eMedicine Specialties > Dermatology > Reactive & Inflammatory Dermatoses
Nummular Dermatitis: Treatment & Medication
Updated: Aug 3, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Treatment is aimed at rehydration of the skin and repair of the epidermal lipid barrier, reduction of inflammation and treatment of any infection.
- Lukewarm or cool baths or showers reduce itching and help rehydrate the skin. Patients should be instructed to bathe 1-2 times a day at least, followed by the application of moisturizers or medicated topical preparations to seal the water in the skin. The "soak-and-smear" therapeutic regimen includes a 20-minute plain water soak each night followed by application of steroid ointment or petrolatum to wet skin and includes alteration of cleansing habits so that soap is applied only to the axilla and groin. One study showed greater than 90% response in 27 of 28 patients with refractory chronic pruritic eruptions when the regimen was followed as directed.17
- Wet wrap treatments are often helpful. This involves dampening the skin with lukewarm water until it is well hydrated (usually 10 min). Then, petrolatum or steroid ointment is applied liberally, followed by occlusion for 1 hour with damp pajamas or a nonbreathable sauna suit. For small areas of involvement, plastic wrap may be used to occlude the area. This process may be repeated 5-6 times a day with petrolatum. Caution must be used when prescription steroid medications are used because overuse of these medications can cause striae, thinning of the skin, and, rarely, enough systemic absorption of steroid to affect the hypothalamic-pituitary-adrenal axis.
- Steroids are the most commonly used therapy to reduce inflammation.
- Topical steroids are effective. Less erythematous, less pruritic lesions may be treated with low-potency (class III-VI) steroids. Severely inflamed lesions with intense erythema, vesicles, and pruritus require high-potency (class I-II) preparations. Penetration of the medication is enhanced by occlusion or presoaking in a tub of plain water followed immediately (without drying) by application of the steroid-containing ointment.
- Application of the medicine to damp skin allows more effective penetration and faster healing.
- Ointments are usually more effective than creams because they are more occlusive, form a barrier between the skin and the environment, and more effectively hold water into the skin.
- Emollients and topical class I-III topical steroids may be used short term.
- Oral, intramuscular, or parenteral steroids may be required in cases of severe, generalized eruptions.
- Tar preparations are helpful to decrease inflammation, particularly in older, thickened, scaly plaques.
- Topical immune modulators (tacrolimus and pimecrolimus) also reduce inflammation. These are often initiated a few days after the topical steroid to decrease the risk of a burning sensation that may occur when applied to extremely irritated skin.
- When eruptions are generalized and prolonged, phototherapy (generally UVB) may be helpful.18
- Oral antihistamines or sedatives may help reduce itching and improve sleep.
- Oral antibiotics, such as dicloxacillin, cephalexin, or erythromycin, should be used in cases of secondary infection. Swab cultures of the skin guide selection of antibiotics.
- Once the eruption has resolved, ongoing aggressive hydration may decrease the frequency between flares, particularly in dry climates. Heavy moisturizers (preferably a sensitive-skin formulation) or petroleum jelly applied to damp skin after showering may be helpful.
Consultations
Because lesions are persistent and may be difficult to treat, consultation with a dermatologist in an outpatient setting may be advisable.
Activity
Activities that heat or dry the skin worsen the pruritus and the eruption.
- Resting in a cool, moist environment is therapeutic.
- Heat, drying conditions, and irritating activities should be avoided.
- Sunlight or phototherapy may be beneficial, particularly in chronic cases. Ultraviolet radiation helps reduce the inflammatory activity within the skin. The risk of heat worsening the pruritus and of ultraviolet light inducing cutaneus malignancies must be weighed against the potential benefits.
Medication
A potent-to-intermediate potency steroid may be applied 2-4 times daily to the affected areas. They are most effective when used in ointment form (rather than cream) and applied to damp skin. Once lesions improve, a lower-potency steroid or moisturizer should be prescribed to avoid skin atrophy.
If the patient has an overt infection, a combination of a topical antibiotic and a steroid ointment applied twice daily is usually very effective. This therapy decreases inflammation and colonization by staphylococci.
Use of sedating antihistamines at night helps with sleep.
Severe or generalized flares may be treated with tap water–moistened dressings on top of the steroid ointment. Oral or parenteral steroids may be used in severe flares, followed by topical therapy.
Oral antibiotics, such as dicloxacillin, cephalexin, or erythromycin, should be used in cases of secondary infection.
Corticosteroids
Have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, modify the body's immune response to diverse stimuli.
Triamcinolone (Aristocort)
For inflammatory dermatosis responsive to steroids; decreases inflammation by suppressing migration of PMN leukocytes and reversing capillary permeability. A good choice once lesions stabilize and the threat of secondary infection has passed. Use 0.025-0.1% strength.
Adult
Apply thin film to affected area bid
Pediatric
Not established
None reported
Documented hypersensitivity; fungal, viral, or bacterial skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Prolonged use may induce skin atrophy; avoid use in sensitive areas (eg, groin, axillae, face); prolonged use, applications over large areas, and use of potent steroids and occlusive dressings may result in systemic absorption; systemic absorption may cause Cushing syndrome, reversible HPA-axis suppression, hyperglycemia, and glycosuria
Prednisone (Deltasone, Meticorten, Orasone)
For severe generalized flares. May decrease inflammation by reversing increased capillary permeability and suppressing PMN leukocyte activity.
Adult
40-60 mg PO qd with rapid taper
Pediatric
0.14 mg/kg or 4-6 mg/m2 PO in divided doses
May decrease oral anticoagulant effectiveness; increases metabolism of isoniazid and salicylates; coadministration with estrogens may decrease clearance; when used with digoxin, digitalis toxicity secondary to hypokalemia may increase; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral, fungal, tubercular skin, or connective-tissue infections; peptic ulcer disease; hepatic dysfunction
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur; adjust dose in persons with hypoglycemia and in those on insulin
Clobetasol propionate (Clobex, Cormax)
Class I superpotent topical steroid; suppresses mitosis and increases synthesis of proteins that decrease inflammation and cause vasoconstriction. Decreases inflammation by stabilizing lysosomal membranes, inhibiting PMN and mast cell degranulation.
Adult
Apply bid for up to 2 wk; not to exceed 50 g/wk
Pediatric
Not established
None reported
Documented hypersensitivity; viral or fungal skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May suppress adrenal function in prolonged therapy
Immune modulators
Reduces inflammation.
Pimecrolimus 1% cream (Elidel)
First nonsteroid cream approved in the United States for mild-to-moderate atopic dermatitis. Derived from ascomycin, a natural substance produced by fungus Streptomyces hygroscopicus var ascomyceticus. Selectively inhibits production and release of inflammatory cytokines from activated T-cells by binding to cytosolic immunophilin receptor macrophilin-12. Resulting complex inhibits phosphatase calcineurin, thus blocking T-cell activation and cytokine release. Cutaneous atrophy was not observed in clinical trials, a potential advantage over topical corticosteroids. Indicated only after other treatment options have failed.
Adult
Apply topically to affected areas bid; short-term and intermittent use only
Pediatric
<2 years: Not established
>2 years: Administer as in adults
Short-term and intermittent use only
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Potential exacerbation of existing infection at site of application; may cause burning and irritation; product insert revised and contains a boxed warning stating long-term safety of calcineurin inhibitors has not been established; although a causal relationship has not been established, rare cases of malignancy (eg, skin and lymphoma) have been reported
Tacrolimus 0.03% or 0.1% ointment (Protopic)
The mechanism of action of tacrolimus in atopic dermatitis is not known. Reduces itching and inflammation by suppressing the release of cytokines from T cells. Also inhibits transcription for genes that encode IL-3, IL-4, IL-5, GM-CSF, and TNF-alpha, all of which are involved in the early stages of T-cell activation. Additionally, may inhibit release of preformed mediators from skin mast cells and basophils, and down-regulate expression of FCeRI on Langerhans cells. Can be used in patients as young as 2 y. Drugs of this class are more expensive than topical corticosteroids. Available as an ointment in concentrations of 0.03 and 0.1%. Indicated only after other treatment options have failed.
Adult
Apply thin layer to affected skin areas bid and rub in gently and completely; continue treatment for 1 wk after clearing of signs and symptoms
Short-term and intermittent use only
Pediatric
<2 years: Not recommended
2-15 years: Apply 0.03% ointment bid to affected area(s)
>15 years: Administer as adults
Short-term and intermittent use only
None reported
Documented hypersensitivity to tacrolimus or components of ointment
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use with occlusive dressings; may be associated with an increased risk of folliculitis in adults; may cause local burning sensation, stinging, soreness, or pruritus (typically improve as lesions heal); for external use only; minimize exposure to natural or artificial sunlight (eg, tanning beds or UVA/B treatment); be sure skin is completely dry before application; product insert was revised in January 2006 and contains a boxed warning stating long-term safety of calcineurin inhibitors has not been established; although a causal relationship has not been established, rare cases of malignancy (eg, skin and lymphoma) have been reported; only 0.03% ointment is indicated for use in children aged 2-15 y.
Antihistamines
To help with sleep. Caution must be used because even the traditionally nonsedating classes may cause somnolence.
Hydroxyzine (Atarax, Vistaril, Vistazine)
Antagonizes H1 receptors in periphery. May suppress histamine activity in subcortical region of CNS. Piperazine type of antihistamine that has fewer sedating effects compared with diphenhydramine and is effective. Usually well tolerated in most individuals.
Adult
25-100 mg PO qd/qid
Pediatric
2 mg/kg/d PO; 0.6 mg/kg/dose PO q6h
CNS depression may increase with alcohol or other CNS depressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Associated with clinical exacerbations of porphyria (may not be safe for porphyric patients); ECG abnormalities (alterations in T-waves) may occur; may cause drowsiness
Antibiotics
Used for severe exudative flares with infection. Empiric antimicrobial therapy should cover S aureus and other likely pathogens in the context of the clinical setting.
Sulfamethoxazole and trimethoprim (Bactrim)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa. For MRSA infections.
Adult
160 mg TMP/800 mg SMZ PO q12h for 10-14 d
Pediatric
<2 months: Do not administer
>2 months: 10-20 mg TMP/kg/d PO/IV divided tid/qid for 14 d
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency; age <2 mo
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use during last trimester of pregnancy due to potential toxicity to newborn (eg, jaundice, hemolytic anemia, kernicterus)
Dosage adjustments (adult adjustments)
CrCl (mL/min) 80-50: Recommended IV dose q18h
CrCl 50-10: Recommended IV dose q24h
CrCl <10: Not recommended
Hemodialysis: 4-5 mg/kg after hemodialysis
During peritoneal dialysis: 0.16-0.8 g q48h
Discontinue at first appearance of rash or sign of adverse reaction; obtain CBC counts frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholism, elderly persons, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in persons with G-6-PD deficiency; AIDS patients may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation
Dicloxacillin (Dynapen, Pathocil, Dycill)
Binds to 1 or more penicillin-binding proteins, which, in turn, inhibits synthesis of bacterial cell walls. For treatment of infections caused by penicillinase-producing staphylococci. May use to initiate therapy when staphylococcal infection is suspected.
Adult
125-500 mg PO qid for 7-10 d
Pediatric
Not established
May decrease effects of anticoagulants; probenecid and disulfiram may increase penicillin levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Monitor PT in patients taking anticoagulant medications; toxicity may increase in patients with renal impairment
Erythromycin (E.E.S., E-Mycin, Eryc)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections.
In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half-total daily dose may be taken q12h. For more severe infections, double the dose.
Adult
500 mg PO bid for 7-10 d
Pediatric
Not established
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; adverse GI effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, or abdominal colic occurs
Cephalexin (Biocef, Keflex, Keftab)
First-generation cephalosporin arrests bacterial growth by inhibiting synthesis of bacterial cell walls. Bactericidal activity against rapidly growing organisms. Primary activity against skin flora. Used for skin infections or prophylaxis in minor procedures.
Adult
250-500 mg PO qid for 7-10 d
Pediatric
25-50 mg/kg/d PO divided qid (125 or 250 mg/5 mL)
Probenecid may increase effect of cephalosporins; tetracyclines may decrease effect of cephalosporins with concurrent use
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function
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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Further Reading
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
