ECZEMA (eczema; Greek ekzeo to flash, boil) — the chronic recurrent disease of skin caused by a serous inflammation of preferential papillary layer of a derma and to focal spongiosas of an acanthceous layer of epidermis, which is shown polymorphic pruritic rash.
History. The name «eczema» meets ?u the Byzantine doctor Aetion from Amides (543 g); perhaps, it was applied and earlier. Prior to the beginning of 19 century the term «eczema» was used for designation of various sharply arising diseases of skin (an erythema, an ugly face, a small tortoiseshell, etc.). For the first time E. as the independent disease relating to group of a vesicular dermatosis the English doctor Uillen described in 1808 (R. WM-1ap). In 1813 Mr. Beytmen (T. Bateman) gave exact a wedge, the description E., having characterized it as fever-free and not contagious damage of skin with rashes on slightly hyperemic background of the small bubbles which are quite often grouped. In 1819 Mr. L. Biett entered the concepts «acute eczema» and «chronic eczema». In 1854 Mr. of Deverzhi (M. of G. A. Devergie) specified a wedge, a picture E.: he described so-called eczematic wells (dot erosion) and emphasized a peculiar dot, drop character a moknutiya at this disease. Thus, in the middle of 19 century the kliniko-morphological concept «eczema» was formulated rather accurately. However further wedge, definition E. it was reconsidered. In 1887 the German dermatologist of the Item Un-na described the peculiar eritematoskvamoz-ny damage of skin called by it seborrheal eczema. It revealed at E. and at seborrheal eczema of change of an acanthceous layer of epidermis in the form of focal intercellular hypostasis and on this basis mistakenly identified both diseases. Having found the cocci called by it morokokka at seborrheal eczema, P. Unna put forward the parasitic theory of developing of eczema, edges was disproved by works of such dermatologists as R. Saburo, Y. Yadasson, G. A. Kyuzel, shown that a bubble — primary element E. — it is always sterile. In 1909 to Zh. Darya combined seborrheal eczema of Unna with other peculiar eritematoskvamozny dermatosis under the name «eczematid», having allocated three of its versions — figured (seborrheal eczema of Unna), pitiriaziform-ny and psoriasiform that led to an identification of seborrheal eczema and an eczematid. A. Sezary, R. Saburo, M. G. Mgebrov, M. F. Sinani, etc. was shown that pitiriaziformny and psoriasiform versions represent a wedge, options of the same disease coming on a number of clinical and histologic signs to E., also suggested to keep the name «eczematid». The figured version should be considered as the independent form for the first time described by P. Unna under the name «seborrheal eczema». Its options allocated with P. Unna (in particular, the becoming wet seborrheal eczema), turned out how it was proved by numerous researches, various forms of piokok-kovy damages of skin. However to a crust, time these forms, and also all kinds of an eczematid (according to Darya) are quite often diagnosed as seborrheal eczema.
Borders of use of the term «eczema» for different researchers fluctuate. Many dermatologists expanded the concept «eczema», having combined true eczematic defeats with a so-called ekzemopodobny dermatosis, and identified it with the concept «dermatitis» (see Dermatitis). It led to the fact that nek-ry foreign researchers, e.g. Akkermen and Ragas (A. V. of Ackerman, A. Ragaz, 1982), in general suggested to exclude the term «eczema».
Etiology and pathogeny. AA. represents the disease caused by various exogenous and internal causes. The researchers studying E., paid attention that special predisposition of an organism is the cornerstone of its development, the essence and the reasons a cut speak in a crust, time from positions of the neurogenic and allergic theory of development of eczema. Most of dermatologists, e.g. Raye (R. of F. Rayer), F. Gebr, M. Kaposha, raised a question of a neurogenic origin of a disease. The founder of domestic dermatology
A. G. Polotebnov adhered to the neurogenic theory. All statements in favor of the neurogenic theory of a pathogeny E. were based only on a wedge, observations (symmetric localization of defeat, an itch, and also communication began a disease and its aggravations with mental injuries, heavy experiences, etc.) - Further by means of various fiziol. methods various functional changes of the skin both affected, and not affected were found in patients E., testimonial of disturbances of the receptor device and neurovascular regulation of skin. They precede emergence E., accompany it and weaken in process of subsiding of process. However a complete recovery of normal functions of skin, even after treatment
E., occurs not always. Possibility of functional changes of skin under the influence of heavy mental experiences is proved. About participation of a nervous system in a pathogeny E. development of a disease owing to damage of peripheral nerves after wounds testifies. In these cases there is a constant irritation of separate branches of cutaneous nerves, napr, as a result of formation of a neuroma, a zazhatiya of a nerve in a hem, leading to development of functional changes of skin distalny the locations of a hem. Elimination of these irritations by an operative measure leads to normalization of a functional condition of skin. Indirect demonstration of the neurogenic theory E. the favorable effect at use of hypnotherapy, electrosleep, sedatives is.
In other cases the various disturbances from internals, in particular abdominal organs arising on type vistserokutanno-go a reflex and also frustration of endocrine system can be the cause of functional changes of skin.
Allergic theory of a pathogeny E. it was for the first time put forward in 1923 by Y. Yadasson and gained wide recognition of dermatologists of the different countries. It was based on sensitization of skin to chemical irritants. At E. hypersensitivity, as a rule, of a polivalentn, i.e. arises to several various substances. Further development of the allergic theory concerned preferential so-called contact eczemas, or allergic (ekzemopodobny) dermatitis (see). By means of modern immunol. researches it is established that predisposition to E. it is connected with relative insufficiency of immune system and a sensitization of an organism to various allergens (see). Relative insufficiency of immune system is characterized by oppression of functional activity of T lymphocytes (with m. And m of m unokompetentny C of e of t to and) that is shown by reaction of a blastotransformation (see Blastotransformation of lymphocytes) with fitogemagglyu-tininy and increase in quantity of the V-lymphocytes synthesizing immunoglobulins that leads to ratio distortion of immunoglobulins in blood. It occurs against the background of functional disturbances of c. N of page and a vegetodistoniya with dominance of parasympathetic influences.
Thus, previous E. the changes of reactivity of an organism leading to sensitization to various irritants can be caused by both neurogenic, and allergic mechanisms (see the Allergy). Most likely, leading role in development true E. play reflex influences, coming from c. N of page, internals and skin, and in development of microbic and professional eczemas — a sensitization respectively to microorganisms or chemical substances. A sensitization can cause chronic infectious damages of skin (a streptoderma, mycoses of feet, candidiasis), persistent focal infection of other bodies (tonsillitis, tooth granulomas, a cholangitis, cholecystitis, etc.) -
Patogistolgiya. In an acute stage E. in epidermis are found a parakeratosis (see), focal spongiosas (see), and also small, quite often multichamber cavities, in to-rykh there is a small amount of lymphocytes, is more rare than neutrophils (microbic E.). In a derma infiltrates and hypostasis of a papillary layer are observed perivascular, preferential lymphocytic. In hron. stages E. in epidermis the parakeratosis, an interpapillary acanthosis (see) which is combined with a focal spongio-z and small cavities comes to light; in a papillary layer of a derma the rno-histiocytic infiltrate expressed a lymphocyte is noted.
Clinical picture. Allocate true, professional and microbic E. Ryad researchers to versions E. carry also seborrheal eczema. True eczema differs in a considerable variety a wedge, manifestations that is caused by a peculiar course of a disease. AA. begins sharply, proceeds tolchkoobrazno, with a frequent recurrence and, as a rule, passes in hron. stage. In an acute stage E. it is characterized by a rash of microvesicles on erythematic, slightly edematous skin, to-rye are quickly opened. On their place small dot erosion (eczematic wells) with drops (like dew) serous exudate are formed (acute becoming wet E.). In process of subsiding of the inflammatory phenomena the quantity of bubbles decreases, and on a surface of affected areas the small scaly peeling develops. During this period a part of bubbles shrinks in small crusts. Patients are disturbed by an itch. Simultaneous existence of various elements (a vesicle, an erosion, a crust, a scale) creates a picture false, or evolutionary, the polymorphism characteristic for E. At the same time dominance of one of morfol can be observed. elements.
Transition of an acute stage to chronic is made gradually and is followed by a likhenization (see), i.e. the accruing infiltration of an affected area of skin and strengthening of the skin drawing (lichenified E.). The active erythema is replaced passive (see the Erythema), and skin accepts a cyanotic shade. On a surface of an affected area the peeling prevails, the rash of bubbles, but in much smaller quantity, than in an acute stage is sometimes observed. In hron. stages are possible aggravations, is frequent even in the course of treatment; the itch at the same time amplifies.
Centers E. have various size and indistinct contours. Rather seldom eczematic defeat is limited to one center, usually them a little, and they are symmetrized. In some cases the centers can reach the considerable size (an erythrodermic form). More often E. it is localized on skin of the back of brushes (tsvetn. tab., Art. 64, fig. 18). On palms and soles in connection with a special structure of skin (considerable thickness of epidermis, especially corneous layer) so-called disgidrotichesky eczema develops, edges it is characterized by education on limited sites of skin of bubbles, dense to the touch, up to 0,5 cm, reminding razvarenny sago grains. The dermahemia because of the big thickness of epidermis is expressed poorly. Bubbles are opened with formation of erosion or dry up, turning in flat, yellowish color of a crust. Sometimes bubbles on palms and soles merge in large multichamber cavities. Further the limited centers of defeat with clearly the expressed hyperemia are formed, against the background of a cut there are new bubbles, small erosion (tsvetn. tab., Art. 64, fig. 19), scales and crusts. Centers disgidroti-chesky E. are accurately delimited and quite often surrounded with a collar of the exfoliating corneous layer, to-rogo at aggravations it is possible to watch formation of new bubbles limits. Gradually increasing in sizes, the center disgidrotichesky E. can extend to the back of foot or brush where inflammatory process gets typical for true E. current. Chronic stage E. palms and soles the hl is shown. obr. excess keratinization (see the Hyperkeratosis) — keratosic, or tilotichesky (mozolevidny), eczema.
AA. can be complicated by a consecutive piokokkovy infection. At the same time on a surface of the eczematic center are formed friable, layered, honey-yellow or greenish color of a crust, after removal to-rykh comes to light typical drop moknuty — impetiginous eczema.
Professional eczema develops as a result of professional allergic dermatitis more often (see). The centers of eczema (usually after several recurrence of dermatitis) arise not only on site contact of skin with irritants, but also on other its sites, as a rule, of symmetric. The disease is characterized by the same manifestations and has the same current, as true E. Unlike dermatitis professional E. the patient does not give in to bystry treatment after the termination of contact of skin with chemical substance, to Krom sensibilizirovan. At such patients by means of skin tests (see) not the monovalent, but polyvalent sensitization comes to light (see).
Microbic eczema arises usually owing to secondary eczematization of superficial streptococcal or fungal infections of skin — a chronic diffusion streptoderma, an intertriginozny streptoderma (see the Pyoderma), chronic impetigo of a pilar part of the head (see Impetigo), disgidroti-chesky mycosis of feet, candidiasis (see Candidiasis, candidiasis of skin). Therefore the centers of defeat at this version carry lines as true E., and basic disease. They have sharp border, round or krupnofestonchaty outlines, on the periphery the collar of the exfoliating corneous layer is quite often noted. The affected area of skin is covered with lamellar crusts, after removal to-rykh the becoming wet surface of pink color with a cyanotic shade is found, against the background of a cut small dot erosion with drops of serous exudate clearly appear. Microbic eczema is most often localized on skin of shins (tsvetn. the tab., Art. 64, fig. 17), the back of brushes, a pilar part of the head and the person, in particular in the field of growth of moustaches and a beard (sikoziformny E.). Further around primary center there are mikrovezikulez-ny rashes that leads to deleting of its borders. Then eczematic process can extend to the symmetric and remote sites of skin and proceed as true E.
Mikrobnuyu E., developing around wounds, burns, freezing injuries, ulcers, fistulas, call paratraumatic, or okoloranevy, eczema (see. Paratraumatic damages of skin).
Version microbic E. is also varicose E., complicating a varicosity.
Allocate so-called nuammulyarny (monetovidny, or blyashechny) the eczema which is characterized by formation of sharply limited centers of defeat of the roundish outlines with a diameter from 1,5 to 3 cm and more slightly towering over normal skin. On a surface of the centers it is noted plentiful drop moknuty; skin has cyanotic-red coloring. Sometimes in the central part process fades owing to what they remind the centers of a superficial trichophytosis (see). Nummulyar-ny E. it is most often localized on the back of brushes; in some cases process can have the disseminated character.
Abortal form nummulyarny E. the eczematid is — the peculiar eritematoskvamozny damage of skin which is characterized by a rash of round or oval pink spots of various size, a surface to-rykh it is covered with scaly (psoriazopodobny) or melkoplastinchaty scales. Sometimes on the periphery the narrow border of the exfoliating corneous layer is noted. At poskablivanp of spots microerosion with droplets of serous exudate come to light. Quantity of spots variously. They are localized preferential on skin of a trunk and extremities, necks, the person and a pilar part of the head are more rare, can merge, occupying considerable sites of skin. The itch of various intensity is subjectively noted. The disease begins sharply, further accepts a long current and several weeks and even can last months. Tendency to a recurrence is quite often noted.
The eczematid arises for the second time at the patients suffering from superficial forms of a pyoderma (a chronic diffusion streptoderma, an intertriginozny streptoderma), a typiform of microbic eczema or a disgidrotichesky form of an epidermophitia of feet more often (see the Epidermophitia). Sometimes the eczematid arises initially: in such cases it is quite often possible to establish connection of damage of skin with the masked, focal infection. Development of an eczematid can be promoted postponed acute pnf. diseases (flu, quinsy). In some cases, especially in connection with irrational treatment and the wrong care of skin, transformation of the centers of an eczematid in typical nummulyarny eczema is observed.
Kinds of microbic eczema are more often observed at advanced and senile age.
Seborrheal eczema — peculiar to a porazhany skin, observed at the persons having seborrhea (see). The etiology is not established. Seborrheal E. it is localized on skin of a breast, a back (between shovels, along a backbone), and also on face skin (especially in nososhchechny folds, in eyebrows) and on a pilar part of the head. It is characterized by a rash of the small dot follicular small knots of flesh-colored color covered with grayish-yellow scales. Being grouped and expanding, small knots merge in the plaques of various size covered with fat scales. Merge of plaques leads to formation of larger centers with scalloped outlines. The central permission of the centers with formation of ring-shaped figures is quite often noted. Subjectively at patients the non-constant slight itch is noted.
The diagnosis is made on the basis by a wedge, pictures and data of the anamnesis. Acute true E. it is necessary to differentiate with allergic dermatitis (see Dermatitis) and with solar eczema (see the Photo a dermatosis); disgidro-tichesky E. it is necessary to distinguish from a disgidrotichesky epidermophitia (see), toxidermias (see), a pustular microbid (see), pustular psoriasis of Barber (see Psoriasis), a dyshydrosis (see); likhenifitsirovan-ny E. differentiate with neurodermatitis (see); keratosic E. it is necessary to distinguish from a tinea (see), psoriasis, keratodermias (see Keratoza). Professional E. differentiate with allergic dermatitis; microbic E. — with the streptodermas preceding it (see the Pyoderma) and mycoses (see); the eczematid — with pink is deprived (see. Deprive pink), seborrheal eczema, psoriasis (see), a blyashechny parapsoriasis (see), eczematoid erit-rodermicheskoy a stage of fungoid mycosis (see Mycosis fungoid).
Eczema at children (children's eczema) develops at chest age (usually on the 3rd month of life, sometimes on 2 — the 3rd week) against the background of exudative and catarral diathesis and is characterized by puffiness of the affected skin, abundance of microvesicles, formation of massive crusts of brownish color. More often face skin and a pilar part of the head is surprised, is more rare than a trunk and extremities. In a wedge, a picture of children's eczema symptoms of true, microbic and seborrheal eczema quite often are at the same time observed. In some cases eczematic rashes are replaced by pruriginous, gaining lines of a strophulus, or a children's small tortoiseshell, and then (on
2 — the 3rd year of life of the child) — lines of diffusion neurodermatitis (see Neurodermatitis).
Treatment. Before purpose of treatment of the patient E. it is necessary to inspect carefully for the purpose of identification and elimination of those patol. influences, to-rye could cause changes of reactivity of an organism — neurosises, diseases of internals, allergens infectious (hron. the centers of an infection) and noninfectious (chemical substances) origins, etc. Besides, it is necessary to exclude the irritating influence of various external factors both on a nervous system of the patient, and on skin. The diet with restriction of sodium chloride, carbohydrates, an exception of alcohol, a citrus, jam, chocolate, broths, fried and smoked dishes is of great importance.
Patient E. appoint sedative and somnolent drugs, an electrosleep (see), hypnotherapy (see Hypnosis). Use also antihistaminic drugs, redoxons, P, groups B inside, drugs of calcium and sodium thiosulphate parenterally. At insufficient effect and prevalence of process use corticosteroid drugs.
At localization of the eczematic centers on extremities after subsiding of the acute inflammatory phenomena apply UVCh-therapy (see), ultrasound (see. Ultrasonic therapy) on the corresponding juxtaspinal nodes of a sympathetic trunk, a microwave (see. Microwave therapy) on area of adrenal glands.
Topical treatment depends on a stage of inflammatory process. On the becoming wet centers impose lotions or the wet drying bandages with the antibacterial knitting solutions. After the termination the moknutiya is recommended the cold cream, corticosteroid aerosols, creams, ointments which are shaken up vzvesp, the pastes containing Naphthalanum, Dermatolum, etc. Centers hron. eczemas process the pastes containing 2 — 5% of tar of a pla the EXPERT of D-3 and then similar ointments. At eczematids the spirits of aniline dyes, corticosteroid ointments containing antibacterial agents (lorindenm With, etc.), then consistently 2 — 5% the Ichthyol shaken-up suspension, 5 — 10% naftalano-vy paste and tar naftalanovuyu (2 — 5% of tar, 5 — 10% of Naphthalanum) paste apply 2% in the beginning.
Patient E. it is shown a dignity. - hens. treatment by hydrosulphuric bathtubs (see) in the resorts of Sochi (Matsesta), Zheleznovodsk, radonic bathtubs in the resorts of Tsqaltubo, Pyatigorsk, etc., applications in the resorts of Anapa, Berdyansk, Yevpatoria, Yessentuki, etc.
The forecast for life favorable. The forecast concerning recovery depends on a possibility of elimination of the reasons which caused change of reactivity of skin.
562 EKZENTERATSIYA EYE-SOCKETS
Prevention. In primary prevention E. (see Prevention primary) an important role is played by timely elimination of the exogenous and internal causes promoting its development (the termination of contact with allergens, early identification and treatment hron. diseases went. - kish. path, diseases of a metabolism, functional disturbances of a nervous system, endocrine frustration, etc.). Radical treatment of wounds, injuries, burns, trophic ii of piokokkovy ulcers and the correct care of the skin surrounding them promote the prevention microbic E. Prevention professional E. includes elimination of contact with professional vrednost, protection of skin of workers from influence of chemical and other irritants (overalls, protective creams, a hygienic shower, etc.). Timely treatment of seborrhea mozheg to prevent development of seborrheal eczema. In primary prevention of the nursery E. the balanced diet of women is of great importance during pregnancy. It is especially important if in the anamnesis there is an instruction on existence of allergic diseases (see) at the pregnant woman, her husband or relatives since in these cases risk of development in the child E. raises. Also correct feeding of the child and food of mother is important during feeding of the child. Nursing mothers should exclude or to sharply limit allergogenny products (e.g., a citrus, chocolate, eggs), and also sweets and hot dishes. Are necessary also rational care of skin of the child (see the Baby) and timely treatment of exudative and catarral diathesis (see).
Secondary prevention E., carried out for the purpose of the prevention of a recurrence of a disease, consists in strengthening of a nervous system and protective forces of an organism, observance of a rational diet (with an exception of food-borne allergens). The sufficient dream, daily walks in the fresh air, exercises, sea bathings, solar bathtubs are important. For patients E. wearing clothes from cottons and an exception of synthetic fabrics is preferable. Patient E. it is not necessary to use soap powders, it is long to be in not aired svezheokrashenny rooms, and also to contact to insecticides and other irritating substances. Patients E. shall be under dispensary observation of the dermatologist.
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