A Closer Look At Eczematous Dermatitis In Athletes

By Mark A. Caselli, DPM

Recognizing Atopic Dermatitis

   Also known as atopic or allergic eczema, atopic dermatitis is another common skin condition that causes pruritis in athletes. Atopic dermatitis represents a chronically relapsing skin eczema that may begin in infancy, childhood, adolescence or adulthood. Therefore, taking a good history is important in making a proper diagnosis. There is frequently a family history of atopic dermatitis, associated allergic rhinitis and asthma. In many adolescent and adult cases, patients may have previously had eczema that went into remission.    Atopic dermatitis usually occurs as an erythematous papulovesicular eruption that evolves into a dry, scaly dermatitis with accentuated skin lines. The skin distribution of the rash varies somewhat with age, with the flexural surfaces, face, wrists, knees, hands and feet showing xerosis, lichenification and papular eruptions in adolescents and adults.    One may diagnose atopic dermatitis by combining the clinical symptoms, especially the extremely pruritic rash, with the typical appearance and distribution, and the tendency toward a chronic and recurrent course. The personal or family history of asthma, seasonal allergies and eczema also plays a significant role in reaching a diagnosis. The emotional stress and increased temperatures that often occur in sports activities may also worsen the pruritis and subsequent dermatitis.    When treating atopic dermatitis, one strives to eliminate inflammation, provide hydration and control the factors, such as stress, that cause exacerbation. Topical therapy includes:    • moisturizers with urea or lactic acid;    • bathing in tepid water with bath oils;    • low-potency group V or VI corticosteroids for mild to moderate rashes; and    • group II to IV corticosteroids applied two to three times a day for severe lichenified dermatoses    Oral medications may include antihistamines to control pruritus. In rare severely resistant cases, one may employ a short course of corticosteroids. Use the lowest potency of topical corticosteroid that controls a patient’s symptoms and avoid systemic corticosteroids if possible to prevent rebound flares after treatment.

Resolving Lichen Simplex Chronicus

   Lichen simplex chronicus, or circumscribed neurodermatitis, is a pruritic condition that occurs as variably sized patches of thick, lichenified skin that one most commonly sees on the outer lower portion of the lower leg and the ankle. This condition arises on skin that previously looked normal and represents the response of the predisposed skin to repeated scratching and rubbing. External factors such as an insect bite or friction from a shoe may play a role in initiating the lesion.    Emotions appear to play a role in perpetuation of the condition. Once the area becomes lichenified from rubbing or scratching, there may be pleasure derived from additional scratching of the pruritic area. This effect probably explains the high rate of recurrence of this chronic condition.    Patients often complain of pruritis that is much greater than one might expect from the appearance of the lesion. The fully developed lesion presents as a sharply demarcated patch of thickened skin. It is red and edematous during its early stage and subsequently becomes dry, scaly, excoriated and hyperpigmented. This condition may also appear on the soles. Keep in mind that this condition may appear on the soles and it is often misdiagnosed as callus or psoriasis.    Patient education is key as one has to break the “itch-scratch” cycle. However, since scratching may take place subconsciously or at night, occlusive dressings are preferable for chronic lesions. They provide a barrier to prevent scratching and permit the medication to work for longer periods of time.    One can reapply topical corticosteroids and antipruretics under modified Unna boots weekly or reapply them under an occlusive plastic dressing that is changed once or twice a day. Cortisone-impregnated adhesive, such as Cordran Tape, is convenient for this purpose. While intralesional cortisone injections are often used to treat lichen simplex chronicus, one should avoid using these for lesions on the ankle and foot. In chronic recurrent eruptions, psychological consultations may be necessary to help resolve the condition.

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