Rational approach to the management of eczemas

Eczema is an inflammatory skin disease commonly encountered in clinical practice where the underlying cause often appears uncertain. Diagnosis is essentially clinical, depending on clinical signs which varies with the stage of evolution of the inflammatory process. Although the mainstay of treatment is still topical corticosteroid preparations, much more can be done if an accurate diagnosis of the type of eczema is made and patients advised about the prognosis, and natural history of this troublesome and sometimes disabling condition.

[Remarks and recommendations on the definition and classification of eczematous diseases]

Numerous nomenclatures and classifications of eczemas have puzzled dermatologists for a long time. This confusion is due to the great number of external as well as internal noxious factors and/or agents causing eczemas being themselves a distinct and histologically well defined reaction of the papillary-epidermal compartment. Current classifications do not adequately reflect the complex causative conditions involved in the etiopathogenesis of eczematous disorders. I propose, therefore, to classify eczematous disorders according to the following three principal categories: "mainly endogenous" (or "atopic") eczemas, "mainly exogenous" (or "contact") eczemas, and "dysregulatory microbial" eczemas. The latter group comprises eczemas caused by various kinds of functional derangement of epidermal protective properties (e.g., venous stasis, exsiccation of horny layer, seborrhea/hyperhidrosis, epidermal atrophy), which in turn permit the resident and/or transient microflora of the horny layer to induce inflammatory responses of eczematous pattern. Since morphological, topical, and other clinical attributes may change in the course of the very same eczematous disease, they are inappropriate for basic classification of eczemas and should be only employed as minor criteria to characterize the predominant "type" or subset (i.e., clinical appearance) of the specific eczema. The possible combination of eczemas representing two (or even three) categories in one patient leads to intermediate forms entirely in keeping with the division into three principal groups. The classification proposed is aimed at eliminating the terminological confusion as well as enabling reliable documentation for compatible statistics, and should consequently improve the sematic communication between dermatologists and other physicians.

[Eczema of the lower leg--clinical, allergological and differential diagnostic aspects]

More than 50% of patients with dermatitis of the lower legs have a contact allergy. In 60 of our out-patients, the most frequent allergens were found to be balsam of Peru, lanolin and terpentine, followed by benzocaine, p-phenylenediamine, neomycin, oxychinoline, and parabens. Contact sensitization should be chiefly suspected in patients showing resistance to treatment despite apparently adequate therapy, and in those complaining of intolerance to definite topical treatment. Further indices are vesiculation and oozing in the environment of the ulceration, or scattered foci of dermatitis in the face (blepharoedema) or on the hands. The importance of patch testing is emphasized. Suggestions for differential diagnosis and treatment are given.

Sociological implications of an epidemiological study of eczema in the City of Birmingham

An epidemiological study has been made of 4696 cases of eczematous dermatitis referred to hospital outpatient clinics in the City of Birmingham over a 3-year period. Some sociological implications of the investigation are discussed. The need for further sociological accounts of skin disease is stressed.