Eczema

The term eczema is used to describe all types of redness, blistering, discharge, scaling, brown discoloration, thickening, and itching of the skin.
There are different types of eczema, such as: allergic contact eczema, dandruff eczema, and coin eczema. Here, we will examine only the most common type of eczema, which is known as atopic dermatitis or natural eczema. 
The word “Atopic” includes a group of allergic or allergic diseases that often affect several members of the same family.
These families may have allergies such as hay fever (seasonal allergies), pollen allergies, and asthma.
In addition, there are skin lesions called “atopic dermatitis” in them.
While in the family of people with atopic dermatitis, there are people with similar problems, but in 20% of cases, only one person in the family may have this disease.
Atopic dermatitis is very common in all parts of the world. Unfortunately, accurate statistics of the prevalence of this disease in Iran are not available, but this disease affects about 10% of infants and 3% of the entire population in the United States of America.
Although this disease can occur at any age, it is more common in infants and children.
The skin lesion is itchy and sometimes ugly and unpleasant.
Atopic dermatitis usually resolves spontaneously in childhood and sometimes before the age of 25. But some patients suffer from this problem all their lives.
In such cases, both the patient and the doctor are usually tired and unable to continue the treatment and persistence of the disease.

Acute eczema:
includes both acute and chronic symptoms. There is erythema and redness, but the form and zicule are less. The symptoms are swelling, itching and cracking of the skin. The histology of subacute eczema shows both acute eczema and chronic eczema
. Chronic eczema:
chronic eczema with erythema And the redness of the skin is different and variable. There are sometimes crusts and scaly skin with increased skin pigmentation. Skin cracks are formed earlier than zicules and large wounds. Chronic eczema is the final stage without presenting acute and subacute eczema.
Atopic eczema (natural):
prevalence of atopic eczema or childhood eczema It is one of the most common skin diseases. About 20% of affected people are 7-year-old children. The symptoms are itching and swelling of the skin, mostly in the face area. The skin of these children becomes dry, and about 60-70% of these children They get better during life. The prevalence of this disease after children is high in people over 30 years old, the cause of which is not completely clear. But environmental factors are influential and important. Atopic eczema is high in rich families. There is no doubt that this disease affects both the patient’s life and his family life.
Seborrheic Eczema:
Seborrheic Eczema is currently thought to be caused by Porum pityros fungi in adults. Patients are usually characterized by erythema and increased skin fat in the central part of the face/eyebrow scalp/around the ear/chest and back.
In adults, this eczema is very severe, the skin of the scalp and face is inflamed/ they show a lot of symptoms (dandruff) in the scalp and it is accompanied by itching and irritation of the skin and erythema in the face, ears/chest/around the nose and front of the head. It is common. In babies, the first symptom is yellow/thick fat scales on the scalp and it is difficult to move the scalp and hair. This inflammation may continue around the eyebrows and ears.

When the disease appears in infancy, it is sometimes called “infant eczema”. Itchy, oozing and crusted lesions appear, especially on the face and head of the baby, but these lesions can also exist anywhere else. To get rid of itching, the child may rub the face, cheeks and other affected areas with his hands or rub his head and face with a pillow or anything available. Parents should know that most babies before reaching They get rid of this disease at the age of two. But proper treatment can be very beneficial in controlling the disease and make it easier to bear it until the time passes to solve the problem. If the disease continues or appears after infancy, the skin has less tendency to redness, blister oozing and crusting. Instead, the lesions are dry, brownish-red, or gray, and the skin becomes scaly and thick. There is also severe and almost unbearable itching that is worse at night. Some patients scratch their skin so much that it becomes sore and bleeds. In this case, the defense barrier of the skin is damaged and may lead to skin infection. In teenagers and young adults, the lesions are especially in the elbow bend areas. and young adults, the lesions appear specifically in the areas of the elbows and backs of the knees, ankles and ankles, as well as on the face, neck and upper chest. Know that any other part of the body may also be infected with this disease. Dry skin or sedation includes a set (wide spectrum) that is accompanied by itching of the skin and then redness and the underlying crust. In addition, there are different types of eczema. In every age and age, the location of eczema is different, as well as a wide range of autoimmune skin diseases such as psoriasis, Lincoln Plan Vulpus can show itself in the form of eczema. People who wash a lot and also with stimulants such as detergent or other chemicals or animal prophms are dealt with, they are more likely to suffer from eczema.

The skin is damaged for various reasons.
A type of inflammation occurs, which is called dryness, eczema, or dermatitis, which is red, itchy, sometimes painful, burning, and slightly swollen. The main treatment strategy is prevention and elimination of contact with all irritants. 

• The first step is not to wash frequently 
• Second, avoid exposing the skin to unfavorable environmental factors such as wind, even if it is cold, and even worse, dry wind, heat and humidity 
• Third, various chemicals and even their vapors do not reach the skin 
• Fourth, use pen instead of soap 
• Fifth, moisturizers should be used, the drier the skin, the more it should not be used in the T area of ​​the face or much less 
• If a moisturizer is used, do not go to cold or hot air for 20 to 30 minutes so that the water does not evaporate quickly, and if you are in a hurry, it has more fat or blocking substances. 

Eczema on the hands of both workers and housewives due to excessive washing reduces the fat layer and makes them susceptible to eczema. 
The hand area that is washed a lot should have the most blocking (fat)

and also add silicone, which repels water and neutralizes the washing a little. 
Avoid rubbing and rubbing the skin. They should wear gloves, the best type is the type of thread that is not useful, so plastic gloves with a linen lining, so 
that there is inflammation and disease in the skin, no moisturizer should be used, and medical treatment should be done first, and the inflammation will disappear, then it is time to protect with moisturizers. is

The most important of them is the use of cortenic compounds on the skin, which the doctor prescribes, which recommends the use of various concentrations of ointments or creams and how many times a day, it is all the responsibility of the doctor after the examination. 
Depending on the severity, sometimes corten tablets or antihistamines are also prescribed. In some cases, local treatments become inflamed or oral medications cause side effects, which requires caution.

Chronic and recurring inflammatory skin disease, which is usually combined with respiratory allergy (atopic inheritance) and responds to both stimuli and allergens, causing severe irritation to the patient and absenteeism from school, and even nervous and mental problems. It needs 4 factors, genetics and environment are common with other diseases, but special immunology and epidermal barrier dysfunction are also necessary.
An increase in the prevalence of atopic eczema has been observed worldwide.
Atopic eczema is the most common chronic inflammatory skin disease with a diverse clinical spectrum.
Atopic eczema is often the first manifestation of an atopic patient, and with timely intervention, it may be possible to prevent and stop the atopic march.
Atopic eczema is an important issue in public health due to its impact on quality of life and socio-economic burden.

During the recent decades, we have seen an increase in the prevalence rate. In all parts of the world today, the average of 15% of children is affected, which has increased 2-5 times compared to before. In Japan, 5-6 years old is 24%, 8-10 years old is 15%, and 16-18 years old is 11%. Reported
causes of increased prevalence: urban life,
air pollution
, increased indoor allergens,
more parental awareness, 5-less period, drinking breast milk,
moderate areas, prosperous life, black race are more affected.
90% of the onset is under 5 years old, and only 20-30% get better until puberty, and the remaining 70% only get milder.
The similarity with asthma
is very important in terms of statistics, even its severity and prolongation means if a child starts eczema before 3 months old – if childhood eczema is severe and if two members of someone’s family have eczema, the probability of him getting asthma is much higher, and if this history exists, chronic and severe asthma will follow. Immunological inflammatory markers are found in the skin, both in the blood and in the breath,
such as respiratory allergies to allergens and stimuli, both of them react to a stimulant called sodium lauryl sulfite, which causes inflammation for the healthy skin of people with kidney eczema in times of non-asthma attacks. There are general triggers such as allergens for atopy, genetic
pathophysiology
: mutation in the FLG gene (on chromosome 1, long arm of the Q locus 21) causes a decrease in a protein called filaggrin, which works to accumulate filaments, so with the absence of filaments, the skin does not have firmness. It is interesting that T Helper2 substances, including interleukin 4 and 13, cause a decrease in filaggrin, which through the reduction of the expression of the corresponding gene and T Helper2, which also makes interleukin 22, if they are reduced, then filaggrin will decrease.
This mutation, even if it is in the skin, can cause asthma, and if a person with When the skin becomes sensitive to an allergen, it shows more and more severe asthma. The
following steps are needed to start the inflammation

1. Disturbance of the balance between the endogenous protease (yachymotryptase) of the skin and its inhibitor, which we have in the use of alkaline soap, when the balance is disturbed, the protease becomes problematic, and the colonization of staph and mite bacteria, which causes an increase in external protease and damage to the epidermis.
2. Lack of ceramides and skin fat
3. and filaggrin deficiency
4.  Dehydration of the skin (water loss from the epidermis)
5. Entry of allergens, antigens or stimuli or chemicals into the skin 
6. Reduction of enzymes that play a moisturizing role, such as arginase and then 
7. The introduction of allergens and the colonization of more bacteria 
8. By increasing the expression of the protein that binds with the free acid of fats, Staph Arius reduces skin fat and creates an eicosanoid inflammatory signal. 
9. And finally the beginning of inflammation

Staphylococcus aureus, which has exotoxins called enterotoxin A and B, etc., which act as super antigens that activate both specific IgE and specific T cells, and the intensity of the skin test has a linear relationship with the severity of the disease. These super antigens cause T disorders. Reg means the severity of the disease and it means resistance to steroids.
Malassezia sympodials and Trichophyton are fungi and we see them on the neck and head. In people with eczema, they have both IgE and specific T cells against them. And it gets better.

The role of allergens in pathogenesis

Although up to 85% of these people have a positive skin test or rash and have the same or higher total IGA, but the role of allergens is not in the cause, and mostly in relapse or the course of the disease, it is more complicated and difficult to respond to treatment. It was found to be the role of allergens, abstinence is necessary for treatment, otherwise it is considered resistant to corten,
only one-third of the positive foods in skin prick were clinically validated with challenges and 66% were invalid, but if abstinence is proven, don’t forget mites
– animal dander and plant pollen that we have both IGA and specific T cell in the body of people with eczema, then it is important to avoid them because contact with the skin and inhaling them will cause a relapse of eczema dermatitis, so more attention should be paid to inhaling these substances. There is a linear relationship between the intensity of the skin reaction and this materials (even skin patch test) we have the severity of disease symptoms.

The role of autoantigens

Autoantibodies were found in the serum of these people, both IgE and IGG against speckle 70, as well as IgE and specific T cell against the protein inside the keratinocytes that was cloned and its presence in the immune complex with IgE.
These autoimmune proteins are either nuclear or microsomal. There are injury (scratching) and infection causes the release of these proteins and the disease becomes more and more
resistant
. and it is permanent, but most of them are recurrent, and we have both common and uncommon recurrences.
In the acute form of the papule, we have severe itching (grabbing) with vesicles (tiny blisters) and secretions
.
In the chronic form, the itching is less, but the leathery skin (lichenfai) and the papules have also become fibrotic, but most of the cases are chronic and acute together.
In infants, the face, head, and extensors of the joints of the limbs and the lower hips are more involved, and in the diaper area, it is very rare if it occurs. Both secondary infection with Candida fungus and inflammation spread even under the feet because it works systemically,
the neck and flexors of the limbs are affected in teenagers and adults.

Eye complications , which are the most important,
eyelid involvement is very rare, and first we should think about diagnosing allergic contact dermatitis,
but in the case of acute keratoconjunctivitis, it is a problem that bilateral itching and burning, tearing, and the discharge of a pile of mucus from the corner of the eye are unfortunately associated with eyelid dermatitis. or dermatitis is chronic blepharitis, corneal ulcer causes vision impairment and subcapsular cataract may also occur at a young age due to keratoconus itching,
hand complications
of hand dermatitis, especially if it is related to a job that involves a lot of washing, or people who are obsessive about
infectious complications
Due to the reduction of interferon gamma, the susceptibility to viruses is more, simple herpes, eczema herpeticum is very severe because the smallpox vaccine is no longer injected, we do not have eczema vaccinatum, which was in these people, the
human papilloma virus also causes warts,
molluscum, which spreads quickly,
and fungus. Malassezia, but most importantly, Staph Arius, whose colonization plays a role in the course of the disease, which is recommended in the treatment of an ointment that contains both corticosteroid and staph anti-pus,
mood disorders
, social relations disorder, loss of self-confidence, and insomnia, all of which lead to a decrease in the quality of Health is life. Of course, it should be added that mental emotions and stress cause the recurrence of the disease, but it is not considered whether people with mental problems have more staph colonization or not. It is under investigation.
The differential diagnosis
is congenital: Netherton’s syndrome.
Other dermatoses: dermatitis. Seborrhoea – contact (which is no longer vesicobullous if it is mounted on eczema) Annular eczema – but chronic simplex
of infection and contamination: Scabies parasite (genital area, armpits and the edges of the fingers and the linear condition of night itching) and AIDS,
skin cancer, lymphoma (mycosis fungoidos – Caesarian syndrome)
Immune deficiencies: Aldrich Wiscott (eczema-thrombocytopenia and insidious bacterial and viral infection) – Skids (combined and severe immunodeficiency) Hyper IgE (rough eczema and cold and deep skin infection or staph in the lung) another type of Hyper It is IgE that does not have a rough appearance and most people get viral infections. EPX syndrome (eczema – enteropathy – diabetes 1 and thyroiditis – anemia and thrombocytopenia and T Reg Cell deficiency) – polyendocrinopathy
(several disorders of glandular diseases, eczema and immunodeficiency, and frequent fungal infection)
_ PKU disease and infiltrating carboxyl metabolic disorder
: Letter Siu (histiocytosis) is a clinical 
diagnosis based on symptoms Major symptoms: scratching with grasping _ course of the disease _ typical lesion _ atopy in the family Minor symptoms: dry skin _ skin infection _ undifferentiated dermatitis Hands and soles of the feet – multiline ichthyosis of the palms, keratosis pilar (chicken skin), pietrasis alba (white spots without itching on children’s faces), nipple eczema – white dermographism – eye cataract – EGE Total (high) and skin or serum test positive for allergens if If there are two major factors, the diagnosis is certain, or one major and two minor

Immunology of
different cells in atopic dermatitis. B
Cell, which produces EGE Total and specifically . Intrinsic is different, for example, in the laboratory, the endogenous type has no effect on EGE production . monocytes and macrophages become Langerhans, eosinophils , which together with interleukin 5, play a large role in the chronic phase, tonerophils, whose absence is considered to be the reason for susceptibility to infection, which leads to deterioration and lack of response to treatment, keratinocytes , which also produce less antibacterial substances (the reason for the risk of infection). Just like Helper2, the production of interleukin 4 and 13 and the reduction of gamma interferon cause gamma interferon and vitamin D in the keratinocytes of healthy skin to produce antibacterial proteins that do not work in eczematous skin. Pathology first of all, cohesion and adhesion between cells in the epidermis are damaged, which is called acanthosis. Then it enters the cell and more importantly between the cells, which is called spongiosis, which spreads even to the cells of the dermis, and in the chronic phase, we have hyperkeratosis, which is lichenification, leathery, and thick epidermis. Superantigen antibiotic treatment is effective in controlling this type of eczema. So, Staph aureus and its substances play an important role. Super antigen causes the production of TNFα and interleukin, one of the keratinocytes, Langerhans and monocytes, which helps in the movement of Langerhans to the lymph nodes as a progenitor to T cells. With the increase of E-selectin in the vascular endothelium, it causes cells to migrate and pass to the lesion site with more production of interleukin 12 and CL A-positives (lymphocyte cells), whether allergens or other stimuli enter, although they are specific, but they lead to non-specific and general hyper-responsiveness.

treatment

• Paying attention to many factors including allergens – stimuli – infections – physical environment – mood and stress
• Paying attention to the acute, sub-acute or chronic phase of the disease
• Paying attention to daily skin care – avoiding aggravating factors – correct use of medicines

Alkaline soap and non-soap cleaners (detergents), various chemical substances, air pollution, skin exfoliating substances in the beauty of both extremes of temperature (cold and heat) and humidity (air dryness and humidity)
alternatives,
writing a care plan equivalent to an asthma action plan,
pan or soap which is neutral and has the least fat reduction, cotton or mainly cotton
clothes
– not clingy – wash new first and then wear (formaldehyde N is removed) – wash with plenty of water – use liquid in the washing machine, not
activity powder minimum sweating – swimming is good ,
but a shower after swimming is necessary for chlorine on the skin The history or the challenge test have been positive. It is mandatory to test the foods in the food test. A negative prick test has a higher predictive value, and a positive prick test has a lot of false positives and is not worth more than a third, because most of them are negative in the blind challenge test, both in terms of the number of people and the number of skin reactions in one person. milk, eggs, peanuts, soybeans, bread, fish, six main foods are the clinical culprits in more than 90% of eczema, the immunocap rest test has clinical value up to 95%, but the prick is cheaper and faster, and the patch test is also research . Anti-allergy bedding – Washing with hot water weekly – No carpet in the bedroom – Reducing the humidity in the home Neurological consultation Accepting the chronicity and recurrence of this disease – Not delaying treatment – Reviewing the daily self care plan and relaxing when visiting the doctor – behavior Treatment – biofeedback hydrotherapy, reduction of ceramide means that the ability to retain water in the skin is reduced, so hydrotherapy is mandatory, if possible, put the dermatitis site in hot (not lukewarm) water three times a day for ten minutes until it gets wet, then take a shower. It is different (frequent showering is prohibited) and after getting wet with Vaseline, it should be quickly greased so that it remains wet and the towel does not dry tightly, and of course the head and neck should be covered with a damp towel, for example three times for 10 minutes each time – Oatmeal if If we add it to hot water, the skin becomes soft, or alkaline cooking water and avoid water evaporation on the skin, washing and bathing, if it is combined with moisturizing, it also prevents the colonization of Staphylococcus aureus. They add that because it can be a stimulant, it is not confirmed much, although it is recommended very little. The best treatment to prevent staph colonization is Mu Prosin ointment inside the nose and the lesion. They know that there are three forms of emollient, ointment, cream, lotion, and the lotion has more water. It will give more evaporation to the skin, and because the cream and lotion contain preservatives, there is a possibility of being a stimulant. There are various emollients in the market, ammonium lactic 12% makes the skin soft and firm, and especially reduces the long-term effect of topical corten. A new non-corten cream has arrived (not approved by FD A). ) such as Atopical Air-Api cream is the cheapest herbal butter emollient

Topical steroid
has seven different intensities because they have different vital access and various formulations are available, including cream, ointment, lotion, solution, which have different biological half-lives, ointment (ointment) is stronger than cream (Azic product and Gelat) and water lotion. It has more that can evaporate and this is not useful. The ointment has the least evaporation and the best coverage of the lesion, but the cream and lotion spread better on all the lesions, but they work weaker
. Valerit and Menthazone cream have an average effect, the weakest is hydrocortisone (some people may be mistaken in the percentage of ingredients, for example, 1% is stronger than 0.05%, while the main ingredient is important.
Determining the type of corticosteroid depends on the severity of the eczema, but the minimum that provides excellent control. Slow is important, not just being weak, and if it doesn’t work with the weak type, go one step stronger, and if it doesn’t work with the strong type, it should be put under the cover, of course, we should know that we increase the possibility of atrophy and systemic complications

Until the age of 3 months, fluticasone 0.05% cream, and then until 2 years of its lotion, and above 2 years of age and up to 6 years of intement or Momentazone cream,
the face, eyelids, armpits and groin only from hydrocortisone because they give an addiction to corten, which should be stopped
in the anal areas that Intement causes folliculitis and even itching. The cream type is better tolerated.
The solutions are for the scalp and hairy areas because it contains alcohol
. Let’s make
the rule of type finger unit – the size of the first joint of the index finger, which is enough for a surface equal to one palm. For the face, 2 units, for the arm and forearm, 3 units, for the whole leg, 6 units, and for the body, 14 units are needed,
from strong to weaker type. It should be changed and then stopped, and the moisturizer should be continued,
except for the weak type, the majority should be applied once a day, and after complete recovery, it is recommended twice a week for a long time to prevent recurrence, of course, in cases where it seems necessary. (proactive therapy)
emollients should not be applied to the cortex (it reduces its effect)

1. Skin thinning
2. Skin injection
3. Impact bruise
4. Reduction of skin pigmentation (hypopigmentation 
5. acne
6. stretch marks 
7. Hair folliculitis (being under the cover
8. Secondary infection
9. Systemic (strong type of Minister Kaveri)

Failure to respond to topical corticosteroids

1. None Adherence (distrust – a lot of fear of corticosteroids and those waiting for a miracle) who did not take the medicine correctly are the most common reason.
2. Inadequacy of the type and amount of skin corten
3. Possibility of secondary infection
4. The genetic type resistant to corten or the acquired type of involvement of monocytes,
   oral corten is not necessary if everything is taken and observed correctly, and in extremely rare cases, if the oral is short-term, it will quickly become topical.

There are two types of topical treatment with urinary calcination inhibitor
in the market

1. Tacrolimus, which has 0.03% (children) and 1% (adults) (market name Protopic), which we still do not give to children under one year of age, and it causes a little burning and tingling.
2. PIM Crolimus (Elidel in the market) 1% is prohibited for use under 3 months.
   Oral cortin is not necessary if everything is taken and observed correctly, and in extremely rare cases, if it is a short-term oral, it can quickly be turned into a topical.

There are two types of topical treatment with urinary calcination inhibitor
in the market

1. Tacrolimus, which has 0.03% (children) and 1% (adults). 
2. (market name Protopic) which we don’t give under one year and it gives a little burning and tingling.