Neurodermatitis

Neurodermatitis belongs to the group of allergic dermatoses and is the most common skin disease.

Characterized by rashes on the skin of nodular (papular) elements, prone to merging and forming foci of infiltration and lichenification, accompanied by severe itching.

[ 1 ], [ 2 ]

Epidemiology

In recent decades, its incidence has tended to increase. The proportion of this disease in patients of all age groups seeking outpatient care for skin diseases is about 30%, and among those hospitalized in dermatological hospitals - up to 70%. This disease has a chronic course, often recurs, is one of the main causes of temporary disability and can cause disability of patients.

[ 3 ], [ 4 ], [ 5 ], [ 6 ], [ 7 ]

Causes neurodermatitis

It is a multifactorial, chronic, recurrent inflammatory disease, in the development of which the most important factors are functional disorders of the nervous system, immune disorders and allergic reactions, as well as hereditary predisposition.

The cause of neurodermatitis has not been definitively established. According to modern concepts, it is a genetically determined disease with multifactorial inheritance of predisposition to allergic reactions. The importance of genetic factors is confirmed by the high frequency of the disease among close relatives and in monozygotic twins. According to immunogenetic research, allergic dermatosis is reliably associated with HLA B-12 and DR4.

The expression of genetic predisposition to allergies is determined by various environmental influences - trigger factors. There are food, inhalation, external irritants, psycho-emotional and other factors. Contact with these factors can occur both in everyday life and in production conditions (professional factors).

Exacerbation of the skin process due to the use of food products (milk, eggs, pork, poultry, crabs, caviar, honey, sweets, berries and fruits, alcohol, spices, seasonings, etc.). The disease is observed in more than 90% of children and 70% of adults. As a rule, polyvalent sensitivity is detected. Children have a seasonal increase in sensitivity to food products. With age, the role of inhaled allergens in the development of dermatitis becomes more noticeable: house dust, wool hairs, cotton, bird feathers, mold, perfumes, paints, as well as wool, fur, synthetic and other fabrics. Unfavorable weather conditions worsen the course of the pathological condition.

Psychoemotional stress contributes to the exacerbation of allergic dermatosis in almost a third of patients. Among other factors, endocrine changes (pregnancy, menstrual irregularities), medications (antibiotics), preventive vaccinations, etc. are noted. Of great importance to them are foci of chronic infection in the ENT organs, digestive and genitourinary spheres, as well as bacterial colonization of the skin. Activation of these foci often leads to an exacerbation of the underlying disease.

In the pathogenesis of neurodermatitis, as well as eczema, the leading role belongs to dysfunctions of the immune, central and autonomic nervous systems. The basis of immune disorders is a decrease in the number and functional activity of T-lymphocytes, mainly T-suppressors, which regulate the synthesis of immunoglobulin E by B-lymphocytes. IgE binds to blood basophils and mast cells, which begin to produce histamine, causing the development of GNT.

Disorders of the nervous system are represented by neuropsychiatric (depression, emotional lability, aggressiveness) and vegetative-vascular disorders (paleness and dryness of the skin). In addition, allergic dermatosis is combined with pronounced white dermographism.

Impaired microvascular tone is combined with changes in the rheological properties of the skin, which leads to disruption of the structure and barrier function of the skin and mucous membranes, increased permeability to antigens of various natures, and contributes to the development of infectious complications. Immune disorders lead to polyvalent sensitization, which underlies atopy (strange disease), which is understood as increased sensitivity of the body to various irritants. Therefore, these patients often have a combination of neurodermatitis with other atopic, mainly respiratory, diseases: vasomotor rhinitis, bronchial asthma, hay fever, migraine, etc.

[ 8 ], [ 9 ]

Pathogenesis

Neurodermatitis is characterized by pronounced uniform acanthosis with elongation of epithelial processes; spongiosis without vesicle formation: the granular layer is weakly expressed or absent, hyperkeratosis, sometimes alternating with parakeratosis. There is a moderate perivascular infiltrate in the dermis.

The limited form has acanthosis, papillomatosis with pronounced hyperkeratosis. In the papillary layer of the dermis and in its upper part, focal, predominantly perivascular infiltrates are detected, consisting of lymphocytes with an admixture of fibroblasts, as well as fibrosis. Sometimes the picture resembles psoriasis. In some cases, areas of spongiosis and intracellular edema are encountered, which resembles contact dermatitis. Proliferating cells are quite large, with conventional staining methods they can be mistaken for atypical ones observed in fungoid mycosis. In such cases, clinical data help to make the correct diagnosis.

The diffuse form of neurodermatitis in fresh foci has acanthosis, edema of the dermis, sometimes spongiosis and exocytosis, as in eczema. In the dermis - perivascular infiltrates of lymphocytes with an admixture of neutrophilic granulocytes. In older foci, in addition to acanthosis, hyperkeratosis and parakeratosis are expressed, sometimes spongiosis. In the dermis - dilation of capillaries with swelling of the endothelium, around which small infiltrates of a lymphohistiocytic nature with an admixture of a significant number of fibroblasts are visible. In the central part of the lesion, pigment in the basal layer is not detected, while in its peripheral parts, especially in old lichenified foci, the amount of melanin is increased.

In adult patients, changes in the dermis prevail over changes in the epidermis. The histological picture in the epidermis resembles that of generalized exfoliative dermatitis or erythroderma, since various degrees of acanthosis with elongation of epidermal outgrowths and their branching, migration of lymphocytes and neutrophilic granulocytes, foci of parakeratosis are observed, but there are no vesicles. In the dermis, edema of the capillary walls with swelling of the endothelium, sometimes hyalinosis, is observed. Elastic and collagen fibers are without significant changes. In the chronic process, infiltration is insignificant, fibrosis is noted.

[ 10 ], [ 11 ], [ 12 ], [ 13 ], [ 14 ], [ 15 ], [ 16 ], [ 17 ], [ 18 ]

Histogenesis

One of the factors predisposing to the development of atopy is considered to be congenital transient immunodeficiency. In the skin of patients, a decrease in the number of Langerhans cells and a decrease in the expression of HLA-DR antigens on them, an increase in the proportion of Langerhans cells with IgE receptors were found. Of the immune disorders, an increased level of IgE in the blood serum is noted, which is believed to be genetically determined, although this sign is not observed in all patients with neurodermatitis, a deficiency of T-lymphopites, especially those with suppressor properties, probably due to a defect in beta-adrenergic receptors. The number of B cells is normal, but there is a slight increase in the proportion of B lymphocytes carrying receptors for the Fc fragment of IgE. Neutrophil chemotaxis, the function of natural killers, and the production of interleukin-1 by monocytes of patients are reduced compared to control observations. The presence of a defect in the immune system is apparently one of the main reasons for the susceptibility of patients to infectious diseases. The pathogenetic significance of nonbacterial allergy to allergens of infectious origin has been shown. Neurovegetative disorders are given both etiologic and aggravating significance in the course of the disease. The disease is characterized by a decrease in the content of prostaglandin precursors in the blood serum, a decrease in the cAMP level in leukocytes due to a defect in beta-adrenergic receptors, as well as as a result of increased phosphodiesterase activity. It is believed that a consequence of a decreased cAMP level may be an increased release of inflammatory mediators from leukocytes, including histamine, which through the H2 receptor cause a decrease in the functional activity of T-lymphocytes. This can explain the hyperproduction of IgE. An association with some histocompatibility antibodies has been found: HLA-A1, A9, B12, D24, DR1, DR7, etc. According to P.M. Alieva (1993), the DR5 antigen is a risk factor for the development of this pathological condition, and the DR4 and DRw6 antigens are resistance factors. Most authors consider the limited and diffuse forms to be an independent disease, however, the detection of immune phenomena characteristic of atopic dermatitis in patients with limited allergodermatosis, the absence of differences in the distribution of histocompatibility antigens in patients with different prevalence of the process, and the similarity in the disruption of biogenic amine metabolism allow us to consider the diffuse and limited forms to be a manifestation of one pathological condition.

[ 19 ], [ 20 ], [ 21 ], [ 22 ], [ 23 ]

Symptoms neurodermatitis

Neurodermatitis of the first age period begins at 2-3 months of age and continues until 2 years. Its features are:

• connection with alimentary stimuli (introduction of complementary foods);
• specific localization (face, collar zone, outer surface of the limbs);
• acute and subacute nature of the lesion with a tendency to exudative changes.

An obligatory sign of the first period is the localization of the lesion on the cheeks. Primary rashes are characterized by erythematous-edematous and erythematous-squamous lesions, papules, vesicles, weeping and crusts - the so-called infantile eczema. Then the process gradually spreads to the collar zone (bib zone), upper limbs. In the 2nd year of life, exudative phenomena in the child subside and are replaced by the appearance of small polygonal shiny papules, accompanied by itching. In addition, the rashes tend to be limited and are located in the area of the ankles, wrists, elbows and neck folds.

Neurodermatitis of the second age period (from 2 years to puberty) is characterized by:

• localization of the process in folds;
• chronic nature of inflammation;
• development of secondary changes (dyschromia);
• manifestations of vegetative dystonia;
• wave-like and seasonal nature of the current;
• response to many provoking factors and reduction of alimentary hypersensitivity.

Typical localization of lesions at this age are the elbow fossa, the back of the hands and the area of the wrist joints, the popliteal fossa and the area of the ankle joints, the folds behind the ears, the neck, and the trunk. This disease has a typical morphological element - a papule, the appearance of which is preceded by severe itching. Due to the grouping of papules, the skin in the folds becomes infiltrated, with a pronounced increase in the pattern (lichenification). The color of the foci is stagnant red. The foci of lichenification become rougher, dyschromatic.

By the end of the second period, an "atonic face" develops - hyperpigmentation and accentuation of the folds in the eyelid area, giving the child a "tired look". Other areas of the skin are also changed, but without clinically expressed inflammation (dryness, dullness, bran-like peeling, dyschromia, infiltration). The disease is characterized by seasonality of the course and consists of the development of exacerbations in the autumn-winter period and a significant improvement or resolution of the process in the summer, especially in the south.

The distinctive features of the third age period (the phase of puberty and adulthood) are:

• changes in the localization of lesions:
• pronounced infiltrative nature of the lesions.
• less noticeable reaction to allergens:
• unclear seasonality of exacerbations.

The fold lesions are replaced by changes in the skin of the face, neck, trunk, and limbs. The nasolabial triangle is involved in the process. The inflammation has a stagnant-cyanotic tint. The skin is infiltrated, lichenified with multiple biopsy scratches, hemorrhagic crusts.

It should be emphasized that throughout all age periods neurodermatitis has a leading clinical sign - itching, which persists for a long time even after the disappearance of skin lesions. The intensity of itching is high (biopsizing ZKD), with paroxysms at night.

Limited neurodermatitis is more common in adult men and is characterized by the presence of one or more plaque-like lesions of various sizes and shapes on the skin of the neck, genitals (anogenital area), elbows and popliteal folds. The plaques are located symmetrically, relatively clearly delimited from the unaffected skin by a zone of herpigmentation. In the area of the lesions, the skin is dry, infiltrated, with an emphasized pattern, more pronounced in the center. On the periphery of the lesions are small (with a pinhead) polygonal flat papules with a shiny surface of brownish-red or pink color.

With pronounced infiltration and lichenification, warty hyperpigmented foci appear. The onset of the disease is usually associated with psychoemotional or neuroendocrine disorders. Patients are bothered by intense itching. White dermographism is observed in those suffering from various forms of this allergic dermatosis.

[ 24 ], [ 25 ]

Forms

A distinction is made between: diffuse, limited (chronic lichen vitiligo) and Broca's neurodermatitis, or atopic dermatitis (according to the WHO classification).

Atopic dermatitis most often affects women (the ratio of sick women to men is 2:1). Three age periods are distinguished during the course of the disease.

Limited neurodermatitis (syn.: lichen simplex chronicus Vidal, dermatitis lichenoides pruriens Neisser) is clinically manifested by one or several very itchy dry plaques, located mainly on the posterolateral surfaces of the neck, in the area of skin folds and surrounded by small papular elements and slight pigmentation, gradually turning into normal skin. Sometimes depigmentation develops at the sites of scratches. With pronounced infiltration and lichenification, hypertrophic, warty lesions may occur. Rare variants include depigmented, linear, moniliform, decalving, psoriasiform form, giant lichenification of Pautrier.

Diffuse neurodermatitis (syn.: prurigo ordinary Darier, prurigo diathesis Besnier, atopic dermatitis, endogenous eczema, constitutional eczema, atopic allergic dermatosis) is a more severe pathological condition than limited neurodermatitis, with more pronounced skin inflammation, itching, greater prevalence of the process, sometimes occupying the entire skin like erythroderma. The skin of the eyelids, lips, hands and feet is often affected. Unlike the limited form, it develops mainly in childhood, often combined with other manifestations of atopy, which gives grounds in these cases to consider this disease as atopic allergic dermatosis. Sometimes cataracts are detected (Andogsky syndrome), often - ordinary ichthyosis. In children, skin lesions of the eczematized allergic dermatosis type may be a manifestation of Wiskott-Aldrich syndrome, inherited recessively linked to the X chromosome and manifested, in addition, by thrombocytopenia, bleeding, dysglobulinemia, an increased risk of developing infectious and malignant diseases, primarily of the lymphohistiocytic system.

[ 26 ], [ 27 ], [ 28 ], [ 29 ], [ 30 ]

Complications and consequences

Neurodermatitis is complicated by recurrent bacterial, viral and fungal infections, especially in people who have been using hormonal ointments for a long time. Bacterial complications include folliculitis, furunculosis, impetigo, and hidradenitis. The causative agent of these complications is usually Staphylococcus aureus, less often Staphylococcus epidermidis, Staphylococcus alba or Streptococcus, the source of which are foci of chronic infection. The development of complications is accompanied by chills, increased body temperature, sweating, increased hyperemia and itching. The peripheral lymph nodes are enlarged and painless.

One of the most severe complications that can accompany the disease is Kaposi's eczema herpetiformis, the mortality rate of which among children ranges from 1.6 to 30%. The causative agent is the herpes simplex virus, mainly type 1, which causes damage to the upper respiratory tract and skin around the nose and mouth. Less common is type 2 virus, which affects the mucous membrane and skin of the genitals. The disease begins acutely 5-7 days after contact with a patient with herpes simplex and is manifested by chills, an increase in body temperature to 40 ° C, weakness, adynamism, prostration. After 1-3 days, a rash of small, pinhead-sized blisters filled with serous, less often hemorrhagic contents appears. Later, the blisters turn into pustules and acquire a typical appearance with an umbilical depression in the center. During the evolution of elements, bleeding erosions are formed, the surface of which is covered with hemorrhagic crusts. The patient's face acquires a "mask-like" appearance. The damage to the mucous membranes occurs as aphthous stomatitis, conjunctivitis, keratoconjunctivitis.

Kaposi's eczema may be complicated by the development of streptococcal and staphyloderma, pneumonia, otitis media, and sepsis. After 10-14 days, the rash begins to regress, leaving small superficial scars in their place.

Fungal complications include candidal cheilitis, onychia and paronychia. Rarely, neurodermatitis is complicated by atopic cataract, which develops in no more than 1% of patients (Andogsky syndrome).

[ 31 ], [ 32 ], [ 33 ], [ 34 ], [ 35 ]

Diagnostics neurodermatitis

A dermatologist diagnoses neurodermatitis by examining the affected skin. To rule out other diseases, he or she may take a sample of the affected skin for a skin biopsy.

[ 36 ], [ 37 ], [ 38 ], [ 39 ], [ 40 ], [ 41 ], [ 42 ]

Differential diagnosis

Neurodermatitis must be differentiated from chronic eczema, lichen planus, and nodular pruritus. Chronic eczema is characterized by true polymorphism of rash elements, represented by microvesicles, microerosions, microcrusts with pronounced weeping in the form of "serous wells" accompanied by itching. This allergic dermatosis is characterized by itching, which precedes the appearance of papular rashes. Eczema is also characterized by the localization of lesions on limited areas of the skin. Dermographism in eczema is red, while in this allergic dermatosis it is white.

Lichen planus is characterized by scattered polygonal purple papules with an umbilical depression in the center, located on the inner surface of the upper limbs, the anterior surface of the shins, and the trunk. Sometimes the mucous membranes of the oral cavity and genitals are affected. When the papules are lubricated with vegetable oil, a mesh pattern (Wickham's mesh) is revealed.

Nodular and nodular pruritus is characterized by a rash of hemispherical papules that are not prone to merging and grouping and are accompanied by severe itching.

[ 43 ], [ 44 ], [ 45 ], [ 46 ], [ 47 ], [ 48 ]

Treatment neurodermatitis

It is difficult to name a pathological condition in which precise and patient implementation of all preventive and therapeutic recommendations would be more important than in neurodermatitis. In addition, it should be emphasized that its treatment should not be expectant (“it will pass with age”) and masking (prescribing only antihistamines and hormonal ointments).

Neurodermatitis must be treated according to the following principles:

• Enterosorption using polyphenan, enterosorbent, activated carbon. Diuretics (triampur, veroshpiron) Fasting days (1-2 days a week). Prescription of low-molecular agents and plasma substitutes (hemodez, rheopolyglucin, etc.).
• Neurodermatitis requires treatment of foci of chronic bacterial and parasitic infection.
• Restoration of impaired functions of the gastrointestinal tract with normalization of digestion and absorption (depending on the detected deviations). Correction of dysbacteriosis with antibiotics, staphylococcal bacteriophage, lactobacterin, bifidumbacterin, bificol. In case of enzyme deficiency (according to coprogram data) - pepsidin, pancreatin, panzinorm, mezim-forte, festal, digestal. In case of biliary dyskinesia - no-shpa, papaverine, platifillin, halidor, sunflower oil, magnesium sulfate, corn silk decoction, xylitol, sorbitol.
• A non-specific hyposensitizing effect is provided by diet, antihistamines (zaditen, tavegil, suprastin, fenkarol, etc.), prescribed in short courses.
• In case of immune deficiency, sodium nucleinate, methyluracil, and T-activin are used. Vitamins A, C, PP, and group B are used as non-specific stimulants.
• To correct disorders of the central and autonomic nervous system, pyrroxane butyroxane, stugeron (cinnarizine), valerian tincture, and tranquilizers (imenam, seduxen) are used.
• To restore hemocoagulation disorders and microcirculation, infusion therapy (hemodez, rheopolyglucin), trental, curantil, complamin are used.
• In order to restore the function of the adrenal glands, those who have been ill for a long time are prescribed ethimizole, ammonium chloride solution, glyceram, and inductothermy on the adrenal gland area.
• Pastes and ointments (zinc, dermatol, ASD 3rd fraction, birch tar) are used as external therapy. It is not recommended to use hormonal ones, especially on the skin of the face.
• Ultraviolet irradiation using a gentle technique (in suberythemal doses), d'Arsonval currents, inductothermy on the adrenal glands, diathermy on the cervical sympathetic nodes.
• Patients with severe forms of allergic dermatosis are recommended to undergo selective phototherapy (PUVA therapy), hyperbaric oxygenation, and ultraviolet irradiation of the blood.
• Sanatorium and resort treatment. Patients are recommended heliotherapy at southern seaside resorts, Matsesta and other sulphide applications and baths.

[ 49 ], [ 50 ], [ 51 ], [ 52 ], [ 53 ]

Clinical examination

Patients with all clinical forms of diseases are subject to medical examination. When vocational guidance of patients, it is necessary to take into account contraindications for professions associated with prolonged and excessive emotional stress, contact with inhalants (perfume, pharmaceutical, chemical, confectionery production), mechanical and chemical irritants (textile, fur enterprises, hairdressers), strong physical impacts (noise, cooling).

[ 54 ], [ 55 ], [ 56 ], [ 57 ], [ 58 ]

Forecast

Limited neurodermatitis has a more favorable prognosis than diffuse neurodermatitis, although in the latter case the process regresses with age in most patients, sometimes remaining in the form of focal manifestations such as hand eczema. Some authors point to a possible connection between the disease and Sezary syndrome.

[ 59 ]