Diagnostic uncertainties in eczema and psoriasis

General practice nurses and GPs encounter a broad range of skin conditions in their daily work and skin diseases are a frequent reason for consultations: however, formal training in dermatology is usually sparse, and diagnostic uncertainty is common. This photo essay aims to highlight the characteristics of two of the most prevalent conditions

ATOPIC DERMATITIS

Here is the instantly recognisable appearance of atopic dermatitis with the affected area being on the flexor aspect of the limbs in and around the skin creases. The early manifestations of atopic dermatitis can become apparent in the first months of life, with dry skin and inflammation in both flexural areas as well as others such as the face. The most important message for patients is that they need to understand the concept of maintenance therapy. Long term use of adequate quantities of correctly applied emollients will significantly reduce the impact of the disease. Use of once daily topical steroids and immune modulators will be required for flare ups.

PLAQUE PSORIASIS

This is the classic appearance plaque psoriasis. Isolated and often very large areas of skin may be covered by these plaques. The appearance is of well-defined red, inflamed areas covered with silvery scales. They are very often seen on the extensor surfaces of the limbs but also many other areas such as the trunk. The condition most often presents in early adult life, though can come on at any age including childhood. There is probably a genetic link or predisposition, but this has not yet been fully clarified. Management includes emollients, topical agents such as steroids and vitamin D analogues in primary care, moving onto UV light, methotrexate and the biologics under the care of dermatologists.

CONTACT DERMATITIS

This is a common form of eczema triggered by a reaction to an external agent, which can either act as an irritant, or an actual allergen. There are innumerable potential causes for this common type of dermatitis. This patient has a history of glaucoma and has had significant problems with his eye drops. In spite of trying various types, he continued to be troubled by this sore, irritating, nasty reaction around his eyes. Using single dose preservative free drops has made a huge difference by taking the causative factor away. Regular use of an emollient also helps.

PALMOPUSTULAR PSORIASIS

There are many manifestations of psoriasis and one of the more unpleasant affects the palms and soles of the feet. Palmopustulosis is not purely psoriatic as a number of affected patients have no other manifestations of psoriasis. The condition tends to be a long term one with some itching and irritation as well as significant discomfort, which may come from cracks or fissures in the skin. Although lesions may contain pus, this is not an infected or infectious condition. The pus is usually sterile and antibiotics are unlikely to have any effect. Management is similar to other types of psoriasis.

VARICOSE ECZEMA

This common condition among our older patients is also known as venous, stasis or gravitational eczema. It usually results from incompetent valves in veins either as a result of varicose veins or previous DVT. This leads to back pressure from the column of blood in the veins. Fluid then oozes into the tissues producing chronic oedema. The discolouration of the legs usually seen is due to deposition of haemosiderin the tissues. There are various potential complications including of course, ulceration. This is a huge burden for nursing services. Although patients can make a difference to the development of complications through regular exercise, weight loss and leg elevation when resting, it can be difficult to make these lifestyle changes.

SCALP PSORIASIS

This is another fairly common form of psoriasis. It can make for some diagnostic difficulties as the appearance of heavy dandruff due to scaling of the scalp can be hard to distinguish from seborrheic capitis, and not all patients will have other manifestations of the disease elsewhere. The presence of features of seborrheic dermatitis on the face will point in this direction. The two conditions may be very difficult to distinguish, and some dermatologists are now using the term 'sebo-psoriaisis' to describe a pattern of symptoms showing features of both conditions. It can affect patches or the whole of the scalp and may or may not produce some itchiness. Management includes agents to help remove scale and then reduce inflammation.