Nummular Dermatitis Workup: Laboratory Studies, Procedures, Histologic Findings

Sections

Workup

Laboratory Studies

Tinea corporis should be excluded by scraping and microscopically analyzing a potassium hydroxide preparation of a lesion.

For lesions that have erythema spreading away from the lesions, suggesting cellulitis, swab culture of the exudate may be helpful. First-generation cephalosporins are still usually effective first-line treatment. As methicillin-resistant Staphylococcus aureus becomes more common in a community, the culture results help choose appropriate antibiotics in treatment-resistant cases of documented secondarily infected lesions.

Consider a workup for infection, such as with H pylori and for giardiasis, if appropriate history is suggestive of infection.^[19]

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 other research identified positive patch testing in 23 of 50 patients with nummular dermatitis.^{[24, 25]} A 2012 study strongly recommended patch testing in nummular dermatitis, as it showed that 332 (32.5%) of 1022 patients with nummular dermatitis had positive patch test results for one or more allergens.^[5]

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.

Treatment & Management

Devergie MGA. Traite Pratique des Maladies de la Peau. 1857. 2:238.
Bonamarte D, oti C, Vestita M, Ranieri LD, Angelini g. Nummular eczema and contact allergy: a retrospectove study. Dermatitis. 2012 Jul - Aug. 23(4):153-7. [Medline].
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].
Ozkaya E. Adult-onset atopic dermatitis. J Am Acad Dermatol. 2005 Apr. 52(4):579-82. [Medline].
Bonamonte D, Foti C, Vestita M, Ranieri LD, Angelini G. Nummular eczema and contact allergy: a retrospective study. Dermatitis. 2012 Jul-Aug. 23(4):153-7. [Medline].
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. 2004 Feb. 140(2):215-7. [Medline].
Shen Y, Pielop J, Hsu S. Generalized nummular eczema secondary to peginterferon Alfa-2b and ribavirin combination therapy for hepatitis C infection. Arch Dermatol. 2005 Jan. 141(1):102-3. [Medline].
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].
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. 1994 Sep. 131(3):348-53. [Medline].
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. 1997 Jun. 136(6):871-7. [Medline].
Jarvikallio A, Harvima IT, Naukkarinen A. Mast cells, nerves and neuropeptides in atopic dermatitis and nummular eczema. Arch Dermatol Res. 2003 Apr. 295(1):2-7. [Medline].
Kim JW, Ko HC, Kim MB, Kim JM, Kim BS. Features if Staphylococcous aureus colonization in patients with nummular eczema. Br J Dermatol. 2013 Mar. 168(3):658-60. [Medline].
Jiamton S, Tangjaturonrusamee C, Kulthanan K. Clinical features and aggravating factors in nummular eczema in Thais. Asian Pac J Allergy Immunol. 2013 Mar. 31 (1):36-42. [Medline].
Patrizi A, Rizzoli L, Vincenzi C, Trevisi P, Tosti A. Sensitization to thimerosal in atopic children. Contact Dermatitis. 1999 Feb. 40(2):94-7. [Medline].
Pigatto PD, Guzzi G, Persichini P. Nummular lichenoid dermatitis from mercury dental amalgam. Contact Dermatitis. 2002 Jun. 46(6):355-6. [Medline].
Le Coz CJ. Contact nummular (discoid) eczema from depilating cream. Contact Dermatitis. 2002 Feb. 46 (2):111-2. [Medline].
Bendl BJ. Nummular eczema of statis origin. The backbone of a morphologic pattern of diverse etiology. Int J Dermatol. 1979 Mar. 18(2):129-35. [Medline].
Adachi A, Horikawa T, Takashima T, Ichihashi M. Mercury-induced nummular dermatitis. J Am Acad Dermatol. 2000 Aug. 43(2 Pt 2):383-5. [Medline].
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].
Sakurane M, Shiotani A, Furukawa F. Therapeutic effects of antibacterial treatment for intractable skin diseases in Helicobacter pylori-positive Japanese patients. J Dermatol. 2002 Jan. 29(1):23-7. [Medline].
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].
Jiamton S, Tangjaturonrusamee C, Kulthanan K. Clinical features and aggravating factors in nummular eczema in Thais. Asian Pac J Allergy Immunol. 2013 Mar. 31(1):36-42. [Medline].
Patel N, Mohammadi A, Rhatigan R. A comparative analysis of mast cell quantification in five common dermatoses: lichen simplex chronicus, psoriasis, lichen planus, lupus, and insect bite/allergic contact dermatitis/nummular dermatitis. ISRN Dermatol. 2012. 2012:759630. [Medline]. [Full Text].
Khurana S, Jain VK, Aggarwal K, Gupta S. Patch testing in discoid eczema. J Dermatol. 2002 Dec. 29(12):763-7. [Medline].
Krupa Shankar DS, Shrestha S. Relevance of patch testing in patients with nummular dermatitis. Indian J Dermatol Venereol Leprol. 2005 Nov-Dec. 71(6):406-8. [Medline].
Gutman AB, Kligman AM, Sciacca J, James WD. Soak and smear: a standard technique revisited. Arch Dermatol. 2005 Dec. 141(12):1556-9. [Medline].
Bukhari IA. Successful treatment of chronic persistent vesicular hand dermatitis with topical pimecrolimus. Saudi Med J. 2005 Dec. 26(12):1989-91. [Medline].
Gambichler T. Management of atopic dermatitis using photo(chemo)therapy. Arch Dermatol Res. 2009 Mar. 301(3):197-203. [Medline].
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].

Media Gallery

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

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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, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

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, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

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

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: nakedbiome<br/>Received income in an amount equal to or greater than $250 from: elsevier;webMD<br/>editor in chief for: statpearls.

Additional Contributors

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, Royal College of Physicians

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Khristina Collins, MD, and Lloyd King, MD, to the development and writing of this article.

Nummular Dermatitis Workup

Laboratory Studies

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Histologic Findings

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