Nummular dermatitis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief:  Kiran Singh, M.D. [2]

## Overview[edit | edit source]

Nummular dermatitis is one of the many forms of dermatitis. Also known as discoid dermatitis, it is characterized by round or oval-shaped itchy lesions. (The name comes from the Latin word "nummus," which means "coin.")

## Presentation[edit | edit source]

The disorder is recurrent and chronic, and may appear at any age, although it is most common in people in their 60's. Nummular dermatitis does not appear to be a genetic condition, is not related to food allergies, and is not contagious.

The coin-shaped patches can affect any part of the body, but the legs and buttocks are the most common areas. Flare-ups are associated with dry skin, so the winter season is a particularly bad time for those with this condition.

Other forms of dermatitis are at risk of developing.[1]

## Diagnosis[edit | edit source]

### Physical Examination[edit | edit source]

#### Skin[edit | edit source]

##### Extremities[edit | edit source]

* Eczema microbic. Adapted from Dermatology Atlas.[2]

* Eczema microbic. Adapted from Dermatology Atlas.[2]

* Eczema microbic. Adapted from Dermatology Atlas.[2]

* Eczema microbic. Adapted from Dermatology Atlas.[2]

* Eczema microbic. Adapted from Dermatology Atlas.[2]

## Differentiating nummular dermatitis from other diseases[edit | edit source]

Nummulrar dermatitis should be differentiated from other diseases causing papulosquamous or erythmatosquamous rash. The differentials include the following:

Disease  | Rash Characteristics  | Signs and Symptoms  | Associated Conditions  | Images

|
|
|
|

Cutaneous T cell lymphoma/Mycosis fungoides[3] |

* Premycotic phase: A scaly, red rash in areas of the body that usually are not exposed to the sun. This rash does not cause symptoms and may last for months or years.
* Patch phase: Thin, erythematous, eczema-like rash.
* Plaque phase: Small raised bumps (papules) or hardened lesions on the skin, which may be erythematous.
* Tumor phase: Tumors form on the skin. Infection secondary to ulcers.

* Epidermal atrophy or poikiloderma

* Generalized itching (pruritus)
* Pain in the affected area of the skin
* Insomnia
* Red (erythematous) patches scattered over the skin of the trunk and the extremities
* Tumor-like lobulated outgrowths form on the skin in the latter phase of the disease
* Weight loss
* Lymphadenopathy
* Malaise and fatigue
* Anemia
* May progress to Sezary syndrome (skin involvement plus hematogenous dissemination)

* Sezary syndrome

Pityriasis rosea[4] |

* Pink or salmon in color, which may be scaly; referred to as "herald patch"
* Oval shape
* Long axis oriented along the cleavage lines
* Distributed on the trunk and proximal extremities
* Squamous marginal collarette and a “fir-tree” or “Christmas tree” distribution on posterior trunk
* Secondary to viral infections
* Resolves spontaneously after 6-8 weeks

* Preceded by a prodrome of:
* Sore throat
* Gastrointestinal disturbance
* Fever
* Arthralgia

* Infection by any of the following:[5]
* HHV-6
* HHV-7
* HHV-8

Pityriasis lichenoides chronica |

* Recurrent lesions are usually less evenly scattered than in cases of psoriasis
* Brownish red or orange-brown in color
* Lesions are capped by a single detachable, opaque, mica-like scale
* Often leave hypopigmented macules

* High fever
* Malaise
* Myalgias
* Paraesthesia
* Pruritus

* Infection by any of the following:[6]
* Epstein-Barr virus (EBV)
* Toxoplasma gondii
* Human immunodeficiency virus (HIV)

Nummular dermatitis[7] |

* Multiple coin-shaped eczematous lesions
* Commonly affecting the extremities (lower>upper) and trunk
* May ooze fluid and become dry and crusty

* Often appears after a skin injury, such as a burn, abrasion (from friction), or insect bite

* Lesions commonly relapse after occasional remission or may persist for long periods
* Pruritus

* Associated with:
* Dry skin
* Emotional stress
* Allergens (rubber chemicals, formaldehyde, neomycin, chrome, mercury, and nickel)
* Staphylococcus infection
* Seasonal variation
* Alcohol
* Drugs
* Atopy

Secondary syphilis[8] |

* Round, coppery, red colored lesions on palms and soles
* Papules with collarette of scales

* Fever
* Generalized lymphadenopathy
* Sore throat
* Patchy hair loss
* Headache
* Weight loss
* Myalgia
* Fatigue

* Associated with:
* Condylomata lata
* Corona verinata
* Positive VDRL test

Bowen’s disease[9] |

* Erythematous, small, scaly plaque, which enlarges erratically over time
* Scale is usually yellow or white and it is easily detachable without any bleeding
* Well-defined margins

* Pruritus
* Pain
* Bleeding lesions

* Associated with:[10]
* Erythroplasia of Queyrat (Bowen's disease of the penis)
* Squamous cell carcinoma
* Solar radiation and ultraviolet (UV) exposure
* Radiotherapy
* Immunosuppression
* Arsenic exposure
* Human papilloma virus (HPV) type 16
* Merkel cell polyomavirus
* Sjögren’s syndrome

Exanthematous pustulosis[11] |

* Numerous small, primarily non-follicular, sterile pustules, arising within large areas of edematous erythema

* Fever
* Leukocytosis
* Intracorneal, subcorneal, and/or intraepidermal pustules with papillary dermal edema containing neutrophils and eosinophils

* Associated with:[12]
* Antibiotics (penicillins, sulfonamides, tetracyclines)
* Carbamazepine
* Calcium channel blockers (Diltiazem)
* Hydroxychloroquine

Hypertrophic lichen planus[13] |

* Classically involves shin and ankles and is characterized by hyperkeratotic plaques and nodules covered by a scale
* Lesions may transform into hyperkeratotic thickened, elevated, purplish or reddish plaques and nodules

* Chronic pruritus
* Scaling
* May be asymptomatic

* Associated with Hepatitis C virus infection[14]

Sneddon–Wilkinson disease[15] |

* Flaccid pustules that are often generalized and have a tendency to involve the flexural areas
* Annular configuration

* Pruritus
* May be asymptomatic

* Associated with:
* Monoclonal gammopathy, usually an IgA paraproteinemia[16]
* Crohn's disease[17]
* Osteomyelitis
* Adalimumab[18]

Small plaque parapsoriasis[19] |

* Erythematous plaques with fine scaly surface
* May present with elongated, finger-like patches
* Symmetrical distribution on the flanks
* Known as digitate dermatosis

* Lesions may be asymptomatic
* May be mildly pruritic
* May fade or disappear after sun exposure during the summer season, but typically recur during the winter

* May progress to mycosis fungoides[20]

Intertrigo[21] |

* Red and fleshy looking lesion in skin folds
* Itching
* Oozing
* May be sore

* Pruritus
* Musty odor

* Associated with:
* Infections (Fungal, bacterial, viral)
* Allergies
* Diabetes
* Obesity

Langerhans cell histiocytosis[22] |

* Scaling and crusting of scalp

* Pathological fractures[23]
* Visceromegaly (hepatomegaly, spleenomegaly)
* Chronic cough
* Dyspnea[24]
* Lymphadenopathy

* Associated with:
* Diabetes insipidus[25]
* Pancytopenia

Tinea manuum/pedum/capitis[26] |

* Scaling, flaking, and sometimes blistering of the affected areas
* Hair loss with a black dot on scalp in case of tinea capitis

* Pruritus
* KOH preparation of the lesions confirms fungal infection

* Associated with:
* Diabetes
* Immunosupression
* Intimate contact with infected person
* May lead to asthma exacerbation

Seborrheic dermatitis |

* Papulosquamous, scaly, flaky, itchy, and red rash found particularly at sebaceous gland-rich areas of the body

* Pruritus

* Associated with:[27]
* AIDS
* Stress[28]
* Fungal infection
* Fatigue
* Sleep deprivation
* Change of season
* Parkinson's disease
* Biotin deficiency

## Treatment[edit | edit source]

One of the keys to treatment and prevention involves keeping the skin moisturized. Lotions, creams, and bath oils may help prevent an outbreak. If the condition flares up, a common treatment involves the application of topical corticosteroids. Oral antihistamines may help lessen itching. More severe cases sometimes respond to ultraviolet light treatment.

## References[edit | edit source]

1. ↑ Krupa Shankar DS, Shrestha S (2005). "Relevance of patch testing in patients with nummular dermatitis". Indian journal of dermatology, venereology and leprology. 71 (6): 406–8. PMID 16394482.
2. ↑ 2.0 2.1 2.2 2.3 2.4 "Dermatology Atlas".
3. ↑ "Mycosis Fungoides and the Sézary Syndrome Treatment (PDQ®)—Patient Version - National Cancer Institute".
4. ↑ Mahajan K, Relhan V, Relhan AK, Garg VK (2016). "Pityriasis Rosea: An Update on Etiopathogenesis and Management of Difficult Aspects". Indian J Dermatol. 61 (4): 375–84. doi:10.4103/0019-5154.185699. PMC 4966395. PMID 27512182.
5. ↑ Prantsidis A, Rigopoulos D, Papatheodorou G, Menounos P, Gregoriou S, Alexiou-Mousatou I, Katsambas A (2009). "Detection of human herpesvirus 8 in the skin of patients with pityriasis rosea". Acta Derm. Venereol. 89 (6): 604–6. doi:10.2340/00015555-0703. PMID 19997691.
6. ↑ Smith KJ, Nelson A, Skelton H, Yeager J, Wagner KF (1997). "Pityriasis lichenoides et varioliformis acuta in HIV-1+ patients: a marker of early stage disease. The Military Medical Consortium for the Advancement of Retroviral Research (MMCARR)". Int. J. Dermatol. 36 (2): 104–9. PMID 9109005.
7. ↑ Jiamton S, Tangjaturonrusamee C, Kulthanan K (2013). "Clinical features and aggravating factors in nummular eczema in Thais". Asian Pac. J. Allergy Immunol. 31 (1): 36–42. PMID 23517392.
8. ↑ "STD Facts - Syphilis".
9. ↑ Neagu TP, Ţigliş M, Botezatu D, Enache V, Cobilinschi CO, Vâlcea-Precup MS, GrinŢescu IM (2017). "Clinical, histological and therapeutic features of Bowen's disease". Rom J Morphol Embryol. 58 (1): 33–40. PMID 28523295.
10. ↑ Murao K, Yoshioka R, Kubo Y (2014). "Human papillomavirus infection in Bowen disease: negative p53 expression, not p16(INK4a) overexpression, is correlated with human papillomavirus-associated Bowen disease". J. Dermatol. 41 (10): 878–84. doi:10.1111/1346-8138.12613. PMID 25201325.
11. ↑ Szatkowski J, Schwartz RA (2015). "Acute generalized exanthematous pustulosis (AGEP): A review and update". J. Am. Acad. Dermatol. 73 (5): 843–8. doi:10.1016/j.jaad.2015.07.017. PMID 26354880.
12. ↑ Schmid S, Kuechler PC, Britschgi M, Steiner UC, Yawalkar N, Limat A, Baltensperger K, Braathen L, Pichler WJ (2002). "Acute generalized exanthematous pustulosis: role of cytotoxic T cells in pustule formation". Am. J. Pathol. 161 (6): 2079–86. doi:10.1016/S0002-9440(10)64486-0. PMC 1850901. PMID 12466124.
13. ↑ Ankad BS, Beergouder SL (2016). "Hypertrophic lichen planus versus prurigo nodularis: a dermoscopic perspective". Dermatol Pract Concept. 6 (2): 9–15. doi:10.5826/dpc.0602a03. PMC 4866621. PMID 27222766.
14. ↑ Shengyuan L, Songpo Y, Wen W, Wenjing T, Haitao Z, Binyou W (2009). "Hepatitis C virus and lichen planus: a reciprocal association determined by a meta-analysis". Arch Dermatol. 145 (9): 1040–7. doi:10.1001/archdermatol.2009.200. PMID 19770446.
15. ↑ Lutz ME, Daoud MS, McEvoy MT, Gibson LE (1998). "Subcorneal pustular dermatosis: a clinical study of ten patients". Cutis. 61 (4): 203–8. PMID 9564592.
16. ↑ Kasha EE, Epinette WW (1988). "Subcorneal pustular dermatosis (Sneddon-Wilkinson disease) in association with a monoclonal IgA gammopathy: a report and review of the literature". J. Am. Acad. Dermatol. 19 (5 Pt 1): 854–8. PMID 3056995.
17. ↑ Delaporte E, Colombel JF, Nguyen-Mailfer C, Piette F, Cortot A, Bergoend H (1992). "Subcorneal pustular dermatosis in a patient with Crohn's disease". Acta Derm. Venereol. 72 (4): 301–2. PMID 1357895.
18. ↑ Sauder MB, Glassman SJ (2013). "Palmoplantar subcorneal pustular dermatosis following adalimumab therapy for rheumatoid arthritis". Int. J. Dermatol. 52 (5): 624–8. doi:10.1111/j.1365-4632.2012.05707.x. PMID 23489057.
19. ↑ Lambert WC, Everett MA (1981). "The nosology of parapsoriasis". J. Am. Acad. Dermatol. 5 (4): 373–95. PMID 7026622.
20. ↑ Väkevä L, Sarna S, Vaalasti A, Pukkala E, Kariniemi AL, Ranki A (2005). "A retrospective study of the probability of the evolution of parapsoriasis en plaques into mycosis fungoides". Acta Derm. Venereol. 85 (4): 318–23. doi:10.1080/00015550510030087. PMID 16191852.
21. ↑ Janniger CK, Schwartz RA, Szepietowski JC, Reich A (2005). "Intertrigo and common secondary skin infections". Am Fam Physician. 72 (5): 833–8. PMID 16156342.
22. ↑ Satter EK, High WA (2008). "Langerhans cell histiocytosis: a review of the current recommendations of the Histiocyte Society". Pediatr Dermatol. 25 (3): 291–5. doi:10.1111/j.1525-1470.2008.00669.x. PMID 18577030.
23. ↑ Stull MA, Kransdorf MJ, Devaney KO (1992). "Langerhans cell histiocytosis of bone". Radiographics. 12 (4): 801–23. doi:10.1148/radiographics.12.4.1636041. PMID 1636041.
24. ↑ Sholl LM, Hornick JL, Pinkus JL, Pinkus GS, Padera RF (2007). "Immunohistochemical analysis of langerin in langerhans cell histiocytosis and pulmonary inflammatory and infectious diseases". Am. J. Surg. Pathol. 31 (6): 947–52. doi:10.1097/01.pas.0000249443.82971.bb. PMID 17527085.
25. ↑ Grois N, Pötschger U, Prosch H, Minkov M, Arico M, Braier J, Henter JI, Janka-Schaub G, Ladisch S, Ritter J, Steiner M, Unger E, Gadner H (2006). "Risk factors for diabetes insipidus in langerhans cell histiocytosis". Pediatr Blood Cancer. 46 (2): 228–33. doi:10.1002/pbc.20425. PMID 16047354.
26. ↑ Al Hasan M, Fitzgerald SM, Saoudian M, Krishnaswamy G (2004). "Dermatology for the practicing allergist: Tinea pedis and its complications". Clin Mol Allergy. 2 (1): 5. doi:10.1186/1476-7961-2-5. PMC 419368. PMID 15050029.
27. ↑ Schwartz RA, Janusz CA, Janniger CK (2006). "Seborrheic dermatitis: an overview". Am Fam Physician. 74 (1): 125–30. PMID 16848386.
28. ↑ Misery L, Touboul S, Vinçot C, Dutray S, Rolland-Jacob G, Consoli SG, Farcet Y, Feton-Danou N, Cardinaud F, Callot V, De La Chapelle C, Pomey-Rey D, Consoli SM (2007). "[Stress and seborrheic dermatitis]". Ann Dermatol Venereol (in French). 134 (11): 833–7. PMID 18033062.CS1 maint: Unrecognized language (link)

## External links[edit | edit source]

* Treatment details
* http://www.lib.uiowa.edu/hardin/md/dermnet/eczema6.html
* http://library.med.utah.edu/kw/derm/pages/desy_23.htm

* v
* t
* e

Diseases of the skin and subcutaneous tissue (integumentary system) (L, 680-709)

Infections|

Template:Navbox subgroup

Bullous disorders|

acantholysis (Pemphigus, Transient acantholytic dermatosis) * Pemphigoid (Bullous, Cicatricial, Gestational) * Dermatitis herpetiformis

Inflammatory|

Template:Navbox subgroup

Radiation-related disorders|

Sunburn * actinic rays (Actinic keratosis, Actinic cheilitis) * Polymorphous light eruption (Acne aestivalis) * Radiodermatitis * Erythema ab igne

Pigmentation disorder|

hypopigmentation (Albinism, Vitiligo) * hyperpigmentation (Melasma, Freckle, Café au lait spot, Lentigo/Liver spot, Acanthosis nigricans, Acral acanthotic anomaly)

Other skin|

keratosis/hyperkeratosis (Seborrheic keratosis, Callus) * other epidermal thickening (Ichthyosis acquisita, Palmoplantar keratoderma)

skin ulcer (Pyoderma gangrenosum, Bedsore)

Cutaneous Markers of Internal Malignancy (Florid cutaneous papillomatosis, acanthosis nigricans, sign of Leser-Trelat)

atrophic (Lichen sclerosus, Acrodermatitis chronica atrophicans)

necrobiosis (Granuloma annulare, Necrobiosis lipoidica) * other granuloma (Granuloma faciale, Pyogenic granuloma)

cutaneous vasculitis (Livedoid vasculitis, Erythema elevatum diutinum)

Connective tissues|

collagen disease: Keloid
localized connective tissue disorders: Lupus erythematosus (Discoid lupus erythematosus, Subacute cutaneous lupus erythematosus) * Scleroderma/Morphea * Linear scleroderma * Calcinosis cutis * Sclerodactyly * Ainhum

see also congenital, neoplasia

Scheinfeld NS Circular brown-black eruptions (Nummular dermatitis and Discoid lupus erythematosus) Cortlandt Forum 2007;20(6)

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