Request & Reason
The given consultation request is addressed to Ms. Wilson FNP-C, APRN, MSN in order to acquire valuable information regarding Ms. Perez. The reason for consultation is that the patient possesses unresponsive eczema, which did not show any signs of improvement through treatment for the past six months. The consultation provider is a certified family nurse practitioner, advanced practice registered nurse, and master of science in nursing Ms. Wilson.
The patient is an established patient, which makes its Current Procedural Terminology (CPT) code 99244 due to its mid-level category (“Evaluation and management services,” 2020). The current evaluation and treatment recommendations a number of points, which need to be considered prior to the treatment. A deep and comprehensive analysis of the pathogenesis of eczema contributes to the emergence of new approaches to its treatment. It has been established that various immune shifts play a role in the pathogenesis of eczema, accompanied by a change in the profile of inflammatory cytokines, prostaglandins, and cyclic nucleotides.
An eczema patient is characterized by the presence of immunodeficiency of the cellular, humoral and phagocytic immunodeficiency units. The purpose of this consultation was to study the effectiveness of treatment of patients with eczema with interferon stimulants, taking into account the immune status. After the treatment, there was a significant tendency to normalize all impaired indicators of the immune status in the patient of the main category, while the control assessment revealed that this trend was insignificant and complex ineffective. At the same time, under the influence of complex therapy with medications, the length of stay in the patient’s bed decreased slightly compared to the average.
According to the evaluation and subsequent ideas, eczema develops as a sensitization to a microbial antigen against the background of changes in the neuroendocrine, immune systems, and dysfunction of the gastrointestinal tract. The microbial flora of the skin is formed due to the suppression of pathogenic strains non-pathogenic. The onset of the disease is determined by the development of skin sensitization to bacterial agents. With microbial eczema, a pronounced increased reactivity of the skin to the components of the epidermis and streptococci and, to a lesser extent, to whole skin antigens and staphylococci is detected (Wong, Tsuyuki, Cresswell-Melville, Doiron, & Drucker, 2017).
The frequent transformation of chronic diffuse pyoderma skin lesions in patients into microbial eczema is associated with an increase in the specific reactivity of the body not only to pyoderma, but also to the components of their own skin, in particular due to the stimulating effect of pyogenic on the process of autosensitization. The role of immunological disorders in the initial links in the pathogenesis of eczema is shown. This is manifested primarily by cellular immunodeficiency according to the T-system of immunity. It is the T-lymphocytic immunodeficiency that currently explains the primary phase of sensitization of the body and / or skin in eczema-like conditions.
It was established that the patient with eczema expressed severe symptoms, that is, an excess of Ig G, Ig E and Ig M deficiency, and the total number of functionally active T-lymphocytes was reduced. In addition, it was revealed that the patient has a reduced total number of T cells, a change in the ratio of helper and suppressor subpopulations, and therefore the number of B lymphocytes is increased.
The most pronounced immunopathology was detected in the patient carrier of isotropic antigens A, M, N and Rhesus B +. Suppression of the skin’s immune reserves in the presence of infectious antigenic irritants is manifested by the persistence of microbial and bacterial antigens with the formation of chronic recurrent inflammation in the epidermis and dermis. In this case, pathological circulating complexes occur that damage their own microstructures with the formation of a series of autoantigens that initiate the formation of aggressive antibodies.
The immune status in microbial eczema is characterized by a decrease in the levels of T-lymphocytes 4+ and 8+ and subsequent expression by dermis and T-lymphocytes 1a cells + epidermal Langerhans cells of histocompatibility antigen. The number of neutrophils, T-helpers, the level of phagocytic activity are also reduced, and the T-suppressor link is activated. At the same time, the provocative basophilic test and the accumulation of circulating immune complexes change.
The presence of changes at the body level with microbial eczema is confirmed by trophic changes in the epithelium and vascular reactions in areas of apparently healthy skin that are not affected by an obvious erythematous process. Significant disturbances in microcirculatory reactions in response to exposure were noted.
Treatment of the patient with an eczematous process must be carried out based primarily on its neuro-allergic pathogenesis, taking into account the role of disorders of the endocrine system, metabolism, pathology of internal organs, the influence of environmental factors and, finally, age-related characteristics of the body. Naturally, the presence of such a large number of factors contributing to the occurrence and affecting the course of the eczematous process, the tendency of the disease to relapse and exacerbations, and the chronic nature of the course significantly complicate the treatment.
In this case, one should take into account the increased sensitivity of the skin of patients with eczema to various chemicals, including drugs used externally. Being at the stage of allergization, an eczema patient may inadequately respond to drugs taken orally or parenterally, which is manifested primarily in exacerbation of the eczematous process.
A significant pathogenetic role that is not directly related to allergic inflammation, vascular disorders play in the paratraumatic variant of microbial eczema caused by a varicose symptom complex. A common eczematous process is accompanied by impaired hemocoagulation, hypercoagulation develops, thromboplastic activity increases, and inhibition of fibrinolysis is noted (Brown, Weitz, Liang, Stockwell, & Friedman, 2018).
Disturbances of transcapillary metabolism play a noticeable role. There is a release of protein and protein-free exudate into the interstitial space, which, combined with a violation of membrane permeability, is an adaptive mechanism that provides a sufficiently high level of oxidative processes in the dermis. A direct relationship between the severity of skin lesions and the degree of violation of vascular permeability was determined.
The role of hereditary disorders of certain parts of the immune system, the barrier and receptor systems of the skin is not ruled out. Polygenic multifactorial inheritance of the disease with pronounced gene expressivity and penetrance has been established. Meanwhile, a change in the skin is a reflection of a single general pathological condition – inflammation. According to the modern interpretation, inflammation is considered primarily as a local reaction, which only at a certain stage of its development has general control through the neuro-humoral regulation of the body. Most often, microbial eczema is localized in the distal parts of the extremities, the area of the nipples, the navel, the behind the folds, under the mammary glands in women.
The given referral request is addressed to a dermatologist Dr. Owen by a Ms. Perez’s primary care provider and NP in order to refer the patient. The reason for referral request is the fact that the patient possesses eczema, which does not respond to the treatment provided in the past six months. The patient has undergone topical therapies and systemic therapies, which include topical corticosteroids and antiseptics as well as cyclosporine off-label for atopical dermatitis (“Atopic dermatitis clinical guideline,” 2020).
The referee-to provider will bill an evaluation and management code 99205 due to its comprehensive nature and office visit of a new patient (“Evaluation and management services,” 2020). The given evaluation will contain comprehensive information regarding the patient’s condition and the plausible approaches for treatment procedures. Microbial eczema develops at the site of chronic foci of pyoderma – around infected ulcers, fistulas, abrasions, scratches.
It is located asymmetrically in the form of roundish, single or few foci, distinctly defined, edematous and infiltrated, characterized by the presence of erythema, papular vesicular elements, stratification of serous-purulent crusts, under which there is soaking and accumulation of pus. In places freed from crusts, the skin is devoid of the epidermis, has a lacquer-red color, and bleeds easily.
Along the periphery of such foci there is a scalloped rim of exfoliating epidermis, sometimes with a bright pink inflammatory nimbus, indicating a tendency to spread the disease. On the surface of the focus and next to it are individual pustules, folliculitis is noted. With a decrease in inflammatory phenomena, the focus of microbial eczema is covered with large-plate scales, when removed, a dry, shiny, stagnant-red infiltrated surface is visible.
A variety of microbial eczema is the so-called coin-shaped eczema, which is characterized by the formation of sharply limited foci of lesion of rounded outlines of a size of two centimeters. On their edematous-hyperemic surface, profuse weeping, layering of gray-purulent crusts are noted. Coin-like eczema often begins with several isolated foci on the legs and over time, multiple foci appear that do not have any specific location. With the flow, it can last from several days to several months. Irrational treatment or trauma to its foci is accompanied by the occurrence of secondary allergic rashes such as allergens.
They are polymorphic and can be represented by edematous erythematous spots, vesicles, and pustules (Shelley et al., 2018). With a progressive course, secondary rashes merge, disseminate with the formation of a significant number of weeping erosive areas. In such cases, the transformation of microbial eczema into true occurs. Comprehensive treatment of the patient with microbial eczema is carried out with the severity of the skin process, the presence of endogenous and exogenous factors that underlie the development of the disease.
Circulating immune complexes were revealed in the blood with active clinical manifestations of eczema, as well as an increased content of inflammatory mediators in the pathologically altered skin and blood serum of the inflammatory process, such as histamine, acetylcholine, prostaglandins. All this allows care providers to interpret inflammation in eczema as allergic or immune, in which the immune and non-specific phases are secreted.
Qualitative and quantitative characteristics of the immune phase of inflammation distinguish it from a non-specific one. This can be illustrated, on the one hand, by the fact that disturbances in immunological homeostasis in the patient with an eczema in the acute phase are most pronounced, on the other hand, the degree of allergization and immunological rearrangement apparently determine the clinical form of the course of the eczematous process. This goes from the minimum in allergic dermatitis, eczema to the maximum in various clinical forms of eczema, including to a greater extent – with a tendency to spread over the area of skin damage.
Moreover, the immune response in eczema and eczema-like processes is primary and determines the severity of the eczematous allergic reaction, which depends on the degree of hereditary predisposition, functional disorders of the nervous system, the duration of the existence and strength of exposure of the skin to endogenous and exogenous resolving factors in the form of a sufficiently long antigenic effect. It is important to make sure to take into account the condition of internal organs and systems. Methods of nonspecific pathogenetic therapy are diverse, but this is primarily the use of antihistamines.
Parenteral administration of chloropyramine, diphenhydramine is recommended (Brown et al., 2018). This procedure is performed in combination with the intake of II-III generation H1-histamine receptor blockers, H1-histamine receptor blockers with anti-serotonin activity or mast cell membrane stabilizers. The latter may include cetirizine, loratadine, ketotifen, and cyproheptadine. As desensitizing and hyposensitizing therapy, calcium preparations are prescribed, such as calcium chloride and calcium gluconate, both parenterally and orally; In addition, the procedure will include poly-sorbents.
Eczema also includes nonspecific inflammation, corresponding to a greater extent to the proliferative phase of the inflammatory process in a general sense, associated with the features of the connective tissue of the papillary dermis of a particular subject and is largely determined by them. Clinically, at this time, the eczematous process transforms into the chronic stage of eczema with the development of skin lichenification. It is necessary to prescribe multidirectional immune preparations that have an immune-corrective effect on various links of cellular and humoral immunity. Specific immunotherapy of patients with microbial eczema is carried out with anti-staphylococcal gamma-globulin, and staphylococcal vaccine (Wong et al., 2017).
Antibacterial agents are used with preliminary sowing of the flora and the determination of sensitivity, that is, broad-spectrum antibiotics. The latter should be enhanced and anti-staphylococcal penicillin, cephalosporins of the I-II generation, aminoglycosides, macrolides, and fluoroquinolones. Patients with a varicose symptom complex, trophic ulcers are recommended to use xanthinol nicotinate.
An important role is played by the local treatment carried out in all its clinical forms – lotions and wet-drying dressings with anti-inflammatory, antibacterial, astringent solutions, glucocorticoid ointments, and antibiotic ointments. Success in treating the patient with eczema depends on a diet, a healthy lifestyle, and providing a good rest. In the exacerbation period, a strict diet is recommended for 2 days (Shelley et al., 2018). In addition, it is necessary to limit water procedures, try to prevent contact of the foci of inflammation with soap, laundry detergent and other potential irritants. Only an integrated approach to solving the problem can provide the desired result.
Thus, pathogenetic and clinical signs, sensitization to microorganisms, and the leading role of the immune system are characteristic of microbial eczema. At different stages of the development of the study of eczema, the dominant position in the etiology and pathogenesis of the disease was given to the nervous and endocrine systems, the allergic state of the body, and hereditary factors. Currently, in the pathogenesis of the eczematous process, the main importance is given to various immune disorders. It should be noted that the etiology and pathogenesis of eczema is extremely complex and many of its aspects have not yet been overviewed.
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Brown, J., Weitz, N. W., Liang, A., Stockwell, M. S., & Friedman, S. (2018). Does an eczema action plan improve atopic dermatitis? A single-site randomized controlled trial. Clinical Pediatrics, 57(14), 1624-1629.
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Shelley, A. J., McDonald, K. A., McEvoy, A., Sauder, M., Kanigsberg, N., Zemek, R., … Ramien, M. L. (2018). Usability, satisfaction, and usefulness of an illustrated eczema action plan. Journal of Cutaneous Medicine and Surgery, 22(6), 577-582.
Wong, I. T. Y., Tsuyuki, R. T., Cresswell-Melville, A., Doiron, P., & Drucker, A. M. (2017). Guidelines for the management of atopic dermatitis (eczema) for pharmacists. Canadian Pharmacists Journal, 150(5), 285-297.