have a peripheral eosinophilia and some lymphadenopathy.

Differential diagnosis
This eruption has a very characteristic appearance and the clinical label is usually not in doubt, although the underlying cause is often uncertain.

Treatment
If no specific cause is found, topical or oral corticosteroids (e.g. 30-60mg of prednisone every day) may be tried. PUVA and interferon-alpha have been used. Ciclosporin has been reported to be very effective.