Robert H Fletcher, MD
UpToDate performs a continuous review of over 375 journals and other resources. Updates are added as important new information is published. The literature review for version 15.2 is current through April 2007; this topic was last changed on November 27, 2006. The next version of UpToDate (15.3) will be released in October 2007.
OVERVIEW — Rhinitis refers to inflammation of the nasal passages. This inflammation can cause a variety of annoying symptoms, including sneezing, itching, nasal congestion, runny nose, and post-nasal drip (the sensation that mucus is draining from the sinuses down the back of the throat).
Almost everyone experiences rhinitis at some point during their life. Brief episodes of rhinitis are usually caused by respiratory tract infections with viruses (eg, the common cold). Chronic rhinitis is usually caused by allergies, but it can also occur from overuse of certain drugs, some medical conditions, and other unidentifiable factors.
For many people, rhinitis is a lifelong condition that waxes and wanes over time. Fortunately, the symptoms of rhinitis can usually be controlled with a combination of environmental measures, medications, and immunotherapy (also called allergy shots).
ALLERGIC RHINITIS — Allergic rhinitis, also known as hay fever or grass fever, affects approximately 20 percent of people of all ages. The risk of developing allergic rhinitis is much higher in people with asthma or eczema, and in people who have a family history of asthma or rhinitis.
Allergic rhinitis can begin at any age, although most people first develop symptoms in childhood or young adulthood. The symptoms are often at their worst in children and in people in their 30s and 40s. However, the severity of symptoms tends to vary throughout life, and many people experience periods of remission.
Causes — Allergic rhinitis is caused by a nasal reaction to small airborne particles called allergens (substances that provoke an allergic reaction). In some people, these particles also cause reactions in the lungs (asthma), and eyes (allergic conjunctivitis).
The allergic reaction is characterized by activation of two types of inflammatory cells, called mast cells and basophils. These cells produce inflammatory substances, including histamine, that cause fluid to build up in the nasal tissues (congestion), itching, sneezing, and runny nose. Over several hours, these substances activate other inflammatory cells that can cause persistent symptoms.
Seasonal versus perennial allergic rhinitis — Allergic rhinitis can be seasonal (occurring during specific seasons) or perennial (occurring year round). The allergens that most commonly cause seasonal allergic rhinitis are pollens from trees, grasses, and weeds, as well as spores from fungi and molds. The allergens that most commonly cause perennial allergic rhinitis are dust mites, cockroaches, animal dander, and fungi or molds. Of these two types of allergic rhinitis, perennial allergic rhinitis tends to be more difficult to treat.
Symptoms — The symptoms of allergic rhinitis can vary from person to person. Although the term "rhinitis" refers only to the nasal symptoms, many patients also experience problems with their eyes, throat, ears, and sleep, so it is helpful to consider the entire spectrum of symptoms. Nose: watery nasal discharge, blocked nasal passages, sneezing, nasal itching, post-nasal drip, loss of taste, facial pressure or pain Eyes: itchy, red eyes, feeling of grittiness in the eyes, swelling and blueness of the skin below the eyes Throat and ears: sort throat, hoarse voice, congestion or popping of the ears, itching of the throat or ears Sleep: mouth breathing, frequent awakening, daytime fatigue, difficulty performing work
When an allergen is present year round, the predominant symptoms include post-nasal drip, persistent nasal congestion, and poor-quality sleep.
Diagnosis — The diagnosis of allergic rhinitis is based upon the presence of the nasal signs and symptoms described above. A physical examination and medical tests can confirm the diagnosis and identify the offending allergens.
Nasal examination — A nasal examination allows direct visual inspection of the lining of the nasal passages and can occasionally differentiate allergic rhinitis from other types of rhinitis. In people with allergic rhinitis, the lining of the nasal passages is very swollen and pale, sometimes to the degree that it appears bluish in color.
Identification of allergens and other triggers — It is often possible to identify the allergens and other triggers that provoke allergic rhinitis by recalling the factors that precede symptoms; noting the time at which symptoms begin; and examining a person's home, work, and school environments. Skin tests may be useful for people whose symptoms are not well controlled with medications and in whom the offending allergen is not obvious.
Treatment — The treatment of allergic rhinitis entails measures to reduce a person's exposure to known allergens or other triggers, combined with medication therapy. In most people, these measures effectively control the symptoms.
Reducing exposure to triggers — Some simple measures can reduce a person's exposure to the allergens and triggers that provoke allergic rhinitis. These measures do not apply to everyone with allergic rhinitis; persons with a known sensitivity to a particular allergen may consider these suggestions. Dust mites — Exposure to dust mites can be reduced by encasing mattresses and pillows in mite-impermeable barriers and washing sheets and blankets weekly in very hot water (at least 130ºF). Exposure can be further reduced by keeping indoor humidity lower than 50 percent, vacuuming regularly, removing carpets, and avoiding sleeping on upholstered furniture. Animal dander — Exposure to animal dander can be reduced by keeping pets out of bedrooms, sealing or placing filters over the air vents to bedrooms, and removing carpets. In some cases, it may be necessary to remove pets from the home. Cat dander, in particular, can linger in an environment long after a cat has been removed, so a person's symptoms may not improve for several months. Cockroaches — Exposure to cockroaches can be reduced by using poison bait or traps, keeping food and garbage tightly enclosed at all times, and sealing cracks to the outside. Indoor molds — Growth of indoor molds can be reduced by removing sources of standing water and persistent dampness: removing house plants, fixing leaky plumbing, correcting sinks and showers that don't drain completely, and dehumidifying damp areas to levels below 50 percent. Surfaces with visible mold growth should be cleaned with a 10 percent solution of bleach. Pollens and outdoor molds — Exposure to pollens and outdoor molds can be reduced by keeping car and house windows closed and using air conditioning during peak pollen seasons, staying inside on dry, windy days, and showering at night to remove pollens and spores from the hair and skin before bed. The American Academy of Allergy, Asthma, and Immunology has a toll free number (1-800-976-5536) and website (www.aaaai.org) for monitoring pollen and mold spore counts.
Air filters — The effectiveness of high-efficiency particulate air (HEPA) cleaners in reducing a person's exposure to allergens is uncertain. These cleaners are not very effective for reducing exposure to dust mites since little of this allergen is airborne. However, some studies have suggested that HEPA cleaners may be effective for removing cat allergens from the air.
Drug therapy — Several different classes of drugs counter the inflammation that causes symptoms of allergic rhinitis. The severity of symptoms and personal preferences usually guide the selection of specific drugs. Nasal steroids — Nasal steroids (steroids taken by a nasal spray) are usually recommended first for the treatment of allergic rhinitis. These drugs have very few side effects and dramatically relieve symptoms in most people. Studies have shown that nasal steroids are more effective than oral antihistamines for symptom relief [1].
The nasal steroids include fluticasone (Flonase®), mometasone (Nasonex®), beclomethasone (Vancenase®, Beconase®), budesonide (Rhinocort®), flunisolide (Nasarel®), and triamcinolone (Nasocort®). These drugs differ with regard to the base liquid (water-based versus alcohol-based), the frequency of doses, the spray device, and cost, but all are similarly effective for treating all the symptoms of allergic rhinitis. People with severe rhinitis may be advised to also use nasal decongestants for a few days to reduce nasal swelling and allow the steroid spray better access to the nasal passages.
Some symptom relief may occur on the first day of therapy with nasal steroids, but their maximal effectiveness may not be apparent for days to weeks. For this reason, these drugs are most effective when used regularly. Some people are able to gradually use lower doses when symptoms are less severe.
Applying the nasal spray directly onto the nasal lining is important for maximizing the effectiveness of nasal steroids. Application can be improved by directing the spray away from the nasal septum (the cartilage that divides the two sides of the nose), using an alcohol-based spray, and positioning the head down and forward after using water-based sprays.
The side effects of nasal steroids are mild and may include a slight unpleasant smell or taste or drying of the nasal lining. In some people, nasal steroids cause irritation, crusting, and bleeding of the nasal septum, especially during the winter; this side effect can be minimized by applying Vaseline to the septum before using the spray, using a saline nasal spray to restore moisture to the nasal lining, or switching to a water-based spray. Studies suggest that nasal steroids are generally safe when used for many years. However, people who use these drugs for years should have periodic nasal examinations to check for rare side effects, such as nasal infection or ulceration.
Although oral and inhaled steroids have been linked to reduced bone mineral density and hormonal side effects, the doses used in nasal steroids are low and are NOT associated with these side effects. However, clinicians usually recommend using the lowest effective dose of nasal steroids. Antihistamines — Antihistamines relieve the itching, sneezing, and runny nose of allergic rhinitis, but they do not relieve nasal congestion. Combined treatment with nasal steroids or decongestants may provide greater symptom relief than use of either alone.
The oral, over-the-counter antihistamines include brompheniramine (Dimetapp allergy®, Nasahist B®), chlorpheniramine (Chlor-Trimeton®), diphenhydramine (Benadryl®), and clemastine (Tavist®). These drugs often cause sedation and should not be used before driving or operating machinery. Simultaneous use of a decongestant may reduce the sedating effects, but patients should still use caution.
The oral, prescription antihistamines include cetirizine (Zyrtec®) and fexofenadine (Allegra®). Loratadine (Claritin®, Alavert®) is now available without a prescription. These drugs are much less sedating and are available in long-acting formulas; however, they are more expensive and are of no greater benefit than over-the-counter antihistamines for treating rhinitis symptoms.
Azelastine (Astelin®) is a prescription nasal antihistamine spray that can be used daily or only as needed to relieve symptoms of post-nasal drip, congestion, and sneezing. It starts to work within minutes after use. Patients may use up to eight total sprays per day; higher doses can cause sedation. The most commonly observed side effect is a bad taste in the mouth immediately after use. This can be minimized by keeping the head tilted forward so the medicine does not drain down the throat. Decongestants — Decongestants (like pseudoephedrine [Sudafed®, Actifed®, Drixoral®]) are often combined with antihistamines in oral, over-the-counter allergy drugs.
Several decongestant nasal sprays also are available, including oxymetazoline (Afrin®) and phenylephrine (Neo-synephrine®). Nasal decongestants must not be used for more than two to three days at a time because they may cause a different type of rhinitis, called rhinitis medicamentosa. (See "Rhinitis medicamentosa" below).
Oral decongestants elevate blood pressure and are not appropriate for people with hypertension (high blood pressure) or certain cardiovascular conditions. Men with an enlarged prostate who have difficulty urinating may notice a worsening of this symptom when they take decongestants. Cromolyn sodium — Cromolyn sodium (Nasalcrom®) prevents the symptoms of allergic rhinitis by stabilizing mast cells (the cells that can release substances which cause inflammation). This drug is available as an over-the-counter nasal spray that must be used three to four times per day, preferably before symptoms have begun, to effectively prevent the symptoms of allergic rhinitis. Cromolyn sodium has not been associated with any serious side effects. Saline nasal sprays or washes — Saline (salt water) nasal sprays and washes are effective for minimizing the nasal dryness and postnasal drip that may be associated with allergic rhinitis and its treatment. They also rinse out the allergens and irritants from the nose. Saline nasal sprays can be purchased over-the-counter and can be used by virtually everyone.
Saline washing involves rinsing the nasal passages with larger quantities of salt water. This technique can be helpful in patients who are willing and able to do it. Kits can be purchased over-the-counter or a solution can be made at home. (See "Nasal lavage" below).
Immunotherapy — Immunotherapy (desensitization therapy) refers to injections that are given to desensitize a person to known allergens (also known as allergy shots). This therapy is effective for only certain types of allergens, and is both expensive and time-consuming.
Although immunotherapy can benefit many people with allergic rhinitis, it is usually reserved for people who have a poor response to medication therapy or who are reluctant to take drugs. Immunotherapy has been shown to be effective for the treatment of allergies to cat dander and the pollen of trees, weeds, and grass.
Immunotherapy is usually started by an allergist. The therapy begins with several months of weekly injections of gradually increasing doses, followed by monthly maintenance injections. The maintenance injections can be given by a primary care provider.
Immunotherapy is usually a long-term therapy, and the benefits of this therapy may lessen when it is discontinued. However, one study in people with allergies to grass pollen found that the benefits of three to four years of immunotherapy persisted when the injections were stopped [2].
Immunotherapy injections carry a small risk of a severe allergic reaction. These reactions occur with a frequency of 6 of every 10,000 injections. The symptoms usually begin within 30 minutes of the injection. Patients are required to remain in the office after routine injections. Because drugs called beta-blockers may interfere with the ability to treat these reactions, people who take these beta-blockers are often advised not to have immunotherapy.
Other treatments — Other drugs have been studied in people with allergic rhinitis with inconclusive results. Nasal atropine — Nasal atropine is effective for the treatment of severe runny nose. This drug, available as ipratropium bromide (Atrovent®), is not generally recommended for people with glaucoma or men with an enlarged prostate. Leukotriene modifiers — Release of substances called leukotrienes may contribute to the symptoms of allergic rhinitis. Drugs that inhibit the action of leukotrienes, called leukotriene modifiers, can be very useful in patients with asthma and allergic rhinitis. However, nasal steroids are more effective than leukotriene modifiers for treating allergic rhinitis; thus, they are generally reserved for patients who cannot tolerate nasal sprays (due to nose bleeds) or azelastine (a nasal antihistamine spray).
CHRONIC NONALLERGIC RHINITIS — Nonallergic rhinitis is best defined by the chronic presence of one or more of the following four symptoms: sneezing, rhinorrhea, nasal congestion, and postnasal drainage, in the absence of any obvious cause. It usually begins in adulthood or later life. Many people with this condition notice that irritants, such as tobacco smoke, traffic fumes, or strong odors and perfumes trigger symptoms. Patients with chronic nonallergic rhinitis may not be bothered by pollen or furred animals (the common triggers in allergic rhinitis), although about one-half of people with this condition also have allergic rhinitis.
Gustatory rhinitis is a type of nonallergic rhinitis that causes a sudden onset of watery nasal discharge with eating, especially foods that are spicy or heated (such as soup).
Treatment of nonallergic rhinitis — Treatment of nonallergic rhinitis depends upon an individual's symptoms.
Trigger avoidance — Exposure to tobacco smoke can be reduced if household members stop smoking or smoke only outside of the home. It is also important to reduce smoke exposure in day care settings or in the workplace.
Exposure to pollutants and irritants can be reduced by avoiding wood-burning stoves and fireplaces; properly venting other stoves and heaters; and avoiding cleaning agents and household sprays that trigger symptoms.
Exposure to strong perfumes and scented products is more difficult. Patients should avoid personal use of these items and may need to request that coworkers, family, or friends do the same. Some workplaces have policies regarding the use of strongly scented personal products. Azelastine (Astelin®) can be used when needed to relieve symptoms. (See "Drug therapy" above).
Medications — Nasal steroids and azelastine, used on a daily basis, have been shown to benefit patients with nonallergic rhinitis. These medications may be used alone or in combination. Patients with rhinorrhea (profuse, watery discharge from the nose) may be given ipratropium bromide (0.03 percent) nasal spray. Ipratropium is the best treatment for gustatory rhinitis.
Nasal lavage — Rinsing the nose with a saline solution (nasal lavage) or nasal saline spray is helpful for many patients with nonallergic rhinitis, as well as for other rhinitis conditions. It is particularly useful for symptoms of postnasal drainage, sneezing, and congestion. Nasal lavage can be used immediately prior to nasal medication so that the mucosa is freshly cleansed when the medication is applied.
A variety of devices, including bulb syringes and bottle sprayers, may be used to perform nasal lavage (show table 2). Patients should use at least 200 mL in each nostril. Patients can make their own solutions or buy commercially-prepared kits, available without a prescription. Nasal lavage with warmed saline can be performed as needed, daily at baseline, or twice daily for increased symptoms. Nasal lavage carries few risks if performed correctly.
ATROPHIC RHINITIS — Atrophic rhinitis is an uncommon type of rhinitis that results from a gradual thinning of the nasal lining and the nasal bones. This condition most commonly occurs in older adults. The symptoms include nasal congestion, crusting of the nasal passages, and a persistent bad smell. Treatment with a saline spray or lavage often relieves the symptoms of atrophic rhinitis. Occasionally, sinus rinses containing antibiotic solutions are prescribed.
RHINITIS MEDICAMENTOSA — Rhinitis medicamentosa is a type of rhinitis that develops as a result of overuse of over-the-counter decongestant nasal sprays (not nasal steroids) or intranasal cocaine abuse.
Rhinitis medicamentosa is treated by discontinuing the drug that is causing the condition. Steroid nasal sprays can speed the recovery from this condition, but recovery may take as long as one year [3].
MEDICATIONS FOR OTHER PROBLEMS — Certain medications can cause or worsen nasal symptoms (especially congestion), including the following: oral contraceptives, drugs for high blood pressure, antidepressants, medications for erectile dysfunction, medications for prostatic enlargement, sedatives, and aspirin.
ASSOCIATED MEDICAL PROBLEMS — Rhinitis can be a symptom of several underlying medical conditions, including hypothyroidism, certain tumors, and conditions that cause vascular inflammation. Treatment of these underlying conditions may relieve rhinitis. Pregnancy can also cause rhinitis in some women.
NASAL POLYPS — Nasal polyps are painless overgrowths of the lining of the sinuses. These polyps may result from the persistent inflammation of allergic rhinitis, among other causes. Nasal polyps can narrow the nasal passages and cause a decreased sense of smell.
Nasal polyps can be difficult to treat. Nasal steroids can slow the growth of nasal polyps and may cause them to shrink. A brief treatment with oral steroids followed by maintenance treatment with nasal steroids can also control the growth of nasal polyps.
Surgery to remove nasal polyps (called polypectomy) may be necessary when the polyps severely narrow the nasal passages or cause recurrent sinusitis that requires antibiotic treatment. Polyps often grow back after surgery, unless nasal steroid sprays or other medications are used to slow the regrowth process.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html) National Institute of Allergy and Infectious Diseases (NIAID)
(www.niaid.nih.gov) Allergy, Asthma, and Immunology Online
(www.acaai.org) American Academy of Allergy, Asthma, and Immunology
(www.aaaai.org) American Academy of Otolaryngology -- Head and Neck Surgery, Inc.
(www.entnet.org) American Rhinologic Society
(www.american-rhinologic.org)
Wednesday, January 9, 2008
Patient information: Rhinitis
Robert H Fletcher, MD
UpToDate performs a continuous review of over 375 journals and other resources. Updates are added as important new information is published. The literature review for version 15.2 is current through April 2007; this topic was last changed on November 27, 2006. The next version of UpToDate (15.3) will be released in October 2007.
OVERVIEW — Rhinitis refers to inflammation of the nasal passages. This inflammation can cause a variety of annoying symptoms, including sneezing, itching, nasal congestion, runny nose, and post-nasal drip (the sensation that mucus is draining from the sinuses down the back of the throat).
Almost everyone experiences rhinitis at some point during their life. Brief episodes of rhinitis are usually caused by respiratory tract infections with viruses (eg, the common cold). Chronic rhinitis is usually caused by allergies, but it can also occur from overuse of certain drugs, some medical conditions, and other unidentifiable factors.
For many people, rhinitis is a lifelong condition that waxes and wanes over time. Fortunately, the symptoms of rhinitis can usually be controlled with a combination of environmental measures, medications, and immunotherapy (also called allergy shots).
ALLERGIC RHINITIS — Allergic rhinitis, also known as hay fever or grass fever, affects approximately 20 percent of people of all ages. The risk of developing allergic rhinitis is much higher in people with asthma or eczema, and in people who have a family history of asthma or rhinitis.
Allergic rhinitis can begin at any age, although most people first develop symptoms in childhood or young adulthood. The symptoms are often at their worst in children and in people in their 30s and 40s. However, the severity of symptoms tends to vary throughout life, and many people experience periods of remission.
Causes — Allergic rhinitis is caused by a nasal reaction to small airborne particles called allergens (substances that provoke an allergic reaction). In some people, these particles also cause reactions in the lungs (asthma), and eyes (allergic conjunctivitis).
The allergic reaction is characterized by activation of two types of inflammatory cells, called mast cells and basophils. These cells produce inflammatory substances, including histamine, that cause fluid to build up in the nasal tissues (congestion), itching, sneezing, and runny nose. Over several hours, these substances activate other inflammatory cells that can cause persistent symptoms.
Seasonal versus perennial allergic rhinitis — Allergic rhinitis can be seasonal (occurring during specific seasons) or perennial (occurring year round). The allergens that most commonly cause seasonal allergic rhinitis are pollens from trees, grasses, and weeds, as well as spores from fungi and molds. The allergens that most commonly cause perennial allergic rhinitis are dust mites, cockroaches, animal dander, and fungi or molds. Of these two types of allergic rhinitis, perennial allergic rhinitis tends to be more difficult to treat.
Symptoms — The symptoms of allergic rhinitis can vary from person to person. Although the term "rhinitis" refers only to the nasal symptoms, many patients also experience problems with their eyes, throat, ears, and sleep, so it is helpful to consider the entire spectrum of symptoms. Nose: watery nasal discharge, blocked nasal passages, sneezing, nasal itching, post-nasal drip, loss of taste, facial pressure or pain Eyes: itchy, red eyes, feeling of grittiness in the eyes, swelling and blueness of the skin below the eyes Throat and ears: sort throat, hoarse voice, congestion or popping of the ears, itching of the throat or ears Sleep: mouth breathing, frequent awakening, daytime fatigue, difficulty performing work
When an allergen is present year round, the predominant symptoms include post-nasal drip, persistent nasal congestion, and poor-quality sleep.
Diagnosis — The diagnosis of allergic rhinitis is based upon the presence of the nasal signs and symptoms described above. A physical examination and medical tests can confirm the diagnosis and identify the offending allergens.
Nasal examination — A nasal examination allows direct visual inspection of the lining of the nasal passages and can occasionally differentiate allergic rhinitis from other types of rhinitis. In people with allergic rhinitis, the lining of the nasal passages is very swollen and pale, sometimes to the degree that it appears bluish in color.
Identification of allergens and other triggers — It is often possible to identify the allergens and other triggers that provoke allergic rhinitis by recalling the factors that precede symptoms; noting the time at which symptoms begin; and examining a person's home, work, and school environments. Skin tests may be useful for people whose symptoms are not well controlled with medications and in whom the offending allergen is not obvious.
Treatment — The treatment of allergic rhinitis entails measures to reduce a person's exposure to known allergens or other triggers, combined with medication therapy. In most people, these measures effectively control the symptoms.
Reducing exposure to triggers — Some simple measures can reduce a person's exposure to the allergens and triggers that provoke allergic rhinitis. These measures do not apply to everyone with allergic rhinitis; persons with a known sensitivity to a particular allergen may consider these suggestions. Dust mites — Exposure to dust mites can be reduced by encasing mattresses and pillows in mite-impermeable barriers and washing sheets and blankets weekly in very hot water (at least 130ºF). Exposure can be further reduced by keeping indoor humidity lower than 50 percent, vacuuming regularly, removing carpets, and avoiding sleeping on upholstered furniture. Animal dander — Exposure to animal dander can be reduced by keeping pets out of bedrooms, sealing or placing filters over the air vents to bedrooms, and removing carpets. In some cases, it may be necessary to remove pets from the home. Cat dander, in particular, can linger in an environment long after a cat has been removed, so a person's symptoms may not improve for several months. Cockroaches — Exposure to cockroaches can be reduced by using poison bait or traps, keeping food and garbage tightly enclosed at all times, and sealing cracks to the outside. Indoor molds — Growth of indoor molds can be reduced by removing sources of standing water and persistent dampness: removing house plants, fixing leaky plumbing, correcting sinks and showers that don't drain completely, and dehumidifying damp areas to levels below 50 percent. Surfaces with visible mold growth should be cleaned with a 10 percent solution of bleach. Pollens and outdoor molds — Exposure to pollens and outdoor molds can be reduced by keeping car and house windows closed and using air conditioning during peak pollen seasons, staying inside on dry, windy days, and showering at night to remove pollens and spores from the hair and skin before bed. The American Academy of Allergy, Asthma, and Immunology has a toll free number (1-800-976-5536) and website (www.aaaai.org) for monitoring pollen and mold spore counts.
Air filters — The effectiveness of high-efficiency particulate air (HEPA) cleaners in reducing a person's exposure to allergens is uncertain. These cleaners are not very effective for reducing exposure to dust mites since little of this allergen is airborne. However, some studies have suggested that HEPA cleaners may be effective for removing cat allergens from the air.
Drug therapy — Several different classes of drugs counter the inflammation that causes symptoms of allergic rhinitis. The severity of symptoms and personal preferences usually guide the selection of specific drugs. Nasal steroids — Nasal steroids (steroids taken by a nasal spray) are usually recommended first for the treatment of allergic rhinitis. These drugs have very few side effects and dramatically relieve symptoms in most people. Studies have shown that nasal steroids are more effective than oral antihistamines for symptom relief [1].
The nasal steroids include fluticasone (Flonase®), mometasone (Nasonex®), beclomethasone (Vancenase®, Beconase®), budesonide (Rhinocort®), flunisolide (Nasarel®), and triamcinolone (Nasocort®). These drugs differ with regard to the base liquid (water-based versus alcohol-based), the frequency of doses, the spray device, and cost, but all are similarly effective for treating all the symptoms of allergic rhinitis. People with severe rhinitis may be advised to also use nasal decongestants for a few days to reduce nasal swelling and allow the steroid spray better access to the nasal passages.
Some symptom relief may occur on the first day of therapy with nasal steroids, but their maximal effectiveness may not be apparent for days to weeks. For this reason, these drugs are most effective when used regularly. Some people are able to gradually use lower doses when symptoms are less severe.
Applying the nasal spray directly onto the nasal lining is important for maximizing the effectiveness of nasal steroids. Application can be improved by directing the spray away from the nasal septum (the cartilage that divides the two sides of the nose), using an alcohol-based spray, and positioning the head down and forward after using water-based sprays.
The side effects of nasal steroids are mild and may include a slight unpleasant smell or taste or drying of the nasal lining. In some people, nasal steroids cause irritation, crusting, and bleeding of the nasal septum, especially during the winter; this side effect can be minimized by applying Vaseline to the septum before using the spray, using a saline nasal spray to restore moisture to the nasal lining, or switching to a water-based spray. Studies suggest that nasal steroids are generally safe when used for many years. However, people who use these drugs for years should have periodic nasal examinations to check for rare side effects, such as nasal infection or ulceration.
Although oral and inhaled steroids have been linked to reduced bone mineral density and hormonal side effects, the doses used in nasal steroids are low and are NOT associated with these side effects. However, clinicians usually recommend using the lowest effective dose of nasal steroids. Antihistamines — Antihistamines relieve the itching, sneezing, and runny nose of allergic rhinitis, but they do not relieve nasal congestion. Combined treatment with nasal steroids or decongestants may provide greater symptom relief than use of either alone.
The oral, over-the-counter antihistamines include brompheniramine (Dimetapp allergy®, Nasahist B®), chlorpheniramine (Chlor-Trimeton®), diphenhydramine (Benadryl®), and clemastine (Tavist®). These drugs often cause sedation and should not be used before driving or operating machinery. Simultaneous use of a decongestant may reduce the sedating effects, but patients should still use caution.
The oral, prescription antihistamines include cetirizine (Zyrtec®) and fexofenadine (Allegra®). Loratadine (Claritin®, Alavert®) is now available without a prescription. These drugs are much less sedating and are available in long-acting formulas; however, they are more expensive and are of no greater benefit than over-the-counter antihistamines for treating rhinitis symptoms.
Azelastine (Astelin®) is a prescription nasal antihistamine spray that can be used daily or only as needed to relieve symptoms of post-nasal drip, congestion, and sneezing. It starts to work within minutes after use. Patients may use up to eight total sprays per day; higher doses can cause sedation. The most commonly observed side effect is a bad taste in the mouth immediately after use. This can be minimized by keeping the head tilted forward so the medicine does not drain down the throat. Decongestants — Decongestants (like pseudoephedrine [Sudafed®, Actifed®, Drixoral®]) are often combined with antihistamines in oral, over-the-counter allergy drugs.
Several decongestant nasal sprays also are available, including oxymetazoline (Afrin®) and phenylephrine (Neo-synephrine®). Nasal decongestants must not be used for more than two to three days at a time because they may cause a different type of rhinitis, called rhinitis medicamentosa. (See "Rhinitis medicamentosa" below).
Oral decongestants elevate blood pressure and are not appropriate for people with hypertension (high blood pressure) or certain cardiovascular conditions. Men with an enlarged prostate who have difficulty urinating may notice a worsening of this symptom when they take decongestants. Cromolyn sodium — Cromolyn sodium (Nasalcrom®) prevents the symptoms of allergic rhinitis by stabilizing mast cells (the cells that can release substances which cause inflammation). This drug is available as an over-the-counter nasal spray that must be used three to four times per day, preferably before symptoms have begun, to effectively prevent the symptoms of allergic rhinitis. Cromolyn sodium has not been associated with any serious side effects. Saline nasal sprays or washes — Saline (salt water) nasal sprays and washes are effective for minimizing the nasal dryness and postnasal drip that may be associated with allergic rhinitis and its treatment. They also rinse out the allergens and irritants from the nose. Saline nasal sprays can be purchased over-the-counter and can be used by virtually everyone.
Saline washing involves rinsing the nasal passages with larger quantities of salt water. This technique can be helpful in patients who are willing and able to do it. Kits can be purchased over-the-counter or a solution can be made at home. (See "Nasal lavage" below).
Immunotherapy — Immunotherapy (desensitization therapy) refers to injections that are given to desensitize a person to known allergens (also known as allergy shots). This therapy is effective for only certain types of allergens, and is both expensive and time-consuming.
Although immunotherapy can benefit many people with allergic rhinitis, it is usually reserved for people who have a poor response to medication therapy or who are reluctant to take drugs. Immunotherapy has been shown to be effective for the treatment of allergies to cat dander and the pollen of trees, weeds, and grass.
Immunotherapy is usually started by an allergist. The therapy begins with several months of weekly injections of gradually increasing doses, followed by monthly maintenance injections. The maintenance injections can be given by a primary care provider.
Immunotherapy is usually a long-term therapy, and the benefits of this therapy may lessen when it is discontinued. However, one study in people with allergies to grass pollen found that the benefits of three to four years of immunotherapy persisted when the injections were stopped [2].
Immunotherapy injections carry a small risk of a severe allergic reaction. These reactions occur with a frequency of 6 of every 10,000 injections. The symptoms usually begin within 30 minutes of the injection. Patients are required to remain in the office after routine injections. Because drugs called beta-blockers may interfere with the ability to treat these reactions, people who take these beta-blockers are often advised not to have immunotherapy.
Other treatments — Other drugs have been studied in people with allergic rhinitis with inconclusive results. Nasal atropine — Nasal atropine is effective for the treatment of severe runny nose. This drug, available as ipratropium bromide (Atrovent®), is not generally recommended for people with glaucoma or men with an enlarged prostate. Leukotriene modifiers — Release of substances called leukotrienes may contribute to the symptoms of allergic rhinitis. Drugs that inhibit the action of leukotrienes, called leukotriene modifiers, can be very useful in patients with asthma and allergic rhinitis. However, nasal steroids are more effective than leukotriene modifiers for treating allergic rhinitis; thus, they are generally reserved for patients who cannot tolerate nasal sprays (due to nose bleeds) or azelastine (a nasal antihistamine spray).
CHRONIC NONALLERGIC RHINITIS — Nonallergic rhinitis is best defined by the chronic presence of one or more of the following four symptoms: sneezing, rhinorrhea, nasal congestion, and postnasal drainage, in the absence of any obvious cause. It usually begins in adulthood or later life. Many people with this condition notice that irritants, such as tobacco smoke, traffic fumes, or strong odors and perfumes trigger symptoms. Patients with chronic nonallergic rhinitis may not be bothered by pollen or furred animals (the common triggers in allergic rhinitis), although about one-half of people with this condition also have allergic rhinitis.
Gustatory rhinitis is a type of nonallergic rhinitis that causes a sudden onset of watery nasal discharge with eating, especially foods that are spicy or heated (such as soup).
Treatment of nonallergic rhinitis — Treatment of nonallergic rhinitis depends upon an individual's symptoms.
Trigger avoidance — Exposure to tobacco smoke can be reduced if household members stop smoking or smoke only outside of the home. It is also important to reduce smoke exposure in day care settings or in the workplace.
Exposure to pollutants and irritants can be reduced by avoiding wood-burning stoves and fireplaces; properly venting other stoves and heaters; and avoiding cleaning agents and household sprays that trigger symptoms.
Exposure to strong perfumes and scented products is more difficult. Patients should avoid personal use of these items and may need to request that coworkers, family, or friends do the same. Some workplaces have policies regarding the use of strongly scented personal products. Azelastine (Astelin®) can be used when needed to relieve symptoms. (See "Drug therapy" above).
Medications — Nasal steroids and azelastine, used on a daily basis, have been shown to benefit patients with nonallergic rhinitis. These medications may be used alone or in combination. Patients with rhinorrhea (profuse, watery discharge from the nose) may be given ipratropium bromide (0.03 percent) nasal spray. Ipratropium is the best treatment for gustatory rhinitis.
Nasal lavage — Rinsing the nose with a saline solution (nasal lavage) or nasal saline spray is helpful for many patients with nonallergic rhinitis, as well as for other rhinitis conditions. It is particularly useful for symptoms of postnasal drainage, sneezing, and congestion. Nasal lavage can be used immediately prior to nasal medication so that the mucosa is freshly cleansed when the medication is applied.
A variety of devices, including bulb syringes and bottle sprayers, may be used to perform nasal lavage (show table 2). Patients should use at least 200 mL in each nostril. Patients can make their own solutions or buy commercially-prepared kits, available without a prescription. Nasal lavage with warmed saline can be performed as needed, daily at baseline, or twice daily for increased symptoms. Nasal lavage carries few risks if performed correctly.
ATROPHIC RHINITIS — Atrophic rhinitis is an uncommon type of rhinitis that results from a gradual thinning of the nasal lining and the nasal bones. This condition most commonly occurs in older adults. The symptoms include nasal congestion, crusting of the nasal passages, and a persistent bad smell. Treatment with a saline spray or lavage often relieves the symptoms of atrophic rhinitis. Occasionally, sinus rinses containing antibiotic solutions are prescribed.
RHINITIS MEDICAMENTOSA — Rhinitis medicamentosa is a type of rhinitis that develops as a result of overuse of over-the-counter decongestant nasal sprays (not nasal steroids) or intranasal cocaine abuse.
Rhinitis medicamentosa is treated by discontinuing the drug that is causing the condition. Steroid nasal sprays can speed the recovery from this condition, but recovery may take as long as one year [3].
MEDICATIONS FOR OTHER PROBLEMS — Certain medications can cause or worsen nasal symptoms (especially congestion), including the following: oral contraceptives, drugs for high blood pressure, antidepressants, medications for erectile dysfunction, medications for prostatic enlargement, sedatives, and aspirin.
ASSOCIATED MEDICAL PROBLEMS — Rhinitis can be a symptom of several underlying medical conditions, including hypothyroidism, certain tumors, and conditions that cause vascular inflammation. Treatment of these underlying conditions may relieve rhinitis. Pregnancy can also cause rhinitis in some women.
NASAL POLYPS — Nasal polyps are painless overgrowths of the lining of the sinuses. These polyps may result from the persistent inflammation of allergic rhinitis, among other causes. Nasal polyps can narrow the nasal passages and cause a decreased sense of smell.
Nasal polyps can be difficult to treat. Nasal steroids can slow the growth of nasal polyps and may cause them to shrink. A brief treatment with oral steroids followed by maintenance treatment with nasal steroids can also control the growth of nasal polyps.
Surgery to remove nasal polyps (called polypectomy) may be necessary when the polyps severely narrow the nasal passages or cause recurrent sinusitis that requires antibiotic treatment. Polyps often grow back after surgery, unless nasal steroid sprays or other medications are used to slow the regrowth process.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html) National Institute of Allergy and Infectious Diseases (NIAID)
(www.niaid.nih.gov) Allergy, Asthma, and Immunology Online
(www.acaai.org) American Academy of Allergy, Asthma, and Immunology
(www.aaaai.org) American Academy of Otolaryngology -- Head and Neck Surgery, Inc.
(www.entnet.org) American Rhinologic Society
(www.american-rhinologic.org)
UpToDate performs a continuous review of over 375 journals and other resources. Updates are added as important new information is published. The literature review for version 15.2 is current through April 2007; this topic was last changed on November 27, 2006. The next version of UpToDate (15.3) will be released in October 2007.
OVERVIEW — Rhinitis refers to inflammation of the nasal passages. This inflammation can cause a variety of annoying symptoms, including sneezing, itching, nasal congestion, runny nose, and post-nasal drip (the sensation that mucus is draining from the sinuses down the back of the throat).
Almost everyone experiences rhinitis at some point during their life. Brief episodes of rhinitis are usually caused by respiratory tract infections with viruses (eg, the common cold). Chronic rhinitis is usually caused by allergies, but it can also occur from overuse of certain drugs, some medical conditions, and other unidentifiable factors.
For many people, rhinitis is a lifelong condition that waxes and wanes over time. Fortunately, the symptoms of rhinitis can usually be controlled with a combination of environmental measures, medications, and immunotherapy (also called allergy shots).
ALLERGIC RHINITIS — Allergic rhinitis, also known as hay fever or grass fever, affects approximately 20 percent of people of all ages. The risk of developing allergic rhinitis is much higher in people with asthma or eczema, and in people who have a family history of asthma or rhinitis.
Allergic rhinitis can begin at any age, although most people first develop symptoms in childhood or young adulthood. The symptoms are often at their worst in children and in people in their 30s and 40s. However, the severity of symptoms tends to vary throughout life, and many people experience periods of remission.
Causes — Allergic rhinitis is caused by a nasal reaction to small airborne particles called allergens (substances that provoke an allergic reaction). In some people, these particles also cause reactions in the lungs (asthma), and eyes (allergic conjunctivitis).
The allergic reaction is characterized by activation of two types of inflammatory cells, called mast cells and basophils. These cells produce inflammatory substances, including histamine, that cause fluid to build up in the nasal tissues (congestion), itching, sneezing, and runny nose. Over several hours, these substances activate other inflammatory cells that can cause persistent symptoms.
Seasonal versus perennial allergic rhinitis — Allergic rhinitis can be seasonal (occurring during specific seasons) or perennial (occurring year round). The allergens that most commonly cause seasonal allergic rhinitis are pollens from trees, grasses, and weeds, as well as spores from fungi and molds. The allergens that most commonly cause perennial allergic rhinitis are dust mites, cockroaches, animal dander, and fungi or molds. Of these two types of allergic rhinitis, perennial allergic rhinitis tends to be more difficult to treat.
Symptoms — The symptoms of allergic rhinitis can vary from person to person. Although the term "rhinitis" refers only to the nasal symptoms, many patients also experience problems with their eyes, throat, ears, and sleep, so it is helpful to consider the entire spectrum of symptoms. Nose: watery nasal discharge, blocked nasal passages, sneezing, nasal itching, post-nasal drip, loss of taste, facial pressure or pain Eyes: itchy, red eyes, feeling of grittiness in the eyes, swelling and blueness of the skin below the eyes Throat and ears: sort throat, hoarse voice, congestion or popping of the ears, itching of the throat or ears Sleep: mouth breathing, frequent awakening, daytime fatigue, difficulty performing work
When an allergen is present year round, the predominant symptoms include post-nasal drip, persistent nasal congestion, and poor-quality sleep.
Diagnosis — The diagnosis of allergic rhinitis is based upon the presence of the nasal signs and symptoms described above. A physical examination and medical tests can confirm the diagnosis and identify the offending allergens.
Nasal examination — A nasal examination allows direct visual inspection of the lining of the nasal passages and can occasionally differentiate allergic rhinitis from other types of rhinitis. In people with allergic rhinitis, the lining of the nasal passages is very swollen and pale, sometimes to the degree that it appears bluish in color.
Identification of allergens and other triggers — It is often possible to identify the allergens and other triggers that provoke allergic rhinitis by recalling the factors that precede symptoms; noting the time at which symptoms begin; and examining a person's home, work, and school environments. Skin tests may be useful for people whose symptoms are not well controlled with medications and in whom the offending allergen is not obvious.
Treatment — The treatment of allergic rhinitis entails measures to reduce a person's exposure to known allergens or other triggers, combined with medication therapy. In most people, these measures effectively control the symptoms.
Reducing exposure to triggers — Some simple measures can reduce a person's exposure to the allergens and triggers that provoke allergic rhinitis. These measures do not apply to everyone with allergic rhinitis; persons with a known sensitivity to a particular allergen may consider these suggestions. Dust mites — Exposure to dust mites can be reduced by encasing mattresses and pillows in mite-impermeable barriers and washing sheets and blankets weekly in very hot water (at least 130ºF). Exposure can be further reduced by keeping indoor humidity lower than 50 percent, vacuuming regularly, removing carpets, and avoiding sleeping on upholstered furniture. Animal dander — Exposure to animal dander can be reduced by keeping pets out of bedrooms, sealing or placing filters over the air vents to bedrooms, and removing carpets. In some cases, it may be necessary to remove pets from the home. Cat dander, in particular, can linger in an environment long after a cat has been removed, so a person's symptoms may not improve for several months. Cockroaches — Exposure to cockroaches can be reduced by using poison bait or traps, keeping food and garbage tightly enclosed at all times, and sealing cracks to the outside. Indoor molds — Growth of indoor molds can be reduced by removing sources of standing water and persistent dampness: removing house plants, fixing leaky plumbing, correcting sinks and showers that don't drain completely, and dehumidifying damp areas to levels below 50 percent. Surfaces with visible mold growth should be cleaned with a 10 percent solution of bleach. Pollens and outdoor molds — Exposure to pollens and outdoor molds can be reduced by keeping car and house windows closed and using air conditioning during peak pollen seasons, staying inside on dry, windy days, and showering at night to remove pollens and spores from the hair and skin before bed. The American Academy of Allergy, Asthma, and Immunology has a toll free number (1-800-976-5536) and website (www.aaaai.org) for monitoring pollen and mold spore counts.
Air filters — The effectiveness of high-efficiency particulate air (HEPA) cleaners in reducing a person's exposure to allergens is uncertain. These cleaners are not very effective for reducing exposure to dust mites since little of this allergen is airborne. However, some studies have suggested that HEPA cleaners may be effective for removing cat allergens from the air.
Drug therapy — Several different classes of drugs counter the inflammation that causes symptoms of allergic rhinitis. The severity of symptoms and personal preferences usually guide the selection of specific drugs. Nasal steroids — Nasal steroids (steroids taken by a nasal spray) are usually recommended first for the treatment of allergic rhinitis. These drugs have very few side effects and dramatically relieve symptoms in most people. Studies have shown that nasal steroids are more effective than oral antihistamines for symptom relief [1].
The nasal steroids include fluticasone (Flonase®), mometasone (Nasonex®), beclomethasone (Vancenase®, Beconase®), budesonide (Rhinocort®), flunisolide (Nasarel®), and triamcinolone (Nasocort®). These drugs differ with regard to the base liquid (water-based versus alcohol-based), the frequency of doses, the spray device, and cost, but all are similarly effective for treating all the symptoms of allergic rhinitis. People with severe rhinitis may be advised to also use nasal decongestants for a few days to reduce nasal swelling and allow the steroid spray better access to the nasal passages.
Some symptom relief may occur on the first day of therapy with nasal steroids, but their maximal effectiveness may not be apparent for days to weeks. For this reason, these drugs are most effective when used regularly. Some people are able to gradually use lower doses when symptoms are less severe.
Applying the nasal spray directly onto the nasal lining is important for maximizing the effectiveness of nasal steroids. Application can be improved by directing the spray away from the nasal septum (the cartilage that divides the two sides of the nose), using an alcohol-based spray, and positioning the head down and forward after using water-based sprays.
The side effects of nasal steroids are mild and may include a slight unpleasant smell or taste or drying of the nasal lining. In some people, nasal steroids cause irritation, crusting, and bleeding of the nasal septum, especially during the winter; this side effect can be minimized by applying Vaseline to the septum before using the spray, using a saline nasal spray to restore moisture to the nasal lining, or switching to a water-based spray. Studies suggest that nasal steroids are generally safe when used for many years. However, people who use these drugs for years should have periodic nasal examinations to check for rare side effects, such as nasal infection or ulceration.
Although oral and inhaled steroids have been linked to reduced bone mineral density and hormonal side effects, the doses used in nasal steroids are low and are NOT associated with these side effects. However, clinicians usually recommend using the lowest effective dose of nasal steroids. Antihistamines — Antihistamines relieve the itching, sneezing, and runny nose of allergic rhinitis, but they do not relieve nasal congestion. Combined treatment with nasal steroids or decongestants may provide greater symptom relief than use of either alone.
The oral, over-the-counter antihistamines include brompheniramine (Dimetapp allergy®, Nasahist B®), chlorpheniramine (Chlor-Trimeton®), diphenhydramine (Benadryl®), and clemastine (Tavist®). These drugs often cause sedation and should not be used before driving or operating machinery. Simultaneous use of a decongestant may reduce the sedating effects, but patients should still use caution.
The oral, prescription antihistamines include cetirizine (Zyrtec®) and fexofenadine (Allegra®). Loratadine (Claritin®, Alavert®) is now available without a prescription. These drugs are much less sedating and are available in long-acting formulas; however, they are more expensive and are of no greater benefit than over-the-counter antihistamines for treating rhinitis symptoms.
Azelastine (Astelin®) is a prescription nasal antihistamine spray that can be used daily or only as needed to relieve symptoms of post-nasal drip, congestion, and sneezing. It starts to work within minutes after use. Patients may use up to eight total sprays per day; higher doses can cause sedation. The most commonly observed side effect is a bad taste in the mouth immediately after use. This can be minimized by keeping the head tilted forward so the medicine does not drain down the throat. Decongestants — Decongestants (like pseudoephedrine [Sudafed®, Actifed®, Drixoral®]) are often combined with antihistamines in oral, over-the-counter allergy drugs.
Several decongestant nasal sprays also are available, including oxymetazoline (Afrin®) and phenylephrine (Neo-synephrine®). Nasal decongestants must not be used for more than two to three days at a time because they may cause a different type of rhinitis, called rhinitis medicamentosa. (See "Rhinitis medicamentosa" below).
Oral decongestants elevate blood pressure and are not appropriate for people with hypertension (high blood pressure) or certain cardiovascular conditions. Men with an enlarged prostate who have difficulty urinating may notice a worsening of this symptom when they take decongestants. Cromolyn sodium — Cromolyn sodium (Nasalcrom®) prevents the symptoms of allergic rhinitis by stabilizing mast cells (the cells that can release substances which cause inflammation). This drug is available as an over-the-counter nasal spray that must be used three to four times per day, preferably before symptoms have begun, to effectively prevent the symptoms of allergic rhinitis. Cromolyn sodium has not been associated with any serious side effects. Saline nasal sprays or washes — Saline (salt water) nasal sprays and washes are effective for minimizing the nasal dryness and postnasal drip that may be associated with allergic rhinitis and its treatment. They also rinse out the allergens and irritants from the nose. Saline nasal sprays can be purchased over-the-counter and can be used by virtually everyone.
Saline washing involves rinsing the nasal passages with larger quantities of salt water. This technique can be helpful in patients who are willing and able to do it. Kits can be purchased over-the-counter or a solution can be made at home. (See "Nasal lavage" below).
Immunotherapy — Immunotherapy (desensitization therapy) refers to injections that are given to desensitize a person to known allergens (also known as allergy shots). This therapy is effective for only certain types of allergens, and is both expensive and time-consuming.
Although immunotherapy can benefit many people with allergic rhinitis, it is usually reserved for people who have a poor response to medication therapy or who are reluctant to take drugs. Immunotherapy has been shown to be effective for the treatment of allergies to cat dander and the pollen of trees, weeds, and grass.
Immunotherapy is usually started by an allergist. The therapy begins with several months of weekly injections of gradually increasing doses, followed by monthly maintenance injections. The maintenance injections can be given by a primary care provider.
Immunotherapy is usually a long-term therapy, and the benefits of this therapy may lessen when it is discontinued. However, one study in people with allergies to grass pollen found that the benefits of three to four years of immunotherapy persisted when the injections were stopped [2].
Immunotherapy injections carry a small risk of a severe allergic reaction. These reactions occur with a frequency of 6 of every 10,000 injections. The symptoms usually begin within 30 minutes of the injection. Patients are required to remain in the office after routine injections. Because drugs called beta-blockers may interfere with the ability to treat these reactions, people who take these beta-blockers are often advised not to have immunotherapy.
Other treatments — Other drugs have been studied in people with allergic rhinitis with inconclusive results. Nasal atropine — Nasal atropine is effective for the treatment of severe runny nose. This drug, available as ipratropium bromide (Atrovent®), is not generally recommended for people with glaucoma or men with an enlarged prostate. Leukotriene modifiers — Release of substances called leukotrienes may contribute to the symptoms of allergic rhinitis. Drugs that inhibit the action of leukotrienes, called leukotriene modifiers, can be very useful in patients with asthma and allergic rhinitis. However, nasal steroids are more effective than leukotriene modifiers for treating allergic rhinitis; thus, they are generally reserved for patients who cannot tolerate nasal sprays (due to nose bleeds) or azelastine (a nasal antihistamine spray).
CHRONIC NONALLERGIC RHINITIS — Nonallergic rhinitis is best defined by the chronic presence of one or more of the following four symptoms: sneezing, rhinorrhea, nasal congestion, and postnasal drainage, in the absence of any obvious cause. It usually begins in adulthood or later life. Many people with this condition notice that irritants, such as tobacco smoke, traffic fumes, or strong odors and perfumes trigger symptoms. Patients with chronic nonallergic rhinitis may not be bothered by pollen or furred animals (the common triggers in allergic rhinitis), although about one-half of people with this condition also have allergic rhinitis.
Gustatory rhinitis is a type of nonallergic rhinitis that causes a sudden onset of watery nasal discharge with eating, especially foods that are spicy or heated (such as soup).
Treatment of nonallergic rhinitis — Treatment of nonallergic rhinitis depends upon an individual's symptoms.
Trigger avoidance — Exposure to tobacco smoke can be reduced if household members stop smoking or smoke only outside of the home. It is also important to reduce smoke exposure in day care settings or in the workplace.
Exposure to pollutants and irritants can be reduced by avoiding wood-burning stoves and fireplaces; properly venting other stoves and heaters; and avoiding cleaning agents and household sprays that trigger symptoms.
Exposure to strong perfumes and scented products is more difficult. Patients should avoid personal use of these items and may need to request that coworkers, family, or friends do the same. Some workplaces have policies regarding the use of strongly scented personal products. Azelastine (Astelin®) can be used when needed to relieve symptoms. (See "Drug therapy" above).
Medications — Nasal steroids and azelastine, used on a daily basis, have been shown to benefit patients with nonallergic rhinitis. These medications may be used alone or in combination. Patients with rhinorrhea (profuse, watery discharge from the nose) may be given ipratropium bromide (0.03 percent) nasal spray. Ipratropium is the best treatment for gustatory rhinitis.
Nasal lavage — Rinsing the nose with a saline solution (nasal lavage) or nasal saline spray is helpful for many patients with nonallergic rhinitis, as well as for other rhinitis conditions. It is particularly useful for symptoms of postnasal drainage, sneezing, and congestion. Nasal lavage can be used immediately prior to nasal medication so that the mucosa is freshly cleansed when the medication is applied.
A variety of devices, including bulb syringes and bottle sprayers, may be used to perform nasal lavage (show table 2). Patients should use at least 200 mL in each nostril. Patients can make their own solutions or buy commercially-prepared kits, available without a prescription. Nasal lavage with warmed saline can be performed as needed, daily at baseline, or twice daily for increased symptoms. Nasal lavage carries few risks if performed correctly.
ATROPHIC RHINITIS — Atrophic rhinitis is an uncommon type of rhinitis that results from a gradual thinning of the nasal lining and the nasal bones. This condition most commonly occurs in older adults. The symptoms include nasal congestion, crusting of the nasal passages, and a persistent bad smell. Treatment with a saline spray or lavage often relieves the symptoms of atrophic rhinitis. Occasionally, sinus rinses containing antibiotic solutions are prescribed.
RHINITIS MEDICAMENTOSA — Rhinitis medicamentosa is a type of rhinitis that develops as a result of overuse of over-the-counter decongestant nasal sprays (not nasal steroids) or intranasal cocaine abuse.
Rhinitis medicamentosa is treated by discontinuing the drug that is causing the condition. Steroid nasal sprays can speed the recovery from this condition, but recovery may take as long as one year [3].
MEDICATIONS FOR OTHER PROBLEMS — Certain medications can cause or worsen nasal symptoms (especially congestion), including the following: oral contraceptives, drugs for high blood pressure, antidepressants, medications for erectile dysfunction, medications for prostatic enlargement, sedatives, and aspirin.
ASSOCIATED MEDICAL PROBLEMS — Rhinitis can be a symptom of several underlying medical conditions, including hypothyroidism, certain tumors, and conditions that cause vascular inflammation. Treatment of these underlying conditions may relieve rhinitis. Pregnancy can also cause rhinitis in some women.
NASAL POLYPS — Nasal polyps are painless overgrowths of the lining of the sinuses. These polyps may result from the persistent inflammation of allergic rhinitis, among other causes. Nasal polyps can narrow the nasal passages and cause a decreased sense of smell.
Nasal polyps can be difficult to treat. Nasal steroids can slow the growth of nasal polyps and may cause them to shrink. A brief treatment with oral steroids followed by maintenance treatment with nasal steroids can also control the growth of nasal polyps.
Surgery to remove nasal polyps (called polypectomy) may be necessary when the polyps severely narrow the nasal passages or cause recurrent sinusitis that requires antibiotic treatment. Polyps often grow back after surgery, unless nasal steroid sprays or other medications are used to slow the regrowth process.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html) National Institute of Allergy and Infectious Diseases (NIAID)
(www.niaid.nih.gov) Allergy, Asthma, and Immunology Online
(www.acaai.org) American Academy of Allergy, Asthma, and Immunology
(www.aaaai.org) American Academy of Otolaryngology -- Head and Neck Surgery, Inc.
(www.entnet.org) American Rhinologic Society
(www.american-rhinologic.org)
Dermatitis
James C Shaw, MD
UpToDate performs a continuous review of over 375 journals and other resources. Updates are added as important new information is published. The literature review for version 15.2 is current through April 2007; this topic was last changed on September 13, 2006. The next version of UpToDate (15.3) will be released in October 2007.
INTRODUCTION — Dermatitis is defined as an inflammation of the skin. The terms dermatitis include a wide variety of skin disorders, including atopic dermatitis (eczema), seborrheic dermatitis, contact dermatitis, latex dermatitis and allergy, and dyshidrotic dermatitis.
Depending upon the underlying cause, dermatitis can be a short-term or lifelong condition. In most cases, self-care measures and drug therapy can control the symptoms and prevent complications.
ATOPIC DERMATITIS (ECZEMA) — About 8 to 25 percent of people worldwide have atopic dermatitis (eczema). It often occurs in people who have other allergic disorders, such as asthma and allergic rhinitis (nasal inflammation caused by allergies, also known as hay fever). Family members are often affected.
Cause — The cause of eczema is unknown, but hereditary factors appear to play a strong role. The skin inflammation of atopic dermatitis results from an abnormal immune reaction that is triggered or worsened by exposure to allergens (substances that provoke an allergic reaction). About 85 percent of people with eczema have antibodies (proteins formed by the immune system) to foods or airborne allergens, such as dust mites and animal dander.
In children, eczema is often linked to food allergies. Common food allergens include milk, egg whites, wheat, corn, soybeans, and peanuts.
Symptoms — Most people with eczema develop their first symptoms before age five. Intense itching of the skin, redness, small bumps, and skin flaking are common (show picture 1). Scratching can cause additional skin inflammation, which can further worsen the itching. The itchiness may be more noticeable at nighttime. The skin is often dry, increasing the risk of skin injury with scratching. The skin lesions are therefore at risk for developing infection. Features of infection include pus-containing bumps in inflamed areas; prompt evaluation by a healthcare provider is recommended if this occurs
Features of eczema vary from one individual to another, and can change over time. Other features can include: Lichenification - Thick, leathery skin (usually as a result of frequent scratching) Icthyosis - Dry scales (show picture 2) Keratosis pilaris - Plugged hair follicles resulting in the development of small bumps, usually on the face, upper arms, and thighs Cheilitis - Inflammation around the lips Hyperlinear palms - Increased skin creasing on the palms Dennie-Morgan line - An extra fold of skin under the eye Periorbital darkening - Darkening of the skin around the eyes
Although eczema is usually confined to specific areas of the body, it may be widespread in severe cases: In young children, it typically occurs on the face, scalp, extremities, or trunk, and rarely occurs in the diaper area (show picture 3). In older children and adolescents, it is often accompanied by thickening and darkening of the skin, as well as scarring from repeated scratching. In adults, it commonly affects the back of the neck, the elbow creases, and the backs of the knees . Other affected areas may include the face, wrists, and forearms.
Diagnosis — There is no specific test used to diagnose eczema; diagnosis is usually based upon a person's history and the signs noted during a physical examination.
Factors that strongly suggest eczema include long-standing and recurrent itching, a personal or family history of allergic conditions, and an early age at onset. Other factors include a worsening of symptoms after exposure to certain triggers, and any of the skin findings noted above.
Allergy testing is usually reserved for people who have eczema in addition to features of asthma or allergic rhinitis. Allergy testing may also be recommended for children with suspected food allergies.
Treatment — Eczema is a chronic condition; it typically improves and then flares (worsens) periodically. Some people can have no symptoms for several years, only to have the disease return at a later time. It is not curable, although symptoms can be controlled with a variety of self-care measures and drug therapy. Eliminate exacerbating factors — Eliminating factors that worsen eczema can effectively control the symptoms. These factors may include frequent bathing and low-humidity environments (which can further dry the skin), emotional stress, rapid temperature changes, and exposure to certain chemicals and cleaning solutions. Common irritants include soaps and detergents, perfumes and cosmetics, wool or synthetic fibers, dust, sand, and cigarette smoke.
The following tips are recommended: Dust frequently and avoid placing upholstered furniture in the bedroom. Reducing exposure to house dust mites may reduce the severity of atopic dermatitis. Food allergies are relatively uncommon in adults, but may be a problem for a small percentage of infants and young children. However, changes to an infant or child's diet should be made only after consulting an allergy specialist because of the risk of eliminating a nutritionally important food group (eg, cow's milk, eggs, soy products). Emollients — Emollients are creams and ointments that moisturize the skin and can help relieve symptoms. The best emollients for people with atopic dermatitis are creams (such as Eucerin®, Cetaphil®, and Nutraderm®) and ointments (such as petroleum jelly, Aquaphor®, and Vaseline®). Emollients are most effective when applied immediately after bathing. Lotions should be avoided because they can worsen dry skin. Bathing — Lukewarm baths can hydrate and cool the skin, temporarily relieving the itching of eczema. Hot or long baths (greater than 10 to 15 minutes) and showers should be avoided since they can cause excessive drying. A mild soap or nonsoap cleanser (such as Cetaphil®) should be used sparingly. Application of an emollient immediately after bathing or showering prevents the drying that occurs through evaporation. Some experts recommend showers for their antibacterial effect, though individuals should determine which method is best for their situation. Topical steroids — Topical steroid creams and ointments are often effective for controlling mild to moderate atopic dermatitis. They are usually applied twice daily and help to reduce symptoms and moisturize the skin; non-medicated emollients can be resumed when symptoms resolve. Strong topical steroids may be needed to control severe flares of eczema; however, highly potent steroids should be used for only short periods of time to prevent thinning of the skin. Other topical treatments — Newer topical therapies for eczema include tacrolimus (Protopic®) and pemicrolimus (Elidel®). They are effective for controlling eczema in persons who have not improved with topical steroids, although do not work as quickly as topical steroids. They are useful in sensitive areas such as the face and groin, and can be used in children over age two. Due to safety concerns, it is recommended that these treatments be used only as instructed by a healthcare provider. Oral steroids — Oral steroids occasionally are used to treat a flare of chronic eczema, though should not be used on a regular basis because of side effects. Oral antihistamines — Oral antihistamines help relieve the itching of eczema and the accompanying eye irritation. The over-the-counter antihistamine diphenhydramine (Benadryl®), and other antihistamines, such as hydroxyzine and cyproheptadine, are most effective for eczema, although these drugs can cause drowsiness. The nonsedating antihistamines such as cetirizine (Zyrtec®) and loratadine (Claritin®) also may relieve symptoms, and loratadine is available without a prescription in the United States. Doxepin is an antidepressant that has antihistamine actions and may be recommended if other antihistamines are not helpful. Ultraviolet light therapy (phototherapy) — Ultraviolet light therapy (phototherapy) can effectively control atopic dermatitis. However, this therapy is expensive, may increase a person's risk for skin cancer, and is therefore recommended only for persons with severe eczema who do not respond to other treatments. Immunosuppressive drugs — Immunosuppressive drugs can effectively control severe eczema. These drugs include oral cyclosporine, tacrolimus, methotrexate, mycophenylate mofetil, and azathioprine. Treatment with these drugs can cause serious side effects, including an increased risk for infection, and their use is generally limited to persons who do not improve with other treatments.
SEBORRHEIC DERMATITIS — Seborrheic dermatitis causes overproduction of skin cells and sebum, the skin's natural oil. Seborrheic dermatitis usually occurs in areas of the body that have many oil-producing glands, including the scalp, face, upper chest, and back. It is most common during infancy; this is called cradle cap. Cradle cap usually resolves by 8 to 12 months of age.
Cause — The cause of seborrheic dermatitis is unknown, although it is known that an overgrowth of a normal skin yeast fungus occurs with this condition. It is not clear whether the fungus causes the flaking and redness or the increased flaking allows overgrowth of the fungus.
Symptoms — The symptoms of seborrheic dermatitis include redness, scaling, and itching of the affected skin. The dermatitis most often occurs on the scalp and face, especially on the eyebrows, the bridge and sides of the nose, and in the crease between the nose and lip (show picture 5). In men, seborrheic dermatitis is usually worse on the skin beneath mustaches and beards. Seborrheic dermatitis can also affect the chest, upper back, armpits, and pubic area, and the condition can affect the entire body in infants.
The term seborrhea refers to oiliness of the skin, without redness or scaling. Dandruff causes scalp scaling without redness, although it can commonly progress to seborrheic dermatitis of the scalp.
Diagnosis — There is no specific test for diagnosing seborrheic dermatitis. The diagnosis is usually based upon a person's history and the signs noted on physical examination. In rare cases, a skin biopsy (a collection of a small sample of skin tissue) may be necessary to confirm the diagnosis or rule out other conditions that mimic seborrheic dermatitis.
Treatment — The symptoms of seborrheic dermatitis can be effectively controlled with a combination of self-care measures and drug therapy. Washing and shampooing — Diligent washing and shampooing can control the symptoms of seborrheic dermatitis. Frequent washing counters the build-up of skin scales, and daily shampooing with a medicated shampoo controls scaling and itching on the scalp. For best results, the shampoo should be left in place for a few minutes before rinsing.
The growth of skin cells is slowed by shampoos that contain tar (Z-Tar®, Pentrax®, DHS tar®, Ionil T plus®, and T-Gel extra strength®), selenium sulfide (Selsun® and Exelderm®), and zinc pyrithione (Head and Shoulders®, Zincon®, and DHS zinc®). Shampoos containing antifungal medications (Nizoral®, Stieprox®) are quite effective. All of these shampoos can be used indefinitely. Topical steroids — Low potency topical steroids are usually the drugs selected first for the treatment of seborrheic dermatitis. These drugs are available in creams and lotions for the face and in alcohol-based liquids and aerosol sprays for the scalp. The topical steroids should be applied daily until the dermatitis improves; they can then be gradually discontinued. The lower potency steroid preparations are used, so that even prolonged use results in few, if any side effects. Topical antifungal drugs — The topical antifungal cream ketoconazole (Nizoral®) appears to be as effective as topical steroids for the treatment of seborrheic dermatitis. In cases of severe seborrheic dermatitis, treatment may include both topical steroids and topical antifungal drugs.
CONTACT DERMATITIS — Contact dermatitis refers to dermatitis that is caused by direct contact of the skin with a substance. The substance can be an allergen (a substance that provokes an immune reaction) or an irritant (a substance that directly damages the skin). The dermatitis results from contact with an irritant in about 80 percent of people with contact dermatitis.
Irritant contact dermatitis — Irritant contact dermatitis occurs when the skin comes in direct contact with a substance that physically, mechanically, or chemically irritates the skin.
Cause — The skin becomes inflamed when the normal skin barrier is irritated. The most common cause are products used on a daily basis, including soap, cleansers, and rubbing alcohol. Persons with other skin conditions, dry skin, and light-colored or "fair" skin are at greatest risk, although anyone can develop irritant dermatitis.
Symptoms — Mild irritants cause redness, dryness, and fissures (small cracks), with itching. Strong irritants cause swelling, oozing, tenderness, and blisters (show picture 6).
Irritant contact dermatitis most commonly affects the hands, often beginning in the area between the fingers. It can also affect the face, especially the eyelids.
Diagnosis — The diagnosis of irritant contact dermatitis is usually based upon a person's history and the physical examination. In some cases, a patch test (applying a small amount of the possible irritant to the skin) may be recommended to determine if the dermatitis is caused by an allergy.
Treatment — The treatment of irritant contact dermatitis helps to restore the normal skin barrier and protecting the skin from additional injury by the irritant. Reducing exposure to known irritants is essential. In some cases, simply reducing the use of soap and using emollient creams or ointment alleviates symptoms. Wearing gloves when working with irritants may help as well.
In more severe cases, topical steroids may be used. These are most effective when applied and covered with a barrier, such as plastic wrap, a gauze dressing, cotton gloves, or petroleum jelly. Oral steroids are not used for the long-term treatment of irritant contact dermatitis; however, they may be used briefly to treat severe dermatitis.
Allergic contact dermatitis — Allergic contact dermatitis occurs in some individuals when the skin comes in direct contact with an allergen. This activates the body's immune system, which triggers inflammation. Anyone can experience allergic contact dermatitis. Allergic contact dermatitis can occur when someone is newly exposed to a product, but can also occur after years of use.
Common allergens — Poison ivy, poison oak, and poison sumac are the most common contact allergens. (See "Patient information: Poison ivy"). Other common allergens include nickel (show picture 7) in jewelry, perfumes and cosmetics, components of rubber, nail polish, and chemicals in shoes (both leather and synthetic, show picture 8). Allergic contact dermatitis can also be triggered by certain medications, including topical hydrocortisone, topical antibiotics, benzocaine, and thimerosol.
Symptoms — Symptoms include intense itching and a red rash that develops quickly. The rash is usually limited to areas that were in direct contact with the allergen, but a rash can appear in other areas of the body if the allergen was transferred to those areas on a person's hands (show picture 9). Washing the allergen away with soap and water can usually prevent this spread.
The rash typically appears within 12 to 48 hours of exposure to the allergen, although in some cases it may not appear for up to two weeks. Less commonly, the rash persists for months or years, which makes it difficult to identify what caused the reaction.
Diagnosis — The diagnosis of allergic contact dermatitis is based upon a person's history and the signs noted during a physical examination. An improvement of symptoms after eliminating exposure to the suspected allergen supports the diagnosis. Patch testing (applying a small amount of the possible irritant to the skin) can be helpful in identifying the allergen.
Treatment — Allergic contact dermatitis usually resolves within two to four weeks after a person's exposure to the allergen stops. Several measures can minimize symptoms during this time and can help control symptoms in people who have chronic allergic contact dermatitis.
Whenever possible, identify and stop all exposure to the allergen. Topical steroids can alleviate inflammation. Calamine lotion may relieve mild symptoms.
For more severe symptoms, oral drugs, including steroids (such as prednisone) and antihistamines, may be recommended. Wet-to-dry compresses help dry out oozing skin and cool the skin, relieving severe itching. Wet-to-dry compresses can be easily made and applied at home as follows: Dampen a thin piece of fabric (such as one layer of a cotton or linen sheet) in water or a mixture of water and aluminum acetate (Burow's solution) Apply the dampened fabric to the affected skin Allow the fabric to dry over 15 to 30 minutes Remove the dry fabric gently Repeat the procedure several times
LATEX DERMATITIS — Latex is a fluid produced by rubber trees that is processed into a variety of products, including gloves, balloons, and condoms. In some individuals, exposure to these products and others (such as rubber bands, erasers, feeding nipples, pacifiers) can cause a contact dermatitis that is either an irritant or allergic reaction. Less commonly, a person can develop a potentially life threatening allergic reaction to latex.
Irritant dermatitis — Irritant dermatitis can occur while wearing latex gloves. It usually occurs on the hands of people who wear latex or other rubber gloves; the latex acts as an irritant and the gloves trap moisture against the skin. The skin dries out when the gloves are removed, leading to the dermatitis.
The symptoms of irritant rubber or latex dermatitis include redness and itching on the skin. There may also be dryness and cracking. Symptoms usually occur within 12 to 36 hours of contact with a latex product. Treatment involves avoiding use of any latex-containing products.
Latex allergy — Latex can trigger allergic contact dermatitis. The skin reaction caused by a latex allergy does not differ significantly from that of irritant latex dermatitis.
Some people with latex allergy have severe allergic reactions to latex, including swelling, sneezing, and wheezing. Rarely, anaphylaxis can occur, which causes life-threatening difficulty with breathing. Typically, the most severe allergic reactions occur during procedures when latex comes into contact with mucous membranes (such as in the mouth, vagina, or during surgical procedures). However, some people are so sensitive that severe reactions can occur with even brief contact. (See "Patient information: Anaphylaxis").
Latex allergy is most common among people who have undergone many surgeries and who have other allergic conditions. Latex allergy is also common among health care workers and workers in the latex industry, particularly those who have atopic dermatitis or a history of other types of allergies (such as allergic rhinitis or asthma).
Latex can become aerosolized (often from powder in gloves) and cause nasal symptoms and asthma in sensitized individuals. Some people with latex allergy may also develop reactions to certain foods, including avocado, kiwi, banana, and chestnuts.
Diagnosis — In most cases, the diagnosis of latex allergy is based upon a person's history of exposure. The more serious type of latex allergy causes an immediate onset of hives, nasal symptoms, swelling, or wheezing after latex exposure. Some of these individuals may need to see a dermatologist or allergist for specialized skin patch tests and blood testing to verify the latex allergy.
Treatment — The primary mode of treatment for latex allergy is to avoid all latex-containing products. Non-latex examination gloves are widely available, and use of glove liners may also be an effective approach. Natural membrane (sometimes called sheep skin) condoms may be used in place of latex condoms. Natural membrane condoms are effective for preventing pregnancy, but do not protect against transmission of sexually transmitted diseases such as HIV, gonorrhea, and chlamydia.
Those with serious latex allergy should wear a bracelet, necklace, or similar alert tag at all times. If a reaction occurs and the person is too ill to explain their condition, this will help responders get the proper care for the person as quickly as possible. This measure is especially important in children.
The alert tag should include a list of known allergies, as well as the name and phone number of an emergency contact. One device, Medic Alert®, provides a toll-free number that emergency medical workers can call to find out a person's medical history, list of medications, family emergency contact numbers, and healthcare provider names and numbers.
Persons with a latex allergy should inform their doctors, dentists, and other health care providers about the allergy. These individuals also may be advised to carry an anaphylaxis kit (containing epinephrine that can be injected under the skin) as a precautionary measure. Because latex allergy is common among people with spina bifida, doctors often recommend that people with this condition undergo a screening for latex allergies before any medical procedures are performed. (See "Patient information: Use of an epinephrine autoinjector").
DYSHIDROTIC DERMATITIS — Dyshidrotic dermatitis (also called pompholyx or dyshidrosis) is an intensely itching chronic, recurring dermatitis of unknown cause that typically involves the palms, soles, and fingers. Most people experience acute episodes of intense itching on the palms and/or soles that progress to multiple small vesicles (fluid-filled bumps), which peel off over one to two weeks, leaving cracks in the skin that slowly resolve (show picture 10). Recurrent episodes alternating with symptom-free periods are common.
Medium strength to potent topical steroids can control outbreaks in mild cases. Occasionally, brief courses of oral steroids are necessary to control symptoms. Local treatments with ultraviolet light therapy are helpful in people who have not responded to other measures.
NUMMULAR DERMATITIS — Nummular dermatitis causes intensely itchy patches of skin, with redness, small bumps, skin flaking, slight crusting, and some serous oozing on close inspection. A person may have as few as one lesion or as many as 20 to 50 lesions. Each lesion tends to be circular, measuring 2 to 10 cm in diameter.
Lesions are usually on the trunk and lower extremities, and the head is generally spared. The onset is usually spontaneous, and the cause often cannot be identified; some people may have exposures to drying or irritating substances (eg, excessive water exposure, chlorine, soaps).
A potent topical steroid ointment is the treatment of choice for nummular dermatitis. Systemic steroids in short courses are occasionally required. It may be helpful to avoid irritants, if they can be identified. Skin moisturization is an important part of the management of nummular dermatitis; a rich moisturizing cream should be applied immediately after bathing.
SUMMARY Dermatitis is defined as an inflammation of the skin; there are several different types of dermatitis. Atopic dermatitis (eczema) is a common chronic condition that causes skin to become red, itchy, and dry. People with other allergies are more likely to develop the condition; the diagnosis is often based on this as well as examination of the skin. Treatment includes avoiding things that make symptoms worse (such as dry air and irritating fabrics) and applying creams or ointments to soothe the itchy rash. (See "Atopic dermatitis (eczema)" above). Seborrheic dermatitis causes overproduction of skin cells and oil; it is most common in infants (cradle cap). This type of dermatitis causes redness, itching, and scaling of the skin, and often affects the face and scalp; it is diagnosed based on a person's history and examination of the skin. Symptoms can be controlled by washing the skin and hair carefully and applying creams to relieve itching and redness. (See "Seborrheic dermatitis" above). Irritant contact dermatitis is a reaction caused by contact with a substance that is irritating to the skin, such as a soap or cleanser. This can make the skin red, itchy, and dry. Persons with other skin conditions, dry skin, and light-colored or "fair" skin are at greatest risk, although anyone can develop irritant dermatitis. Diagnosed may be done by testing the skin's reaction to a very small amount of the irritant; avoiding the substance usually relieves symptoms, but medicated creams may be prescribed in severe cases. (See "Irritant contact dermatitis" above). Allergic contact dermatitis occurs when the skin touches a substance that not only irritates, but actually causes an allergic reaction (such as with poison ivy). A rash appears where contact occurred, and usually resolves on its own if the substance is avoided; creams or compresses may be used to relieve itching and inflammation. (See "Allergic contact dermatitis" above). Latex dermatitis is caused by contact with latex (eg, latex gloves). Some people have a serious, life-threatening allergy to latex, and must be very careful to avoid it. (See "Latex dermatitis" above). Dyshidrotic dermatitis is a condition that causes intense itching and bumps, often on the palms of the hands and soles of the feet; steroids that are applied to the skin or taken as a pill are often used to treat this condition. (See "Dyshidrotic dermatitis" above).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html) National Institute on Arthritis and Musculoskeletal and Skin Diseases
(www.niams.nih.gov/hi/index.htm) American Academy of Dermatology
(www.aad.org) American Academy of Allergy, Asthma and Immunology
(www.aaaai.org) EczemaNet
(www.skincarephysicians.com/eczemanet/) National Eczema Association for Science and Education
(www.eczema-assn.org)
UpToDate performs a continuous review of over 375 journals and other resources. Updates are added as important new information is published. The literature review for version 15.2 is current through April 2007; this topic was last changed on September 13, 2006. The next version of UpToDate (15.3) will be released in October 2007.
INTRODUCTION — Dermatitis is defined as an inflammation of the skin. The terms dermatitis include a wide variety of skin disorders, including atopic dermatitis (eczema), seborrheic dermatitis, contact dermatitis, latex dermatitis and allergy, and dyshidrotic dermatitis.
Depending upon the underlying cause, dermatitis can be a short-term or lifelong condition. In most cases, self-care measures and drug therapy can control the symptoms and prevent complications.
ATOPIC DERMATITIS (ECZEMA) — About 8 to 25 percent of people worldwide have atopic dermatitis (eczema). It often occurs in people who have other allergic disorders, such as asthma and allergic rhinitis (nasal inflammation caused by allergies, also known as hay fever). Family members are often affected.
Cause — The cause of eczema is unknown, but hereditary factors appear to play a strong role. The skin inflammation of atopic dermatitis results from an abnormal immune reaction that is triggered or worsened by exposure to allergens (substances that provoke an allergic reaction). About 85 percent of people with eczema have antibodies (proteins formed by the immune system) to foods or airborne allergens, such as dust mites and animal dander.
In children, eczema is often linked to food allergies. Common food allergens include milk, egg whites, wheat, corn, soybeans, and peanuts.
Symptoms — Most people with eczema develop their first symptoms before age five. Intense itching of the skin, redness, small bumps, and skin flaking are common (show picture 1). Scratching can cause additional skin inflammation, which can further worsen the itching. The itchiness may be more noticeable at nighttime. The skin is often dry, increasing the risk of skin injury with scratching. The skin lesions are therefore at risk for developing infection. Features of infection include pus-containing bumps in inflamed areas; prompt evaluation by a healthcare provider is recommended if this occurs
Features of eczema vary from one individual to another, and can change over time. Other features can include: Lichenification - Thick, leathery skin (usually as a result of frequent scratching) Icthyosis - Dry scales (show picture 2) Keratosis pilaris - Plugged hair follicles resulting in the development of small bumps, usually on the face, upper arms, and thighs Cheilitis - Inflammation around the lips Hyperlinear palms - Increased skin creasing on the palms Dennie-Morgan line - An extra fold of skin under the eye Periorbital darkening - Darkening of the skin around the eyes
Although eczema is usually confined to specific areas of the body, it may be widespread in severe cases: In young children, it typically occurs on the face, scalp, extremities, or trunk, and rarely occurs in the diaper area (show picture 3). In older children and adolescents, it is often accompanied by thickening and darkening of the skin, as well as scarring from repeated scratching. In adults, it commonly affects the back of the neck, the elbow creases, and the backs of the knees . Other affected areas may include the face, wrists, and forearms.
Diagnosis — There is no specific test used to diagnose eczema; diagnosis is usually based upon a person's history and the signs noted during a physical examination.
Factors that strongly suggest eczema include long-standing and recurrent itching, a personal or family history of allergic conditions, and an early age at onset. Other factors include a worsening of symptoms after exposure to certain triggers, and any of the skin findings noted above.
Allergy testing is usually reserved for people who have eczema in addition to features of asthma or allergic rhinitis. Allergy testing may also be recommended for children with suspected food allergies.
Treatment — Eczema is a chronic condition; it typically improves and then flares (worsens) periodically. Some people can have no symptoms for several years, only to have the disease return at a later time. It is not curable, although symptoms can be controlled with a variety of self-care measures and drug therapy. Eliminate exacerbating factors — Eliminating factors that worsen eczema can effectively control the symptoms. These factors may include frequent bathing and low-humidity environments (which can further dry the skin), emotional stress, rapid temperature changes, and exposure to certain chemicals and cleaning solutions. Common irritants include soaps and detergents, perfumes and cosmetics, wool or synthetic fibers, dust, sand, and cigarette smoke.
The following tips are recommended: Dust frequently and avoid placing upholstered furniture in the bedroom. Reducing exposure to house dust mites may reduce the severity of atopic dermatitis. Food allergies are relatively uncommon in adults, but may be a problem for a small percentage of infants and young children. However, changes to an infant or child's diet should be made only after consulting an allergy specialist because of the risk of eliminating a nutritionally important food group (eg, cow's milk, eggs, soy products). Emollients — Emollients are creams and ointments that moisturize the skin and can help relieve symptoms. The best emollients for people with atopic dermatitis are creams (such as Eucerin®, Cetaphil®, and Nutraderm®) and ointments (such as petroleum jelly, Aquaphor®, and Vaseline®). Emollients are most effective when applied immediately after bathing. Lotions should be avoided because they can worsen dry skin. Bathing — Lukewarm baths can hydrate and cool the skin, temporarily relieving the itching of eczema. Hot or long baths (greater than 10 to 15 minutes) and showers should be avoided since they can cause excessive drying. A mild soap or nonsoap cleanser (such as Cetaphil®) should be used sparingly. Application of an emollient immediately after bathing or showering prevents the drying that occurs through evaporation. Some experts recommend showers for their antibacterial effect, though individuals should determine which method is best for their situation. Topical steroids — Topical steroid creams and ointments are often effective for controlling mild to moderate atopic dermatitis. They are usually applied twice daily and help to reduce symptoms and moisturize the skin; non-medicated emollients can be resumed when symptoms resolve. Strong topical steroids may be needed to control severe flares of eczema; however, highly potent steroids should be used for only short periods of time to prevent thinning of the skin. Other topical treatments — Newer topical therapies for eczema include tacrolimus (Protopic®) and pemicrolimus (Elidel®). They are effective for controlling eczema in persons who have not improved with topical steroids, although do not work as quickly as topical steroids. They are useful in sensitive areas such as the face and groin, and can be used in children over age two. Due to safety concerns, it is recommended that these treatments be used only as instructed by a healthcare provider. Oral steroids — Oral steroids occasionally are used to treat a flare of chronic eczema, though should not be used on a regular basis because of side effects. Oral antihistamines — Oral antihistamines help relieve the itching of eczema and the accompanying eye irritation. The over-the-counter antihistamine diphenhydramine (Benadryl®), and other antihistamines, such as hydroxyzine and cyproheptadine, are most effective for eczema, although these drugs can cause drowsiness. The nonsedating antihistamines such as cetirizine (Zyrtec®) and loratadine (Claritin®) also may relieve symptoms, and loratadine is available without a prescription in the United States. Doxepin is an antidepressant that has antihistamine actions and may be recommended if other antihistamines are not helpful. Ultraviolet light therapy (phototherapy) — Ultraviolet light therapy (phototherapy) can effectively control atopic dermatitis. However, this therapy is expensive, may increase a person's risk for skin cancer, and is therefore recommended only for persons with severe eczema who do not respond to other treatments. Immunosuppressive drugs — Immunosuppressive drugs can effectively control severe eczema. These drugs include oral cyclosporine, tacrolimus, methotrexate, mycophenylate mofetil, and azathioprine. Treatment with these drugs can cause serious side effects, including an increased risk for infection, and their use is generally limited to persons who do not improve with other treatments.
SEBORRHEIC DERMATITIS — Seborrheic dermatitis causes overproduction of skin cells and sebum, the skin's natural oil. Seborrheic dermatitis usually occurs in areas of the body that have many oil-producing glands, including the scalp, face, upper chest, and back. It is most common during infancy; this is called cradle cap. Cradle cap usually resolves by 8 to 12 months of age.
Cause — The cause of seborrheic dermatitis is unknown, although it is known that an overgrowth of a normal skin yeast fungus occurs with this condition. It is not clear whether the fungus causes the flaking and redness or the increased flaking allows overgrowth of the fungus.
Symptoms — The symptoms of seborrheic dermatitis include redness, scaling, and itching of the affected skin. The dermatitis most often occurs on the scalp and face, especially on the eyebrows, the bridge and sides of the nose, and in the crease between the nose and lip (show picture 5). In men, seborrheic dermatitis is usually worse on the skin beneath mustaches and beards. Seborrheic dermatitis can also affect the chest, upper back, armpits, and pubic area, and the condition can affect the entire body in infants.
The term seborrhea refers to oiliness of the skin, without redness or scaling. Dandruff causes scalp scaling without redness, although it can commonly progress to seborrheic dermatitis of the scalp.
Diagnosis — There is no specific test for diagnosing seborrheic dermatitis. The diagnosis is usually based upon a person's history and the signs noted on physical examination. In rare cases, a skin biopsy (a collection of a small sample of skin tissue) may be necessary to confirm the diagnosis or rule out other conditions that mimic seborrheic dermatitis.
Treatment — The symptoms of seborrheic dermatitis can be effectively controlled with a combination of self-care measures and drug therapy. Washing and shampooing — Diligent washing and shampooing can control the symptoms of seborrheic dermatitis. Frequent washing counters the build-up of skin scales, and daily shampooing with a medicated shampoo controls scaling and itching on the scalp. For best results, the shampoo should be left in place for a few minutes before rinsing.
The growth of skin cells is slowed by shampoos that contain tar (Z-Tar®, Pentrax®, DHS tar®, Ionil T plus®, and T-Gel extra strength®), selenium sulfide (Selsun® and Exelderm®), and zinc pyrithione (Head and Shoulders®, Zincon®, and DHS zinc®). Shampoos containing antifungal medications (Nizoral®, Stieprox®) are quite effective. All of these shampoos can be used indefinitely. Topical steroids — Low potency topical steroids are usually the drugs selected first for the treatment of seborrheic dermatitis. These drugs are available in creams and lotions for the face and in alcohol-based liquids and aerosol sprays for the scalp. The topical steroids should be applied daily until the dermatitis improves; they can then be gradually discontinued. The lower potency steroid preparations are used, so that even prolonged use results in few, if any side effects. Topical antifungal drugs — The topical antifungal cream ketoconazole (Nizoral®) appears to be as effective as topical steroids for the treatment of seborrheic dermatitis. In cases of severe seborrheic dermatitis, treatment may include both topical steroids and topical antifungal drugs.
CONTACT DERMATITIS — Contact dermatitis refers to dermatitis that is caused by direct contact of the skin with a substance. The substance can be an allergen (a substance that provokes an immune reaction) or an irritant (a substance that directly damages the skin). The dermatitis results from contact with an irritant in about 80 percent of people with contact dermatitis.
Irritant contact dermatitis — Irritant contact dermatitis occurs when the skin comes in direct contact with a substance that physically, mechanically, or chemically irritates the skin.
Cause — The skin becomes inflamed when the normal skin barrier is irritated. The most common cause are products used on a daily basis, including soap, cleansers, and rubbing alcohol. Persons with other skin conditions, dry skin, and light-colored or "fair" skin are at greatest risk, although anyone can develop irritant dermatitis.
Symptoms — Mild irritants cause redness, dryness, and fissures (small cracks), with itching. Strong irritants cause swelling, oozing, tenderness, and blisters (show picture 6).
Irritant contact dermatitis most commonly affects the hands, often beginning in the area between the fingers. It can also affect the face, especially the eyelids.
Diagnosis — The diagnosis of irritant contact dermatitis is usually based upon a person's history and the physical examination. In some cases, a patch test (applying a small amount of the possible irritant to the skin) may be recommended to determine if the dermatitis is caused by an allergy.
Treatment — The treatment of irritant contact dermatitis helps to restore the normal skin barrier and protecting the skin from additional injury by the irritant. Reducing exposure to known irritants is essential. In some cases, simply reducing the use of soap and using emollient creams or ointment alleviates symptoms. Wearing gloves when working with irritants may help as well.
In more severe cases, topical steroids may be used. These are most effective when applied and covered with a barrier, such as plastic wrap, a gauze dressing, cotton gloves, or petroleum jelly. Oral steroids are not used for the long-term treatment of irritant contact dermatitis; however, they may be used briefly to treat severe dermatitis.
Allergic contact dermatitis — Allergic contact dermatitis occurs in some individuals when the skin comes in direct contact with an allergen. This activates the body's immune system, which triggers inflammation. Anyone can experience allergic contact dermatitis. Allergic contact dermatitis can occur when someone is newly exposed to a product, but can also occur after years of use.
Common allergens — Poison ivy, poison oak, and poison sumac are the most common contact allergens. (See "Patient information: Poison ivy"). Other common allergens include nickel (show picture 7) in jewelry, perfumes and cosmetics, components of rubber, nail polish, and chemicals in shoes (both leather and synthetic, show picture 8). Allergic contact dermatitis can also be triggered by certain medications, including topical hydrocortisone, topical antibiotics, benzocaine, and thimerosol.
Symptoms — Symptoms include intense itching and a red rash that develops quickly. The rash is usually limited to areas that were in direct contact with the allergen, but a rash can appear in other areas of the body if the allergen was transferred to those areas on a person's hands (show picture 9). Washing the allergen away with soap and water can usually prevent this spread.
The rash typically appears within 12 to 48 hours of exposure to the allergen, although in some cases it may not appear for up to two weeks. Less commonly, the rash persists for months or years, which makes it difficult to identify what caused the reaction.
Diagnosis — The diagnosis of allergic contact dermatitis is based upon a person's history and the signs noted during a physical examination. An improvement of symptoms after eliminating exposure to the suspected allergen supports the diagnosis. Patch testing (applying a small amount of the possible irritant to the skin) can be helpful in identifying the allergen.
Treatment — Allergic contact dermatitis usually resolves within two to four weeks after a person's exposure to the allergen stops. Several measures can minimize symptoms during this time and can help control symptoms in people who have chronic allergic contact dermatitis.
Whenever possible, identify and stop all exposure to the allergen. Topical steroids can alleviate inflammation. Calamine lotion may relieve mild symptoms.
For more severe symptoms, oral drugs, including steroids (such as prednisone) and antihistamines, may be recommended. Wet-to-dry compresses help dry out oozing skin and cool the skin, relieving severe itching. Wet-to-dry compresses can be easily made and applied at home as follows: Dampen a thin piece of fabric (such as one layer of a cotton or linen sheet) in water or a mixture of water and aluminum acetate (Burow's solution) Apply the dampened fabric to the affected skin Allow the fabric to dry over 15 to 30 minutes Remove the dry fabric gently Repeat the procedure several times
LATEX DERMATITIS — Latex is a fluid produced by rubber trees that is processed into a variety of products, including gloves, balloons, and condoms. In some individuals, exposure to these products and others (such as rubber bands, erasers, feeding nipples, pacifiers) can cause a contact dermatitis that is either an irritant or allergic reaction. Less commonly, a person can develop a potentially life threatening allergic reaction to latex.
Irritant dermatitis — Irritant dermatitis can occur while wearing latex gloves. It usually occurs on the hands of people who wear latex or other rubber gloves; the latex acts as an irritant and the gloves trap moisture against the skin. The skin dries out when the gloves are removed, leading to the dermatitis.
The symptoms of irritant rubber or latex dermatitis include redness and itching on the skin. There may also be dryness and cracking. Symptoms usually occur within 12 to 36 hours of contact with a latex product. Treatment involves avoiding use of any latex-containing products.
Latex allergy — Latex can trigger allergic contact dermatitis. The skin reaction caused by a latex allergy does not differ significantly from that of irritant latex dermatitis.
Some people with latex allergy have severe allergic reactions to latex, including swelling, sneezing, and wheezing. Rarely, anaphylaxis can occur, which causes life-threatening difficulty with breathing. Typically, the most severe allergic reactions occur during procedures when latex comes into contact with mucous membranes (such as in the mouth, vagina, or during surgical procedures). However, some people are so sensitive that severe reactions can occur with even brief contact. (See "Patient information: Anaphylaxis").
Latex allergy is most common among people who have undergone many surgeries and who have other allergic conditions. Latex allergy is also common among health care workers and workers in the latex industry, particularly those who have atopic dermatitis or a history of other types of allergies (such as allergic rhinitis or asthma).
Latex can become aerosolized (often from powder in gloves) and cause nasal symptoms and asthma in sensitized individuals. Some people with latex allergy may also develop reactions to certain foods, including avocado, kiwi, banana, and chestnuts.
Diagnosis — In most cases, the diagnosis of latex allergy is based upon a person's history of exposure. The more serious type of latex allergy causes an immediate onset of hives, nasal symptoms, swelling, or wheezing after latex exposure. Some of these individuals may need to see a dermatologist or allergist for specialized skin patch tests and blood testing to verify the latex allergy.
Treatment — The primary mode of treatment for latex allergy is to avoid all latex-containing products. Non-latex examination gloves are widely available, and use of glove liners may also be an effective approach. Natural membrane (sometimes called sheep skin) condoms may be used in place of latex condoms. Natural membrane condoms are effective for preventing pregnancy, but do not protect against transmission of sexually transmitted diseases such as HIV, gonorrhea, and chlamydia.
Those with serious latex allergy should wear a bracelet, necklace, or similar alert tag at all times. If a reaction occurs and the person is too ill to explain their condition, this will help responders get the proper care for the person as quickly as possible. This measure is especially important in children.
The alert tag should include a list of known allergies, as well as the name and phone number of an emergency contact. One device, Medic Alert®, provides a toll-free number that emergency medical workers can call to find out a person's medical history, list of medications, family emergency contact numbers, and healthcare provider names and numbers.
Persons with a latex allergy should inform their doctors, dentists, and other health care providers about the allergy. These individuals also may be advised to carry an anaphylaxis kit (containing epinephrine that can be injected under the skin) as a precautionary measure. Because latex allergy is common among people with spina bifida, doctors often recommend that people with this condition undergo a screening for latex allergies before any medical procedures are performed. (See "Patient information: Use of an epinephrine autoinjector").
DYSHIDROTIC DERMATITIS — Dyshidrotic dermatitis (also called pompholyx or dyshidrosis) is an intensely itching chronic, recurring dermatitis of unknown cause that typically involves the palms, soles, and fingers. Most people experience acute episodes of intense itching on the palms and/or soles that progress to multiple small vesicles (fluid-filled bumps), which peel off over one to two weeks, leaving cracks in the skin that slowly resolve (show picture 10). Recurrent episodes alternating with symptom-free periods are common.
Medium strength to potent topical steroids can control outbreaks in mild cases. Occasionally, brief courses of oral steroids are necessary to control symptoms. Local treatments with ultraviolet light therapy are helpful in people who have not responded to other measures.
NUMMULAR DERMATITIS — Nummular dermatitis causes intensely itchy patches of skin, with redness, small bumps, skin flaking, slight crusting, and some serous oozing on close inspection. A person may have as few as one lesion or as many as 20 to 50 lesions. Each lesion tends to be circular, measuring 2 to 10 cm in diameter.
Lesions are usually on the trunk and lower extremities, and the head is generally spared. The onset is usually spontaneous, and the cause often cannot be identified; some people may have exposures to drying or irritating substances (eg, excessive water exposure, chlorine, soaps).
A potent topical steroid ointment is the treatment of choice for nummular dermatitis. Systemic steroids in short courses are occasionally required. It may be helpful to avoid irritants, if they can be identified. Skin moisturization is an important part of the management of nummular dermatitis; a rich moisturizing cream should be applied immediately after bathing.
SUMMARY Dermatitis is defined as an inflammation of the skin; there are several different types of dermatitis. Atopic dermatitis (eczema) is a common chronic condition that causes skin to become red, itchy, and dry. People with other allergies are more likely to develop the condition; the diagnosis is often based on this as well as examination of the skin. Treatment includes avoiding things that make symptoms worse (such as dry air and irritating fabrics) and applying creams or ointments to soothe the itchy rash. (See "Atopic dermatitis (eczema)" above). Seborrheic dermatitis causes overproduction of skin cells and oil; it is most common in infants (cradle cap). This type of dermatitis causes redness, itching, and scaling of the skin, and often affects the face and scalp; it is diagnosed based on a person's history and examination of the skin. Symptoms can be controlled by washing the skin and hair carefully and applying creams to relieve itching and redness. (See "Seborrheic dermatitis" above). Irritant contact dermatitis is a reaction caused by contact with a substance that is irritating to the skin, such as a soap or cleanser. This can make the skin red, itchy, and dry. Persons with other skin conditions, dry skin, and light-colored or "fair" skin are at greatest risk, although anyone can develop irritant dermatitis. Diagnosed may be done by testing the skin's reaction to a very small amount of the irritant; avoiding the substance usually relieves symptoms, but medicated creams may be prescribed in severe cases. (See "Irritant contact dermatitis" above). Allergic contact dermatitis occurs when the skin touches a substance that not only irritates, but actually causes an allergic reaction (such as with poison ivy). A rash appears where contact occurred, and usually resolves on its own if the substance is avoided; creams or compresses may be used to relieve itching and inflammation. (See "Allergic contact dermatitis" above). Latex dermatitis is caused by contact with latex (eg, latex gloves). Some people have a serious, life-threatening allergy to latex, and must be very careful to avoid it. (See "Latex dermatitis" above). Dyshidrotic dermatitis is a condition that causes intense itching and bumps, often on the palms of the hands and soles of the feet; steroids that are applied to the skin or taken as a pill are often used to treat this condition. (See "Dyshidrotic dermatitis" above).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html) National Institute on Arthritis and Musculoskeletal and Skin Diseases
(www.niams.nih.gov/hi/index.htm) American Academy of Dermatology
(www.aad.org) American Academy of Allergy, Asthma and Immunology
(www.aaaai.org) EczemaNet
(www.skincarephysicians.com/eczemanet/) National Eczema Association for Science and Education
(www.eczema-assn.org)
Dermatitis
James C Shaw, MD
UpToDate performs a continuous review of over 375 journals and other resources. Updates are added as important new information is published. The literature review for version 15.2 is current through April 2007; this topic was last changed on September 13, 2006. The next version of UpToDate (15.3) will be released in October 2007.
INTRODUCTION — Dermatitis is defined as an inflammation of the skin. The terms dermatitis include a wide variety of skin disorders, including atopic dermatitis (eczema), seborrheic dermatitis, contact dermatitis, latex dermatitis and allergy, and dyshidrotic dermatitis.
Depending upon the underlying cause, dermatitis can be a short-term or lifelong condition. In most cases, self-care measures and drug therapy can control the symptoms and prevent complications.
ATOPIC DERMATITIS (ECZEMA) — About 8 to 25 percent of people worldwide have atopic dermatitis (eczema). It often occurs in people who have other allergic disorders, such as asthma and allergic rhinitis (nasal inflammation caused by allergies, also known as hay fever). Family members are often affected.
Cause — The cause of eczema is unknown, but hereditary factors appear to play a strong role. The skin inflammation of atopic dermatitis results from an abnormal immune reaction that is triggered or worsened by exposure to allergens (substances that provoke an allergic reaction). About 85 percent of people with eczema have antibodies (proteins formed by the immune system) to foods or airborne allergens, such as dust mites and animal dander.
In children, eczema is often linked to food allergies. Common food allergens include milk, egg whites, wheat, corn, soybeans, and peanuts.
Symptoms — Most people with eczema develop their first symptoms before age five. Intense itching of the skin, redness, small bumps, and skin flaking are common (show picture 1). Scratching can cause additional skin inflammation, which can further worsen the itching. The itchiness may be more noticeable at nighttime. The skin is often dry, increasing the risk of skin injury with scratching. The skin lesions are therefore at risk for developing infection. Features of infection include pus-containing bumps in inflamed areas; prompt evaluation by a healthcare provider is recommended if this occurs
Features of eczema vary from one individual to another, and can change over time. Other features can include: Lichenification - Thick, leathery skin (usually as a result of frequent scratching) Icthyosis - Dry scales (show picture 2) Keratosis pilaris - Plugged hair follicles resulting in the development of small bumps, usually on the face, upper arms, and thighs Cheilitis - Inflammation around the lips Hyperlinear palms - Increased skin creasing on the palms Dennie-Morgan line - An extra fold of skin under the eye Periorbital darkening - Darkening of the skin around the eyes
Although eczema is usually confined to specific areas of the body, it may be widespread in severe cases: In young children, it typically occurs on the face, scalp, extremities, or trunk, and rarely occurs in the diaper area (show picture 3). In older children and adolescents, it is often accompanied by thickening and darkening of the skin, as well as scarring from repeated scratching. In adults, it commonly affects the back of the neck, the elbow creases, and the backs of the knees . Other affected areas may include the face, wrists, and forearms.
Diagnosis — There is no specific test used to diagnose eczema; diagnosis is usually based upon a person's history and the signs noted during a physical examination.
Factors that strongly suggest eczema include long-standing and recurrent itching, a personal or family history of allergic conditions, and an early age at onset. Other factors include a worsening of symptoms after exposure to certain triggers, and any of the skin findings noted above.
Allergy testing is usually reserved for people who have eczema in addition to features of asthma or allergic rhinitis. Allergy testing may also be recommended for children with suspected food allergies.
Treatment — Eczema is a chronic condition; it typically improves and then flares (worsens) periodically. Some people can have no symptoms for several years, only to have the disease return at a later time. It is not curable, although symptoms can be controlled with a variety of self-care measures and drug therapy. Eliminate exacerbating factors — Eliminating factors that worsen eczema can effectively control the symptoms. These factors may include frequent bathing and low-humidity environments (which can further dry the skin), emotional stress, rapid temperature changes, and exposure to certain chemicals and cleaning solutions. Common irritants include soaps and detergents, perfumes and cosmetics, wool or synthetic fibers, dust, sand, and cigarette smoke.
The following tips are recommended: Dust frequently and avoid placing upholstered furniture in the bedroom. Reducing exposure to house dust mites may reduce the severity of atopic dermatitis. Food allergies are relatively uncommon in adults, but may be a problem for a small percentage of infants and young children. However, changes to an infant or child's diet should be made only after consulting an allergy specialist because of the risk of eliminating a nutritionally important food group (eg, cow's milk, eggs, soy products). Emollients — Emollients are creams and ointments that moisturize the skin and can help relieve symptoms. The best emollients for people with atopic dermatitis are creams (such as Eucerin®, Cetaphil®, and Nutraderm®) and ointments (such as petroleum jelly, Aquaphor®, and Vaseline®). Emollients are most effective when applied immediately after bathing. Lotions should be avoided because they can worsen dry skin. Bathing — Lukewarm baths can hydrate and cool the skin, temporarily relieving the itching of eczema. Hot or long baths (greater than 10 to 15 minutes) and showers should be avoided since they can cause excessive drying. A mild soap or nonsoap cleanser (such as Cetaphil®) should be used sparingly. Application of an emollient immediately after bathing or showering prevents the drying that occurs through evaporation. Some experts recommend showers for their antibacterial effect, though individuals should determine which method is best for their situation. Topical steroids — Topical steroid creams and ointments are often effective for controlling mild to moderate atopic dermatitis. They are usually applied twice daily and help to reduce symptoms and moisturize the skin; non-medicated emollients can be resumed when symptoms resolve. Strong topical steroids may be needed to control severe flares of eczema; however, highly potent steroids should be used for only short periods of time to prevent thinning of the skin. Other topical treatments — Newer topical therapies for eczema include tacrolimus (Protopic®) and pemicrolimus (Elidel®). They are effective for controlling eczema in persons who have not improved with topical steroids, although do not work as quickly as topical steroids. They are useful in sensitive areas such as the face and groin, and can be used in children over age two. Due to safety concerns, it is recommended that these treatments be used only as instructed by a healthcare provider. Oral steroids — Oral steroids occasionally are used to treat a flare of chronic eczema, though should not be used on a regular basis because of side effects. Oral antihistamines — Oral antihistamines help relieve the itching of eczema and the accompanying eye irritation. The over-the-counter antihistamine diphenhydramine (Benadryl®), and other antihistamines, such as hydroxyzine and cyproheptadine, are most effective for eczema, although these drugs can cause drowsiness. The nonsedating antihistamines such as cetirizine (Zyrtec®) and loratadine (Claritin®) also may relieve symptoms, and loratadine is available without a prescription in the United States. Doxepin is an antidepressant that has antihistamine actions and may be recommended if other antihistamines are not helpful. Ultraviolet light therapy (phototherapy) — Ultraviolet light therapy (phototherapy) can effectively control atopic dermatitis. However, this therapy is expensive, may increase a person's risk for skin cancer, and is therefore recommended only for persons with severe eczema who do not respond to other treatments. Immunosuppressive drugs — Immunosuppressive drugs can effectively control severe eczema. These drugs include oral cyclosporine, tacrolimus, methotrexate, mycophenylate mofetil, and azathioprine. Treatment with these drugs can cause serious side effects, including an increased risk for infection, and their use is generally limited to persons who do not improve with other treatments.
SEBORRHEIC DERMATITIS — Seborrheic dermatitis causes overproduction of skin cells and sebum, the skin's natural oil. Seborrheic dermatitis usually occurs in areas of the body that have many oil-producing glands, including the scalp, face, upper chest, and back. It is most common during infancy; this is called cradle cap. Cradle cap usually resolves by 8 to 12 months of age.
Cause — The cause of seborrheic dermatitis is unknown, although it is known that an overgrowth of a normal skin yeast fungus occurs with this condition. It is not clear whether the fungus causes the flaking and redness or the increased flaking allows overgrowth of the fungus.
Symptoms — The symptoms of seborrheic dermatitis include redness, scaling, and itching of the affected skin. The dermatitis most often occurs on the scalp and face, especially on the eyebrows, the bridge and sides of the nose, and in the crease between the nose and lip (show picture 5). In men, seborrheic dermatitis is usually worse on the skin beneath mustaches and beards. Seborrheic dermatitis can also affect the chest, upper back, armpits, and pubic area, and the condition can affect the entire body in infants.
The term seborrhea refers to oiliness of the skin, without redness or scaling. Dandruff causes scalp scaling without redness, although it can commonly progress to seborrheic dermatitis of the scalp.
Diagnosis — There is no specific test for diagnosing seborrheic dermatitis. The diagnosis is usually based upon a person's history and the signs noted on physical examination. In rare cases, a skin biopsy (a collection of a small sample of skin tissue) may be necessary to confirm the diagnosis or rule out other conditions that mimic seborrheic dermatitis.
Treatment — The symptoms of seborrheic dermatitis can be effectively controlled with a combination of self-care measures and drug therapy. Washing and shampooing — Diligent washing and shampooing can control the symptoms of seborrheic dermatitis. Frequent washing counters the build-up of skin scales, and daily shampooing with a medicated shampoo controls scaling and itching on the scalp. For best results, the shampoo should be left in place for a few minutes before rinsing.
The growth of skin cells is slowed by shampoos that contain tar (Z-Tar®, Pentrax®, DHS tar®, Ionil T plus®, and T-Gel extra strength®), selenium sulfide (Selsun® and Exelderm®), and zinc pyrithione (Head and Shoulders®, Zincon®, and DHS zinc®). Shampoos containing antifungal medications (Nizoral®, Stieprox®) are quite effective. All of these shampoos can be used indefinitely. Topical steroids — Low potency topical steroids are usually the drugs selected first for the treatment of seborrheic dermatitis. These drugs are available in creams and lotions for the face and in alcohol-based liquids and aerosol sprays for the scalp. The topical steroids should be applied daily until the dermatitis improves; they can then be gradually discontinued. The lower potency steroid preparations are used, so that even prolonged use results in few, if any side effects. Topical antifungal drugs — The topical antifungal cream ketoconazole (Nizoral®) appears to be as effective as topical steroids for the treatment of seborrheic dermatitis. In cases of severe seborrheic dermatitis, treatment may include both topical steroids and topical antifungal drugs.
CONTACT DERMATITIS — Contact dermatitis refers to dermatitis that is caused by direct contact of the skin with a substance. The substance can be an allergen (a substance that provokes an immune reaction) or an irritant (a substance that directly damages the skin). The dermatitis results from contact with an irritant in about 80 percent of people with contact dermatitis.
Irritant contact dermatitis — Irritant contact dermatitis occurs when the skin comes in direct contact with a substance that physically, mechanically, or chemically irritates the skin.
Cause — The skin becomes inflamed when the normal skin barrier is irritated. The most common cause are products used on a daily basis, including soap, cleansers, and rubbing alcohol. Persons with other skin conditions, dry skin, and light-colored or "fair" skin are at greatest risk, although anyone can develop irritant dermatitis.
Symptoms — Mild irritants cause redness, dryness, and fissures (small cracks), with itching. Strong irritants cause swelling, oozing, tenderness, and blisters (show picture 6).
Irritant contact dermatitis most commonly affects the hands, often beginning in the area between the fingers. It can also affect the face, especially the eyelids.
Diagnosis — The diagnosis of irritant contact dermatitis is usually based upon a person's history and the physical examination. In some cases, a patch test (applying a small amount of the possible irritant to the skin) may be recommended to determine if the dermatitis is caused by an allergy.
Treatment — The treatment of irritant contact dermatitis helps to restore the normal skin barrier and protecting the skin from additional injury by the irritant. Reducing exposure to known irritants is essential. In some cases, simply reducing the use of soap and using emollient creams or ointment alleviates symptoms. Wearing gloves when working with irritants may help as well.
In more severe cases, topical steroids may be used. These are most effective when applied and covered with a barrier, such as plastic wrap, a gauze dressing, cotton gloves, or petroleum jelly. Oral steroids are not used for the long-term treatment of irritant contact dermatitis; however, they may be used briefly to treat severe dermatitis.
Allergic contact dermatitis — Allergic contact dermatitis occurs in some individuals when the skin comes in direct contact with an allergen. This activates the body's immune system, which triggers inflammation. Anyone can experience allergic contact dermatitis. Allergic contact dermatitis can occur when someone is newly exposed to a product, but can also occur after years of use.
Common allergens — Poison ivy, poison oak, and poison sumac are the most common contact allergens. (See "Patient information: Poison ivy"). Other common allergens include nickel (show picture 7) in jewelry, perfumes and cosmetics, components of rubber, nail polish, and chemicals in shoes (both leather and synthetic, show picture 8). Allergic contact dermatitis can also be triggered by certain medications, including topical hydrocortisone, topical antibiotics, benzocaine, and thimerosol.
Symptoms — Symptoms include intense itching and a red rash that develops quickly. The rash is usually limited to areas that were in direct contact with the allergen, but a rash can appear in other areas of the body if the allergen was transferred to those areas on a person's hands (show picture 9). Washing the allergen away with soap and water can usually prevent this spread.
The rash typically appears within 12 to 48 hours of exposure to the allergen, although in some cases it may not appear for up to two weeks. Less commonly, the rash persists for months or years, which makes it difficult to identify what caused the reaction.
Diagnosis — The diagnosis of allergic contact dermatitis is based upon a person's history and the signs noted during a physical examination. An improvement of symptoms after eliminating exposure to the suspected allergen supports the diagnosis. Patch testing (applying a small amount of the possible irritant to the skin) can be helpful in identifying the allergen.
Treatment — Allergic contact dermatitis usually resolves within two to four weeks after a person's exposure to the allergen stops. Several measures can minimize symptoms during this time and can help control symptoms in people who have chronic allergic contact dermatitis.
Whenever possible, identify and stop all exposure to the allergen. Topical steroids can alleviate inflammation. Calamine lotion may relieve mild symptoms.
For more severe symptoms, oral drugs, including steroids (such as prednisone) and antihistamines, may be recommended. Wet-to-dry compresses help dry out oozing skin and cool the skin, relieving severe itching. Wet-to-dry compresses can be easily made and applied at home as follows: Dampen a thin piece of fabric (such as one layer of a cotton or linen sheet) in water or a mixture of water and aluminum acetate (Burow's solution) Apply the dampened fabric to the affected skin Allow the fabric to dry over 15 to 30 minutes Remove the dry fabric gently Repeat the procedure several times
LATEX DERMATITIS — Latex is a fluid produced by rubber trees that is processed into a variety of products, including gloves, balloons, and condoms. In some individuals, exposure to these products and others (such as rubber bands, erasers, feeding nipples, pacifiers) can cause a contact dermatitis that is either an irritant or allergic reaction. Less commonly, a person can develop a potentially life threatening allergic reaction to latex.
Irritant dermatitis — Irritant dermatitis can occur while wearing latex gloves. It usually occurs on the hands of people who wear latex or other rubber gloves; the latex acts as an irritant and the gloves trap moisture against the skin. The skin dries out when the gloves are removed, leading to the dermatitis.
The symptoms of irritant rubber or latex dermatitis include redness and itching on the skin. There may also be dryness and cracking. Symptoms usually occur within 12 to 36 hours of contact with a latex product. Treatment involves avoiding use of any latex-containing products.
Latex allergy — Latex can trigger allergic contact dermatitis. The skin reaction caused by a latex allergy does not differ significantly from that of irritant latex dermatitis.
Some people with latex allergy have severe allergic reactions to latex, including swelling, sneezing, and wheezing. Rarely, anaphylaxis can occur, which causes life-threatening difficulty with breathing. Typically, the most severe allergic reactions occur during procedures when latex comes into contact with mucous membranes (such as in the mouth, vagina, or during surgical procedures). However, some people are so sensitive that severe reactions can occur with even brief contact. (See "Patient information: Anaphylaxis").
Latex allergy is most common among people who have undergone many surgeries and who have other allergic conditions. Latex allergy is also common among health care workers and workers in the latex industry, particularly those who have atopic dermatitis or a history of other types of allergies (such as allergic rhinitis or asthma).
Latex can become aerosolized (often from powder in gloves) and cause nasal symptoms and asthma in sensitized individuals. Some people with latex allergy may also develop reactions to certain foods, including avocado, kiwi, banana, and chestnuts.
Diagnosis — In most cases, the diagnosis of latex allergy is based upon a person's history of exposure. The more serious type of latex allergy causes an immediate onset of hives, nasal symptoms, swelling, or wheezing after latex exposure. Some of these individuals may need to see a dermatologist or allergist for specialized skin patch tests and blood testing to verify the latex allergy.
Treatment — The primary mode of treatment for latex allergy is to avoid all latex-containing products. Non-latex examination gloves are widely available, and use of glove liners may also be an effective approach. Natural membrane (sometimes called sheep skin) condoms may be used in place of latex condoms. Natural membrane condoms are effective for preventing pregnancy, but do not protect against transmission of sexually transmitted diseases such as HIV, gonorrhea, and chlamydia.
Those with serious latex allergy should wear a bracelet, necklace, or similar alert tag at all times. If a reaction occurs and the person is too ill to explain their condition, this will help responders get the proper care for the person as quickly as possible. This measure is especially important in children.
The alert tag should include a list of known allergies, as well as the name and phone number of an emergency contact. One device, Medic Alert®, provides a toll-free number that emergency medical workers can call to find out a person's medical history, list of medications, family emergency contact numbers, and healthcare provider names and numbers.
Persons with a latex allergy should inform their doctors, dentists, and other health care providers about the allergy. These individuals also may be advised to carry an anaphylaxis kit (containing epinephrine that can be injected under the skin) as a precautionary measure. Because latex allergy is common among people with spina bifida, doctors often recommend that people with this condition undergo a screening for latex allergies before any medical procedures are performed. (See "Patient information: Use of an epinephrine autoinjector").
DYSHIDROTIC DERMATITIS — Dyshidrotic dermatitis (also called pompholyx or dyshidrosis) is an intensely itching chronic, recurring dermatitis of unknown cause that typically involves the palms, soles, and fingers. Most people experience acute episodes of intense itching on the palms and/or soles that progress to multiple small vesicles (fluid-filled bumps), which peel off over one to two weeks, leaving cracks in the skin that slowly resolve (show picture 10). Recurrent episodes alternating with symptom-free periods are common.
Medium strength to potent topical steroids can control outbreaks in mild cases. Occasionally, brief courses of oral steroids are necessary to control symptoms. Local treatments with ultraviolet light therapy are helpful in people who have not responded to other measures.
NUMMULAR DERMATITIS — Nummular dermatitis causes intensely itchy patches of skin, with redness, small bumps, skin flaking, slight crusting, and some serous oozing on close inspection. A person may have as few as one lesion or as many as 20 to 50 lesions. Each lesion tends to be circular, measuring 2 to 10 cm in diameter.
Lesions are usually on the trunk and lower extremities, and the head is generally spared. The onset is usually spontaneous, and the cause often cannot be identified; some people may have exposures to drying or irritating substances (eg, excessive water exposure, chlorine, soaps).
A potent topical steroid ointment is the treatment of choice for nummular dermatitis. Systemic steroids in short courses are occasionally required. It may be helpful to avoid irritants, if they can be identified. Skin moisturization is an important part of the management of nummular dermatitis; a rich moisturizing cream should be applied immediately after bathing.
SUMMARY Dermatitis is defined as an inflammation of the skin; there are several different types of dermatitis. Atopic dermatitis (eczema) is a common chronic condition that causes skin to become red, itchy, and dry. People with other allergies are more likely to develop the condition; the diagnosis is often based on this as well as examination of the skin. Treatment includes avoiding things that make symptoms worse (such as dry air and irritating fabrics) and applying creams or ointments to soothe the itchy rash. (See "Atopic dermatitis (eczema)" above). Seborrheic dermatitis causes overproduction of skin cells and oil; it is most common in infants (cradle cap). This type of dermatitis causes redness, itching, and scaling of the skin, and often affects the face and scalp; it is diagnosed based on a person's history and examination of the skin. Symptoms can be controlled by washing the skin and hair carefully and applying creams to relieve itching and redness. (See "Seborrheic dermatitis" above). Irritant contact dermatitis is a reaction caused by contact with a substance that is irritating to the skin, such as a soap or cleanser. This can make the skin red, itchy, and dry. Persons with other skin conditions, dry skin, and light-colored or "fair" skin are at greatest risk, although anyone can develop irritant dermatitis. Diagnosed may be done by testing the skin's reaction to a very small amount of the irritant; avoiding the substance usually relieves symptoms, but medicated creams may be prescribed in severe cases. (See "Irritant contact dermatitis" above). Allergic contact dermatitis occurs when the skin touches a substance that not only irritates, but actually causes an allergic reaction (such as with poison ivy). A rash appears where contact occurred, and usually resolves on its own if the substance is avoided; creams or compresses may be used to relieve itching and inflammation. (See "Allergic contact dermatitis" above). Latex dermatitis is caused by contact with latex (eg, latex gloves). Some people have a serious, life-threatening allergy to latex, and must be very careful to avoid it. (See "Latex dermatitis" above). Dyshidrotic dermatitis is a condition that causes intense itching and bumps, often on the palms of the hands and soles of the feet; steroids that are applied to the skin or taken as a pill are often used to treat this condition. (See "Dyshidrotic dermatitis" above).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html) National Institute on Arthritis and Musculoskeletal and Skin Diseases
(www.niams.nih.gov/hi/index.htm) American Academy of Dermatology
(www.aad.org) American Academy of Allergy, Asthma and Immunology
(www.aaaai.org) EczemaNet
(www.skincarephysicians.com/eczemanet/) National Eczema Association for Science and Education
(www.eczema-assn.org)
UpToDate performs a continuous review of over 375 journals and other resources. Updates are added as important new information is published. The literature review for version 15.2 is current through April 2007; this topic was last changed on September 13, 2006. The next version of UpToDate (15.3) will be released in October 2007.
INTRODUCTION — Dermatitis is defined as an inflammation of the skin. The terms dermatitis include a wide variety of skin disorders, including atopic dermatitis (eczema), seborrheic dermatitis, contact dermatitis, latex dermatitis and allergy, and dyshidrotic dermatitis.
Depending upon the underlying cause, dermatitis can be a short-term or lifelong condition. In most cases, self-care measures and drug therapy can control the symptoms and prevent complications.
ATOPIC DERMATITIS (ECZEMA) — About 8 to 25 percent of people worldwide have atopic dermatitis (eczema). It often occurs in people who have other allergic disorders, such as asthma and allergic rhinitis (nasal inflammation caused by allergies, also known as hay fever). Family members are often affected.
Cause — The cause of eczema is unknown, but hereditary factors appear to play a strong role. The skin inflammation of atopic dermatitis results from an abnormal immune reaction that is triggered or worsened by exposure to allergens (substances that provoke an allergic reaction). About 85 percent of people with eczema have antibodies (proteins formed by the immune system) to foods or airborne allergens, such as dust mites and animal dander.
In children, eczema is often linked to food allergies. Common food allergens include milk, egg whites, wheat, corn, soybeans, and peanuts.
Symptoms — Most people with eczema develop their first symptoms before age five. Intense itching of the skin, redness, small bumps, and skin flaking are common (show picture 1). Scratching can cause additional skin inflammation, which can further worsen the itching. The itchiness may be more noticeable at nighttime. The skin is often dry, increasing the risk of skin injury with scratching. The skin lesions are therefore at risk for developing infection. Features of infection include pus-containing bumps in inflamed areas; prompt evaluation by a healthcare provider is recommended if this occurs
Features of eczema vary from one individual to another, and can change over time. Other features can include: Lichenification - Thick, leathery skin (usually as a result of frequent scratching) Icthyosis - Dry scales (show picture 2) Keratosis pilaris - Plugged hair follicles resulting in the development of small bumps, usually on the face, upper arms, and thighs Cheilitis - Inflammation around the lips Hyperlinear palms - Increased skin creasing on the palms Dennie-Morgan line - An extra fold of skin under the eye Periorbital darkening - Darkening of the skin around the eyes
Although eczema is usually confined to specific areas of the body, it may be widespread in severe cases: In young children, it typically occurs on the face, scalp, extremities, or trunk, and rarely occurs in the diaper area (show picture 3). In older children and adolescents, it is often accompanied by thickening and darkening of the skin, as well as scarring from repeated scratching. In adults, it commonly affects the back of the neck, the elbow creases, and the backs of the knees . Other affected areas may include the face, wrists, and forearms.
Diagnosis — There is no specific test used to diagnose eczema; diagnosis is usually based upon a person's history and the signs noted during a physical examination.
Factors that strongly suggest eczema include long-standing and recurrent itching, a personal or family history of allergic conditions, and an early age at onset. Other factors include a worsening of symptoms after exposure to certain triggers, and any of the skin findings noted above.
Allergy testing is usually reserved for people who have eczema in addition to features of asthma or allergic rhinitis. Allergy testing may also be recommended for children with suspected food allergies.
Treatment — Eczema is a chronic condition; it typically improves and then flares (worsens) periodically. Some people can have no symptoms for several years, only to have the disease return at a later time. It is not curable, although symptoms can be controlled with a variety of self-care measures and drug therapy. Eliminate exacerbating factors — Eliminating factors that worsen eczema can effectively control the symptoms. These factors may include frequent bathing and low-humidity environments (which can further dry the skin), emotional stress, rapid temperature changes, and exposure to certain chemicals and cleaning solutions. Common irritants include soaps and detergents, perfumes and cosmetics, wool or synthetic fibers, dust, sand, and cigarette smoke.
The following tips are recommended: Dust frequently and avoid placing upholstered furniture in the bedroom. Reducing exposure to house dust mites may reduce the severity of atopic dermatitis. Food allergies are relatively uncommon in adults, but may be a problem for a small percentage of infants and young children. However, changes to an infant or child's diet should be made only after consulting an allergy specialist because of the risk of eliminating a nutritionally important food group (eg, cow's milk, eggs, soy products). Emollients — Emollients are creams and ointments that moisturize the skin and can help relieve symptoms. The best emollients for people with atopic dermatitis are creams (such as Eucerin®, Cetaphil®, and Nutraderm®) and ointments (such as petroleum jelly, Aquaphor®, and Vaseline®). Emollients are most effective when applied immediately after bathing. Lotions should be avoided because they can worsen dry skin. Bathing — Lukewarm baths can hydrate and cool the skin, temporarily relieving the itching of eczema. Hot or long baths (greater than 10 to 15 minutes) and showers should be avoided since they can cause excessive drying. A mild soap or nonsoap cleanser (such as Cetaphil®) should be used sparingly. Application of an emollient immediately after bathing or showering prevents the drying that occurs through evaporation. Some experts recommend showers for their antibacterial effect, though individuals should determine which method is best for their situation. Topical steroids — Topical steroid creams and ointments are often effective for controlling mild to moderate atopic dermatitis. They are usually applied twice daily and help to reduce symptoms and moisturize the skin; non-medicated emollients can be resumed when symptoms resolve. Strong topical steroids may be needed to control severe flares of eczema; however, highly potent steroids should be used for only short periods of time to prevent thinning of the skin. Other topical treatments — Newer topical therapies for eczema include tacrolimus (Protopic®) and pemicrolimus (Elidel®). They are effective for controlling eczema in persons who have not improved with topical steroids, although do not work as quickly as topical steroids. They are useful in sensitive areas such as the face and groin, and can be used in children over age two. Due to safety concerns, it is recommended that these treatments be used only as instructed by a healthcare provider. Oral steroids — Oral steroids occasionally are used to treat a flare of chronic eczema, though should not be used on a regular basis because of side effects. Oral antihistamines — Oral antihistamines help relieve the itching of eczema and the accompanying eye irritation. The over-the-counter antihistamine diphenhydramine (Benadryl®), and other antihistamines, such as hydroxyzine and cyproheptadine, are most effective for eczema, although these drugs can cause drowsiness. The nonsedating antihistamines such as cetirizine (Zyrtec®) and loratadine (Claritin®) also may relieve symptoms, and loratadine is available without a prescription in the United States. Doxepin is an antidepressant that has antihistamine actions and may be recommended if other antihistamines are not helpful. Ultraviolet light therapy (phototherapy) — Ultraviolet light therapy (phototherapy) can effectively control atopic dermatitis. However, this therapy is expensive, may increase a person's risk for skin cancer, and is therefore recommended only for persons with severe eczema who do not respond to other treatments. Immunosuppressive drugs — Immunosuppressive drugs can effectively control severe eczema. These drugs include oral cyclosporine, tacrolimus, methotrexate, mycophenylate mofetil, and azathioprine. Treatment with these drugs can cause serious side effects, including an increased risk for infection, and their use is generally limited to persons who do not improve with other treatments.
SEBORRHEIC DERMATITIS — Seborrheic dermatitis causes overproduction of skin cells and sebum, the skin's natural oil. Seborrheic dermatitis usually occurs in areas of the body that have many oil-producing glands, including the scalp, face, upper chest, and back. It is most common during infancy; this is called cradle cap. Cradle cap usually resolves by 8 to 12 months of age.
Cause — The cause of seborrheic dermatitis is unknown, although it is known that an overgrowth of a normal skin yeast fungus occurs with this condition. It is not clear whether the fungus causes the flaking and redness or the increased flaking allows overgrowth of the fungus.
Symptoms — The symptoms of seborrheic dermatitis include redness, scaling, and itching of the affected skin. The dermatitis most often occurs on the scalp and face, especially on the eyebrows, the bridge and sides of the nose, and in the crease between the nose and lip (show picture 5). In men, seborrheic dermatitis is usually worse on the skin beneath mustaches and beards. Seborrheic dermatitis can also affect the chest, upper back, armpits, and pubic area, and the condition can affect the entire body in infants.
The term seborrhea refers to oiliness of the skin, without redness or scaling. Dandruff causes scalp scaling without redness, although it can commonly progress to seborrheic dermatitis of the scalp.
Diagnosis — There is no specific test for diagnosing seborrheic dermatitis. The diagnosis is usually based upon a person's history and the signs noted on physical examination. In rare cases, a skin biopsy (a collection of a small sample of skin tissue) may be necessary to confirm the diagnosis or rule out other conditions that mimic seborrheic dermatitis.
Treatment — The symptoms of seborrheic dermatitis can be effectively controlled with a combination of self-care measures and drug therapy. Washing and shampooing — Diligent washing and shampooing can control the symptoms of seborrheic dermatitis. Frequent washing counters the build-up of skin scales, and daily shampooing with a medicated shampoo controls scaling and itching on the scalp. For best results, the shampoo should be left in place for a few minutes before rinsing.
The growth of skin cells is slowed by shampoos that contain tar (Z-Tar®, Pentrax®, DHS tar®, Ionil T plus®, and T-Gel extra strength®), selenium sulfide (Selsun® and Exelderm®), and zinc pyrithione (Head and Shoulders®, Zincon®, and DHS zinc®). Shampoos containing antifungal medications (Nizoral®, Stieprox®) are quite effective. All of these shampoos can be used indefinitely. Topical steroids — Low potency topical steroids are usually the drugs selected first for the treatment of seborrheic dermatitis. These drugs are available in creams and lotions for the face and in alcohol-based liquids and aerosol sprays for the scalp. The topical steroids should be applied daily until the dermatitis improves; they can then be gradually discontinued. The lower potency steroid preparations are used, so that even prolonged use results in few, if any side effects. Topical antifungal drugs — The topical antifungal cream ketoconazole (Nizoral®) appears to be as effective as topical steroids for the treatment of seborrheic dermatitis. In cases of severe seborrheic dermatitis, treatment may include both topical steroids and topical antifungal drugs.
CONTACT DERMATITIS — Contact dermatitis refers to dermatitis that is caused by direct contact of the skin with a substance. The substance can be an allergen (a substance that provokes an immune reaction) or an irritant (a substance that directly damages the skin). The dermatitis results from contact with an irritant in about 80 percent of people with contact dermatitis.
Irritant contact dermatitis — Irritant contact dermatitis occurs when the skin comes in direct contact with a substance that physically, mechanically, or chemically irritates the skin.
Cause — The skin becomes inflamed when the normal skin barrier is irritated. The most common cause are products used on a daily basis, including soap, cleansers, and rubbing alcohol. Persons with other skin conditions, dry skin, and light-colored or "fair" skin are at greatest risk, although anyone can develop irritant dermatitis.
Symptoms — Mild irritants cause redness, dryness, and fissures (small cracks), with itching. Strong irritants cause swelling, oozing, tenderness, and blisters (show picture 6).
Irritant contact dermatitis most commonly affects the hands, often beginning in the area between the fingers. It can also affect the face, especially the eyelids.
Diagnosis — The diagnosis of irritant contact dermatitis is usually based upon a person's history and the physical examination. In some cases, a patch test (applying a small amount of the possible irritant to the skin) may be recommended to determine if the dermatitis is caused by an allergy.
Treatment — The treatment of irritant contact dermatitis helps to restore the normal skin barrier and protecting the skin from additional injury by the irritant. Reducing exposure to known irritants is essential. In some cases, simply reducing the use of soap and using emollient creams or ointment alleviates symptoms. Wearing gloves when working with irritants may help as well.
In more severe cases, topical steroids may be used. These are most effective when applied and covered with a barrier, such as plastic wrap, a gauze dressing, cotton gloves, or petroleum jelly. Oral steroids are not used for the long-term treatment of irritant contact dermatitis; however, they may be used briefly to treat severe dermatitis.
Allergic contact dermatitis — Allergic contact dermatitis occurs in some individuals when the skin comes in direct contact with an allergen. This activates the body's immune system, which triggers inflammation. Anyone can experience allergic contact dermatitis. Allergic contact dermatitis can occur when someone is newly exposed to a product, but can also occur after years of use.
Common allergens — Poison ivy, poison oak, and poison sumac are the most common contact allergens. (See "Patient information: Poison ivy"). Other common allergens include nickel (show picture 7) in jewelry, perfumes and cosmetics, components of rubber, nail polish, and chemicals in shoes (both leather and synthetic, show picture 8). Allergic contact dermatitis can also be triggered by certain medications, including topical hydrocortisone, topical antibiotics, benzocaine, and thimerosol.
Symptoms — Symptoms include intense itching and a red rash that develops quickly. The rash is usually limited to areas that were in direct contact with the allergen, but a rash can appear in other areas of the body if the allergen was transferred to those areas on a person's hands (show picture 9). Washing the allergen away with soap and water can usually prevent this spread.
The rash typically appears within 12 to 48 hours of exposure to the allergen, although in some cases it may not appear for up to two weeks. Less commonly, the rash persists for months or years, which makes it difficult to identify what caused the reaction.
Diagnosis — The diagnosis of allergic contact dermatitis is based upon a person's history and the signs noted during a physical examination. An improvement of symptoms after eliminating exposure to the suspected allergen supports the diagnosis. Patch testing (applying a small amount of the possible irritant to the skin) can be helpful in identifying the allergen.
Treatment — Allergic contact dermatitis usually resolves within two to four weeks after a person's exposure to the allergen stops. Several measures can minimize symptoms during this time and can help control symptoms in people who have chronic allergic contact dermatitis.
Whenever possible, identify and stop all exposure to the allergen. Topical steroids can alleviate inflammation. Calamine lotion may relieve mild symptoms.
For more severe symptoms, oral drugs, including steroids (such as prednisone) and antihistamines, may be recommended. Wet-to-dry compresses help dry out oozing skin and cool the skin, relieving severe itching. Wet-to-dry compresses can be easily made and applied at home as follows: Dampen a thin piece of fabric (such as one layer of a cotton or linen sheet) in water or a mixture of water and aluminum acetate (Burow's solution) Apply the dampened fabric to the affected skin Allow the fabric to dry over 15 to 30 minutes Remove the dry fabric gently Repeat the procedure several times
LATEX DERMATITIS — Latex is a fluid produced by rubber trees that is processed into a variety of products, including gloves, balloons, and condoms. In some individuals, exposure to these products and others (such as rubber bands, erasers, feeding nipples, pacifiers) can cause a contact dermatitis that is either an irritant or allergic reaction. Less commonly, a person can develop a potentially life threatening allergic reaction to latex.
Irritant dermatitis — Irritant dermatitis can occur while wearing latex gloves. It usually occurs on the hands of people who wear latex or other rubber gloves; the latex acts as an irritant and the gloves trap moisture against the skin. The skin dries out when the gloves are removed, leading to the dermatitis.
The symptoms of irritant rubber or latex dermatitis include redness and itching on the skin. There may also be dryness and cracking. Symptoms usually occur within 12 to 36 hours of contact with a latex product. Treatment involves avoiding use of any latex-containing products.
Latex allergy — Latex can trigger allergic contact dermatitis. The skin reaction caused by a latex allergy does not differ significantly from that of irritant latex dermatitis.
Some people with latex allergy have severe allergic reactions to latex, including swelling, sneezing, and wheezing. Rarely, anaphylaxis can occur, which causes life-threatening difficulty with breathing. Typically, the most severe allergic reactions occur during procedures when latex comes into contact with mucous membranes (such as in the mouth, vagina, or during surgical procedures). However, some people are so sensitive that severe reactions can occur with even brief contact. (See "Patient information: Anaphylaxis").
Latex allergy is most common among people who have undergone many surgeries and who have other allergic conditions. Latex allergy is also common among health care workers and workers in the latex industry, particularly those who have atopic dermatitis or a history of other types of allergies (such as allergic rhinitis or asthma).
Latex can become aerosolized (often from powder in gloves) and cause nasal symptoms and asthma in sensitized individuals. Some people with latex allergy may also develop reactions to certain foods, including avocado, kiwi, banana, and chestnuts.
Diagnosis — In most cases, the diagnosis of latex allergy is based upon a person's history of exposure. The more serious type of latex allergy causes an immediate onset of hives, nasal symptoms, swelling, or wheezing after latex exposure. Some of these individuals may need to see a dermatologist or allergist for specialized skin patch tests and blood testing to verify the latex allergy.
Treatment — The primary mode of treatment for latex allergy is to avoid all latex-containing products. Non-latex examination gloves are widely available, and use of glove liners may also be an effective approach. Natural membrane (sometimes called sheep skin) condoms may be used in place of latex condoms. Natural membrane condoms are effective for preventing pregnancy, but do not protect against transmission of sexually transmitted diseases such as HIV, gonorrhea, and chlamydia.
Those with serious latex allergy should wear a bracelet, necklace, or similar alert tag at all times. If a reaction occurs and the person is too ill to explain their condition, this will help responders get the proper care for the person as quickly as possible. This measure is especially important in children.
The alert tag should include a list of known allergies, as well as the name and phone number of an emergency contact. One device, Medic Alert®, provides a toll-free number that emergency medical workers can call to find out a person's medical history, list of medications, family emergency contact numbers, and healthcare provider names and numbers.
Persons with a latex allergy should inform their doctors, dentists, and other health care providers about the allergy. These individuals also may be advised to carry an anaphylaxis kit (containing epinephrine that can be injected under the skin) as a precautionary measure. Because latex allergy is common among people with spina bifida, doctors often recommend that people with this condition undergo a screening for latex allergies before any medical procedures are performed. (See "Patient information: Use of an epinephrine autoinjector").
DYSHIDROTIC DERMATITIS — Dyshidrotic dermatitis (also called pompholyx or dyshidrosis) is an intensely itching chronic, recurring dermatitis of unknown cause that typically involves the palms, soles, and fingers. Most people experience acute episodes of intense itching on the palms and/or soles that progress to multiple small vesicles (fluid-filled bumps), which peel off over one to two weeks, leaving cracks in the skin that slowly resolve (show picture 10). Recurrent episodes alternating with symptom-free periods are common.
Medium strength to potent topical steroids can control outbreaks in mild cases. Occasionally, brief courses of oral steroids are necessary to control symptoms. Local treatments with ultraviolet light therapy are helpful in people who have not responded to other measures.
NUMMULAR DERMATITIS — Nummular dermatitis causes intensely itchy patches of skin, with redness, small bumps, skin flaking, slight crusting, and some serous oozing on close inspection. A person may have as few as one lesion or as many as 20 to 50 lesions. Each lesion tends to be circular, measuring 2 to 10 cm in diameter.
Lesions are usually on the trunk and lower extremities, and the head is generally spared. The onset is usually spontaneous, and the cause often cannot be identified; some people may have exposures to drying or irritating substances (eg, excessive water exposure, chlorine, soaps).
A potent topical steroid ointment is the treatment of choice for nummular dermatitis. Systemic steroids in short courses are occasionally required. It may be helpful to avoid irritants, if they can be identified. Skin moisturization is an important part of the management of nummular dermatitis; a rich moisturizing cream should be applied immediately after bathing.
SUMMARY Dermatitis is defined as an inflammation of the skin; there are several different types of dermatitis. Atopic dermatitis (eczema) is a common chronic condition that causes skin to become red, itchy, and dry. People with other allergies are more likely to develop the condition; the diagnosis is often based on this as well as examination of the skin. Treatment includes avoiding things that make symptoms worse (such as dry air and irritating fabrics) and applying creams or ointments to soothe the itchy rash. (See "Atopic dermatitis (eczema)" above). Seborrheic dermatitis causes overproduction of skin cells and oil; it is most common in infants (cradle cap). This type of dermatitis causes redness, itching, and scaling of the skin, and often affects the face and scalp; it is diagnosed based on a person's history and examination of the skin. Symptoms can be controlled by washing the skin and hair carefully and applying creams to relieve itching and redness. (See "Seborrheic dermatitis" above). Irritant contact dermatitis is a reaction caused by contact with a substance that is irritating to the skin, such as a soap or cleanser. This can make the skin red, itchy, and dry. Persons with other skin conditions, dry skin, and light-colored or "fair" skin are at greatest risk, although anyone can develop irritant dermatitis. Diagnosed may be done by testing the skin's reaction to a very small amount of the irritant; avoiding the substance usually relieves symptoms, but medicated creams may be prescribed in severe cases. (See "Irritant contact dermatitis" above). Allergic contact dermatitis occurs when the skin touches a substance that not only irritates, but actually causes an allergic reaction (such as with poison ivy). A rash appears where contact occurred, and usually resolves on its own if the substance is avoided; creams or compresses may be used to relieve itching and inflammation. (See "Allergic contact dermatitis" above). Latex dermatitis is caused by contact with latex (eg, latex gloves). Some people have a serious, life-threatening allergy to latex, and must be very careful to avoid it. (See "Latex dermatitis" above). Dyshidrotic dermatitis is a condition that causes intense itching and bumps, often on the palms of the hands and soles of the feet; steroids that are applied to the skin or taken as a pill are often used to treat this condition. (See "Dyshidrotic dermatitis" above).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html) National Institute on Arthritis and Musculoskeletal and Skin Diseases
(www.niams.nih.gov/hi/index.htm) American Academy of Dermatology
(www.aad.org) American Academy of Allergy, Asthma and Immunology
(www.aaaai.org) EczemaNet
(www.skincarephysicians.com/eczemanet/) National Eczema Association for Science and Education
(www.eczema-assn.org)
Tuesday, January 8, 2008
BACTIPRONT Pfizer
BACTIPRONT Pfizer
Drug Category: Folic acid inhibitor/sulphonamide.
Generic Name: Co-trimoxazole.
Contents: Duplex Tabs: Trimethoprim 160mg, sulphamethoxazole 800mg.
Susp: Per 5ml: Trimethoprim 40mg, sulphamethoxazole 200mg,
Tabs: Trimethoprim 80mg, sulphamethoxazole 400mg.
Indications: Infections of respiratory, gastro-intestinal tracts and skin. UTI.
Dosage: Adults: 1 DS tab or 2 tabs or 20ml twice daily. Children: Under 6 weeks, not recommended; 6 weeks- 5 month,2.5ml; 6 months-5 years, 5nl, 6-12 years, 10ml. All twice daily.
Contra-ind., Precautions etc: See notes at the begining of this section.
Regn.No:Pack:Trade Prices:Retail Prices:
Duplex Tab8(005754):100's: 215.43:253.45.
Susp (005755): 50ml: 12.63:14.86.
Tabs(005621):200's: 237.85:279.82.
Drug Category: Folic acid inhibitor/sulphonamide.
Generic Name: Co-trimoxazole.
Contents: Duplex Tabs: Trimethoprim 160mg, sulphamethoxazole 800mg.
Susp: Per 5ml: Trimethoprim 40mg, sulphamethoxazole 200mg,
Tabs: Trimethoprim 80mg, sulphamethoxazole 400mg.
Indications: Infections of respiratory, gastro-intestinal tracts and skin. UTI.
Dosage: Adults: 1 DS tab or 2 tabs or 20ml twice daily. Children: Under 6 weeks, not recommended; 6 weeks- 5 month,2.5ml; 6 months-5 years, 5nl, 6-12 years, 10ml. All twice daily.
Contra-ind., Precautions etc: See notes at the begining of this section.
Regn.No:Pack:Trade Prices:Retail Prices:
Duplex Tab8(005754):100's: 215.43:253.45.
Susp (005755): 50ml: 12.63:14.86.
Tabs(005621):200's: 237.85:279.82.
BACTIPRONT Pfizer
BACTIPRONT Pfizer
Drug Category: Folic acid inhibitor/sulphonamide.
Generic Name: Co-trimoxazole.
Contents: Duplex Tabs: Trimethoprim 160mg, sulphamethoxazole 800mg.
Susp: Per 5ml: Trimethoprim 40mg, sulphamethoxazole 200mg,
Tabs: Trimethoprim 80mg, sulphamethoxazole 400mg.
Indications: Infections of respiratory, gastro-intestinal tracts and skin. UTI.
Dosage: Adults: 1 DS tab or 2 tabs or 20ml twice daily. Children: Under 6 weeks, not recommended; 6 weeks- 5 month,2.5ml; 6 months-5 years, 5nl, 6-12 years, 10ml. All twice daily.
Contra-ind., Precautions etc: See notes at the begining of this section.
Regn.No:Pack:Trade Prices:Retail Prices:
Duplex Tab8(005754):100's: 215.43:253.45.
Susp (005755): 50ml: 12.63:14.86.
Tabs(005621):200's: 237.85:279.82.
Drug Category: Folic acid inhibitor/sulphonamide.
Generic Name: Co-trimoxazole.
Contents: Duplex Tabs: Trimethoprim 160mg, sulphamethoxazole 800mg.
Susp: Per 5ml: Trimethoprim 40mg, sulphamethoxazole 200mg,
Tabs: Trimethoprim 80mg, sulphamethoxazole 400mg.
Indications: Infections of respiratory, gastro-intestinal tracts and skin. UTI.
Dosage: Adults: 1 DS tab or 2 tabs or 20ml twice daily. Children: Under 6 weeks, not recommended; 6 weeks- 5 month,2.5ml; 6 months-5 years, 5nl, 6-12 years, 10ml. All twice daily.
Contra-ind., Precautions etc: See notes at the begining of this section.
Regn.No:Pack:Trade Prices:Retail Prices:
Duplex Tab8(005754):100's: 215.43:253.45.
Susp (005755): 50ml: 12.63:14.86.
Tabs(005621):200's: 237.85:279.82.
BACITRAN Lisko
BACITRAN Lisko
Drug Category: Folic acid inhibitor/sulphonamide.
Generic Name: Co-trimoxazole.
Contents: DS Tabs: Trimethoprim 160mg, sulphamethoxazole 800mg.Susp: Per 5ml: Trimethoprim 40mg, sulphamethoxazole 200mg.Tabs: Trimethoprim 80mg, sulphamethoxazole 400mg.
Regn.No:Pack:Trade Prices:Retail Prices:
DS Tabs(010518): 10x10's: 127.50:150.00.
Susp(025018):50ml: 11.50:13.00.
Tabs(025020) :20x10's: 181.90:214.00
Drug Category: Folic acid inhibitor/sulphonamide.
Generic Name: Co-trimoxazole.
Contents: DS Tabs: Trimethoprim 160mg, sulphamethoxazole 800mg.Susp: Per 5ml: Trimethoprim 40mg, sulphamethoxazole 200mg.Tabs: Trimethoprim 80mg, sulphamethoxazole 400mg.
Regn.No:Pack:Trade Prices:Retail Prices:
DS Tabs(010518): 10x10's: 127.50:150.00.
Susp(025018):50ml: 11.50:13.00.
Tabs(025020) :20x10's: 181.90:214.00
Subscribe to:
Posts (Atom)