Nummular Dermatitis Clinical Presentation

  • Author: Jami L Miller, MD; Chief Editor: William D James, MD   more...
 
Updated: May 20, 2011
 

History

Patients present with a days-to-months' history of a pruritic eruption, usually starts on the legs. It may also burn or sting.

  • Nummular dermatitis often waxes and wanes with winter; cold or dry climates or swings in temperature may be exacerbating factors. It may improve with sun or humidity exposure or with moisturizer use. Occasionally it may worsen with heat or humidity.
  • New nummular dermatitis lesions often recur in the same locations as old lesions.
  • The patient's medical history may be positive for eczema, atopic dermatitis, or dry and sensitive skin.
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Physical

The diagnosis of nummular dermatitis is made on the basis of observing the characteristic round-to-oval erythematous plaques. They are most commonly located on the extremities, particularly the legs, but they may occur anywhere on the trunk, hands, or feet. Nummular dermatitis does not involve the face and scalp. Lesions are often symmetrically distributed.

See the image below.

Dry, scaling plaque of nummular dermatitis (size, Dry, scaling plaque of nummular dermatitis (size, 3 X 5 cm) on the shin.

Lesions begin as erythematous-to-violaceous papules or vesicles, which then coalesce to form confluent plaques. They may have overlying erosions due to excoriation.

Early lesions, particularly vesicular ones, often become colonized by staphylococci, which produces a yellowish crust. Secondary overt infection may occur, with cellulitis surrounding the plaques, requiring oral antibiotics.

Within a few days, plaques become dry, scaly, and more violaceous, particularly when located below the knee.

The lesions then flatten to macules, usually with brown postinflammatory hyperpigmentation that gradually lightens. The pigment may never completely fade, particularly when located below the knee.

Plaques may show central clearing, making differentiation from tinea corporis based on clinical findings difficult. Tinea corporis usually has few vesicles, a raised narrow border, and leading scale (ie, scale on the outside of the plaque).

Distinguishing between forms of dermatitis (eg, asteatotic eczema, atopic dermatitis, nummular dermatitis) may be difficult, but, fortunately, this is not necessary to make proper treatment decisions. Contact dermatitis may have a pattern that approximates the manner in which the offending agent came into contact with the skin, such as a linear pattern. It may become chronic in the setting of repeated exposure, such as with chromates and formaldehyde. The patient may recall contact with an allergen, such as poison ivy.

Lichen simplex chronicus often occurs on the lower legs, the neck, the scalp, or the scrotum; it is lichenified (thickened by chronic scratching), more violaceous, and, often, has no clear border.

Stasis dermatitis may occur simultaneously on the lower extremities, and venous stasis may lead to the concomitant development of both conditions.

Psoriasis plaques are often found on the extensor surfaces, especially at the elbows and knees, in addition to other areas. The scalp is often involved. Psoriasis scale is usually thick and silver and bleeds when removed (Auspitz sign).

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Causes

The etiology is unknown and likely multifactorial.

Most patients with nummular dermatitis also have very dry (xerotic) skin.

Local trauma, such as arthropod bites, contact with chemicals, or abrasions, may precede an outbreak.

Contact dermatitis may play a role in some cases. Contact dermatitis may be irritant or allergic in nature. Sensitivity to nickel, cobalt, or chromates has been reported in patients with nummular dermatitis. In one study, the most frequent sensitizers were colophony, nitrofurazone, neomycin sulfate, and nickel sulfate. In the past, cases of nummular eczema–like eruptions have been caused by ethyl cyanoacrylate–containing glue, thimerosal,[9] mercury-containing dental amalgams,[10] and depilating creams containing potassium thioglycolate.

Venous insufficiency (and varicosities), stasis dermatitis, and edema may be related to involvement of the affected lower extremities.[11]

Autoeczematization (ie, lesional spread from the initial focal site) may account for the presence of multiple plaques.

Onset of severe, generalized nummular lesions has been reported in association with interferon therapy for hepatitis C as well as exposure to mercury.[12]

Various types of eczematous eruptions, including nummular dermatitis, have been observed following tumor necrosis factor-alpha blocking therapy.[5]

Nummular eczema has been found in association with infection in rare cases. Giardiasis has been reported.[13] One study reported that in patients with Helicobacter pylori infection and nummular dermatitis, eradication of H pylori caused clearance of the skin lesions in 54% of the patients.[14] Another case report noted nummular eczema in association with a dental infection that cleared after the treatment of the infection.[15]

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Contributor Information and Disclosures
Author

Jami L Miller, MD  Assistant Professor, Division of Dermatology, Department of Internal Medicine, Vanderbilt University Medical School; Director of Phototherapy Unit, Vanderbilt University Medical Center; Consulting Attending Physician, Nashville Veterans Affairs Medical Center

Jami L Miller, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

John D Wilkinson, MD, MBBS, MRCS, FRCP  Chairman, Clinical Director, Department of Dermatology, Amersham Hospital and High Wycombe Hospital, UK

John D Wilkinson, MD, MBBS, MRCS, FRCP is a member of the following medical societies: American Academy of Dermatology and Royal College of Physicians

Disclosure: Nothing to disclose.

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Paul Krusinski, MD  Director of Dermatology, Fletcher Allen Health Care; Professor, Department of Internal Medicine, University of Vermont College of Medicine

Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD  Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System

William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

References

  1. Aoyama H, Tanaka M, Hara M, Tabata N, Tagami H. Nummular eczema: An addition of senile xerosis and unique cutaneous reactivities to environmental aeroallergens. Dermatology. 1999;199(2):135-9. [Medline].

  2. Ozkaya E. Adult-onset atopic dermatitis. J Am Acad Dermatol. Apr 2005;52(4):579-82. [Medline].

  3. Moore MM, Elpern DJ, Carter DJ. Severe, generalized nummular eczema secondary to interferon alfa-2b plus ribavirin combination therapy in a patient with chronic hepatitis C virus infection. Arch Dermatol. Feb 2004;140(2):215-7. [Medline].

  4. Shen Y, Pielop J, Hsu S. Generalized nummular eczema secondary to peginterferon Alfa-2b and ribavirin combination therapy for hepatitis C infection. Arch Dermatol. Jan 2005;141(1):102-3. [Medline].

  5. Flendrie M, Vissers WH, Creemers MC, de Jong EM, van de Kerkhof PC, van Riel PL. Dermatological conditions during TNF-alpha-blocking therapy in patients with rheumatoid arthritis: a prospective study. Arthritis Res Ther. 2005;7(3):R666-76. [Medline].

  6. Horsmanheimo L, Harvima IT, Jarvikallio A, Harvima RJ, Naukkarinen A, Horsmanheimo M. Mast cells are one major source of interleukin-4 in atopic dermatitis. Br J Dermatol. Sep 1994;131(3):348-53. [Medline].

  7. Jarvikallio A, Naukkarinen A, Harvima IT, Aalto ML, Horsmanheimo M. Quantitative analysis of tryptase- and chymase-containing mast cells in atopic dermatitis and nummular eczema. Br J Dermatol. Jun 1997;136(6):871-7. [Medline].

  8. Jarvikallio A, Harvima IT, Naukkarinen A. Mast cells, nerves and neuropeptides in atopic dermatitis and nummular eczema. Arch Dermatol Res. Apr 2003;295(1):2-7. [Medline].

  9. Patrizi A, Rizzoli L, Vincenzi C, Trevisi P, Tosti A. Sensitization to thimerosal in atopic children. Contact Dermatitis. Feb 1999;40(2):94-7. [Medline].

  10. Pigatto PD, Guzzi G, Persichini P. Nummular lichenoid dermatitis from mercury dental amalgam. Contact Dermatitis. Jun 2002;46(6):355-6. [Medline].

  11. Bendl BJ. Nummular eczema of statis origin. The backbone of a morphologic pattern of diverse etiology. Int J Dermatol. Mar 1979;18(2):129-35. [Medline].

  12. Adachi A, Horikawa T, Takashima T, Ichihashi M. Mercury-induced nummular dermatitis. J Am Acad Dermatol. Aug 2000;43(2 Pt 2):383-5. [Medline].

  13. Pietrzak A, Chodorowska G, Urban J, Bogucka V, Dybiec E. Cutaneous manifestation of giardiasis - case report. Ann Agric Environ Med. 2005;12(2):299-303. [Medline].

  14. Sakurane M, Shiotani A, Furukawa F. Therapeutic effects of antibacterial treatment for intractable skin diseases in Helicobacter pylori-positive Japanese patients. J Dermatol. Jan 2002;29(1):23-7. [Medline].

  15. Tanaka T, Satoh T, Yokozeki H. Dental infection associated with nummular eczema as an overlooked focal infection. J Dermatol. 2009. Aug;36(8):462-5. [Medline].

  16. Khurana S, Jain VK, Aggarwal K, Gupta S. Patch testing in discoid eczema. J Dermatol. Dec 2002;29(12):763-7. [Medline].

  17. Krupa Shankar DS, Shrestha S. Relevance of patch testing in patients with nummular dermatitis. Indian J Dermatol Venereol Leprol. Nov-Dec 2005;71(6):406-8. [Medline].

  18. Gutman AB, Kligman AM, Sciacca J, James WD. Soak and smear: a standard technique revisited. Arch Dermatol. Dec 2005;141(12):1556-9. [Medline].

  19. Gambichler T. Management of atopic dermatitis using photo(chemo)therapy. Arch Dermatol Res. Mar 2009;301(3):197-203. [Medline].

  20. [Best Evidence] Roberts H, Orchard D. Methotrexate is a safe and effective treatment for paediatric discoid (nummular) eczema: a case series of 25 children. Australas J Dermatol. May 2010;51(2):128 - 130. [Medline].

  21. Bukhari IA. Successful treatment of chronic persistent vesicular hand dermatitis with topical pimecrolimus. Saudi Med J. Dec 2005;26(12):1989-91. [Medline].

  22. Clark RA, Hopkins TT. The other eczemas. In: Moschella SL, Hurley HJ, eds. Dermatology. Vol 1. 3rd ed. Philadelphia, Pa: WB Saunders; 1992:482-4.

  23. Cowan MA. Nummular eczema. A review, follow-up and analysis of a series of 325 cases. Acta Derm Venereol. 1961;41:453-60. [Medline].

  24. Hellgren L, Mobacken H. Nummular eczema--clinical and statistical data. Acta Derm Venereol. 1969;49(2):189-96. [Medline].

  25. Krogh HK. Nummular eczema. Its relationship to internal foci of infection. A survey of 84 case records. Acta Derm Venereol. 1960;40:114-26. [Medline].

  26. Krueger GG, Kahn G, Weston WL, Mandel MJ. IgE levels in nummular eczema and ichthyosis. Arch Dermatol. Jan 1973;107(1):56-8. [Medline].

  27. Le Coz C. Contact nummular (discoid) eczema from depilating cream. Cont Dermat. 2002;46:111-112.

  28. O'Loughlin S, Diaz-Perez JL, Gleich GJ, Winkelmann RK. Serum IgE in dermatitis and dermatosis: an analysis of 497 cases. Arch Dermatol. Mar 1977;113(3):309-15. [Medline].

  29. Soter NA. Nummular eczematous dermatitis. In: Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, Fitzpatrick TB, eds. Fitzpatrick's Dermatology in General Medicine. 5th ed. New York, NY: McGraw-Hill; 1999:1480.

  30. White JW. Eczematous reaction patterns: nummular eczema. In: Sams WM, Lynch PJ, eds. Principles and Practice of Dermatology. 2nd ed. New York, NY: tone: Churchill Livings; 1996:443.

 
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Dry, scaling plaque of nummular dermatitis (size, 3 X 5 cm) on the shin.
 
 
 
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