eMedicine Specialties > Dermatology > Reactive & Inflammatory Dermatoses

Nummular Dermatitis: Differential Diagnoses & Workup

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
Contributor Information and Disclosures

Updated: Aug 3, 2009

Differential Diagnoses

Asteatotic Eczema
Lichen Simplex Chronicus
Atopic Dermatitis
Pityriasis Rosea
Contact Dermatitis, Allergic
Psoriasis, Plaque
Contact Dermatitis, Irritant
Tinea Corporis
Cutaneous T-Cell Lymphoma

Other Problems to Be Considered

Fixed drug eruption

Workup

Laboratory Studies

  • Tinea corporis should be excluded by scraping and microscopically analyzing a potassium hydroxide preparation of a lesion.
  • For lesions that are vesicular or have yellow crusting suggestive of impetiginization, swab culture may be helpful. As methicillin-resistant Staphylococcus aureus becomes more common in the community, appropriate antibiotics must be chosen for therapy of secondarily infected lesions.
  • Consider a workup for infection, such as with H pylori and for giardiasis.14

Procedures

  • A skin biopsy may be performed. The findings are nonspecific, but they may help differentiate nummular dermatitis from tinea corporis, psoriasis, a fixed drug eruption, or cutaneous T-cell lymphoma.
  • Some studies have recommended patch testing in patients with refractory nummular dermatitis. One study found that 50% of 56 patients with nummular eczema showed positive reactions on patch testing, and more recent research identified positive patch testing in 23 of 50 patients with nummular dermatitis.15,16

Histologic Findings

Biopsy findings mirror the evolution of the lesion. In the early stages, a nonspecific infiltrate is present with spongiosis, vesicles, and a predominant lymphocytic infiltrate. Eosinophils may be observed in the papillary dermis. Chronic lesions demonstrate epidermal hyperplasia, hyperkeratosis, and a pronounced granular cell layer. The papillary dermis may be fibrotic, with a perivenular infiltrate of lymphocytes and monocytes.

Lymphocytes are predominately CD8+ in the epidermis and CD4+ in the dermis. Mast cell–derived interleukin 4 appears to be involved in activation of the T lymphocytes.

More on Nummular Dermatitis

Overview: Nummular Dermatitis
Differential Diagnoses & Workup: Nummular Dermatitis
Treatment & Medication: Nummular Dermatitis
Follow-up: Nummular Dermatitis
Multimedia: Nummular Dermatitis
References
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References

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  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. 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].

  6. 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].

  7. 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].

  8. 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].

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

  10. 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].

  11. 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].

  12. 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].

  13. 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].

  14. 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].

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

  16. 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].

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

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

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

  20. 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.

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

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

  23. 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].

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

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

  26. 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].

  27. 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.

  28. 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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Further Reading

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Keywords

nummular dermatitis, discoid eczema, nummular eczema, nummular eczema, coin-shaped eczema, coin-shaped dermatitis, nummular pruritus, Staphylococcus aureus, S aureus, staphylococcal skin infection, staphylococcal dermatitis

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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.

Medical Editor

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.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University 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.

Managing Editor

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

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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