Neurodermatitis

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

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

[1], [2],

Epidemiology

In recent decades, its frequency tends to increase. The proportion of this disease in patients of all age groups who applied for 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 of the neurodermatitis

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

The cause of neurodermatitis is not definitively established. According to modern concepts, this is a genetically determined disease with a multifactorial inheritance of susceptibility to allergic reactions. The significance of genetic factors is confirmed by the high incidence of the disease among close relatives and in monozygous twins. According to immunogenetic studies, allergic dermatosis is significantly associated with HLA B-12 and DR4.

The expression of a genetic predisposition to allergies is determined by the diverse effects of the external environment - starting factors. Allocate food, inhalation, external stimuli, psycho-emotional and other factors. Contact with these factors can occur both in everyday life and in the conditions of production (professional factors).

Exacerbation of the skin process in connection with the consumption of food (milk, eggs, pork, poultry, crabs, caviar, honey, sweets, berries and fruits, alcohol, spices, spices, etc.). More than 90% of children and 70% of adults have the disease. As a rule, found multivalent sensitivity. In children, there is a seasonal increase in sensitivity to food. With age, the role of inhaled allergens becomes more noticeable in the development of dermatitis: house dust, hairs of wool, cotton, feathers of birds, mold, perfumes, paints, as well as wool, fur, synthetic and other fabrics. Worse during the pathological state of adverse weather conditions.

Psycho-emotional stress contributes to the exacerbation of allergic dermatosis in almost one third of patients. Other factors include endocrine changes (pregnancy, irregular menstruation), drugs (antibiotics), prophylactic vaccinations, etc. Of great importance to them are foci of chronic infection in the LOR-organs, the digestive and urinary areas, and bacterial colonization of the skin. Activation of these foci often leads to exacerbation of the underlying disease.

In the pathogenesis of neurodermatitis, as well as eczema, the leading role belongs to impaired function of the immune, central and vegetative nervous systems. The basis of immune disorders is a decrease in the number and functional activity of T-lymphocytes, predominantly T-suppressors, regulating the synthesis of E immunoglobulins by B-lymphocytes E. IgE is associated with blood basophils and mast cells, which begin to produce histamine, which causes the development of HNT.

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, increasing their permeability to antigens of various nature and contributes to the development of infectious complications. Immune disorders lead to polyvalent sensitization, which is the basis of atopy (strange disease), which means the increased sensitivity of the body to various stimuli. 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 lengthening of epithelial processes; spongiosis without blistering: the granular layer is weak or absent, hyperkeratosis, sometimes intermingled with parakeratosis. In the dermis there is a moderate perivascular infiltrate.

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

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 mixed with neutrophilic granulocytes. In older foci, except acanthosis, hyperkeratosis and parakeratosis, sometimes spongiosis, are expressed. In the dermis there is an expansion of capillaries with swelling of the endothelium, around which small infiltrates of a lymphohistiocytic character are seen with an admixture of a significant amount of fibroblasts. In the central part of the lesion, the pigment in the basal layer is not detected, while in the peripheral parts of it, 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 pattern in the epidermis resembles that of generalized exfoliative dermatitis or erythroderma, as there are varying degrees of acanthosis with lengthening of epidermal outgrowths and their branching, migration of lymphocytes and neutrophil granulocytes, parakeratosis foci, but no vesicles. In the dermis, there is swelling of the capillary walls with swelling of the endothelium, sometimes hyalinosis. Elastic and collagen fibers without any special changes. In a chronic process, infiltration is minor, 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 a congenital transient immunodeficiency state. 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 was found in the skin of patients. Of immune disorders, an increased level of serum IgE is noted, which is believed to be genetically determined, although this symptom is not observed in all patients with neurodermatitis, a deficiency of T-lymphopitis. 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 IgE Fc fragment. The neutrophil chemotaxis, the function of natural killer cells, the production of interleukin-1 by monocytes of patients are reduced compared with control observations. The presence of a defect in the immune system, apparently, is one of the main causes of susceptibility of patients to infectious diseases. The pathogenetic significance of non-bacterial allergy to allergens of infectious origin has been shown. Heurovegetative disorders are given both etiological and aggravating importance during the course of the disease. The disease is characterized by a decrease in serum prostaglandin precursors, in leukocytes, a decrease in cAMP level due to a defect in beta-adrenergic receptors, and also as a result of increased phosphodiesterase activity. It is believed that a consequence of a reduced level of cAMF may be an increased release from leukocytes of inflammatory mediators, including histamine, which, through the H2-recipe, cause a decrease in T-lymphocyte functional activity. This may explain the overproduction of IgE. An association with some antibodies of tissue compatibility was found: HLA-A1, A9, B12, D24, DR1, DR7, etc. According to P.M. Aliyeva (1993). DR5 antigen is a risk factor for the development of this pathological condition, and DR4 and DRw6 antigens are resistance factors. Most authors consider limited and diffuse forms as an independent disease, but the discovery in patients with limited allergic dermatosis of immune phenomena characteristic of atopic dermatitis, the absence of differences in the distribution of tissue compatibility antigens in patients with different prevalence of the process, the similarity in metabolic disturbances of biogenic amines suggest that diffuse and limited forms manifestation of one pathological condition.

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

Symptoms of the neurodermatitis

Neurodermatitis of the first age period begins at 2-3 months and lasts up to 2 years. Its features are:

• relationship with nutritional stimuli (introduction of complementary foods);
• certain localization (face, neck area, outer surface of the extremities);
• acute and subacute nature of the lesion with a tendency to exudative changes.

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 foci, papules, vesicles, soak and crusts - the so-called children's eczema. Then the process gradually spreads to the collar zone (bib zone), upper limbs. At the 2nd year of life, the exudative phenomena in a child subside and are replaced by the appearance of small polygonal shiny papules, accompanied by itching. In addition, rashes tend to limit and are located in the ankle, carpal, elbow and neck folds.

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

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

Typical localization of lesions at this age are the elbow fossae, the back surface of the hands and the area of the wrist joints, the popliteal fossae and the ankle area, the ear folds, the neck, and the body. This disease has a typical morphological element - papule, the appearance of which is preceded by pronounced itching. Due to the grouping of papules, the skin in the folds becomes infiltrated, with a marked increase in the pattern (lichenification). Color foci stagnant red. Lichenification foci become more coarse, dyschromatic.

By the end of the second period, an “atonic person” develops - hyperpigmentation and underlined folds in the eyelids, giving the child a “tired look”. The remaining areas of the skin are also changed, but without clinically pronounced inflammation (dryness, dullness, peeling, dyschromia, infiltration). The disease is characterized by seasonality of the course and consists in the development of exacerbations in the autumn-winter period and a significant improvement or resolution of the process in the summer period, especially in the south.

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

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

The lesion in the folds is replaced by changes in the skin of the face, neck, trunk, limbs. Involved in the process of nasolabial triangle. Inflammation is stagnant bluish shade. 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 with the disappearance of skin lesions. The intensity of pruritus is high (biopsy zkd), with paroxysms at night.

Limited neurodermatitis is more common in adult males and is characterized by the presence of one or several lesions in the form of plaques of various sizes and shape on the skin of the neck, genitals (anogenital area), elbows and popliteal folds. The plaques are arranged symmetrically, relatively clearly delimited from unaffected skin by the area of herpigmentation. In the area of ochazhkov skin is dry, infiltrated, with an underlined pattern, more pronounced in the center. On the periphery of the foci there are small (with a pinhead) polygonal flat papules with a shiny brownish-red or pink surface.

With pronounced infiltration and lichenification, warty hyperpigmented foci appear. The onset of the disease is usually associated with psycho-emotional or neuroendocrine disorders. Patients are worried about intense itching. Suffering from various forms of this allergic dermatosis is observed white dermographism.

[24], [25]

Forms

Distinguish: diffuse, limited (chronic lichen Vidal) and neurodermatitis Broca, or atopic dermatitis (according to the WHO classification).

Atopic dermatitis often affects women (the ratio of sick women and men is 2: 1). During the disease there are 3 age periods.

Limited neurodermatitis (synonym: lichen simplex chronicus Vidal, dermatitis lichenoides pruriens Neisser) is clinically manifested by one or more severely itchy dry plaques, located mainly on the posterolateral surfaces of the neck, in the folds of the skin and surrounded by small papular elements and slight pigmentation, mildly passing normal skin. Sometimes on places combing depigmentation develops. With pronounced infiltration and lichenification, hypertrophic, warty lesions may occur. The rare variants include the depigmented, linear, moniliform, decalvating, psoriasiform form, the giant lichenification of Pautrier.

Diffuse atopic dermatitis (synonym: Darya prurigo ordinary, périgo diathetic Bénier, atopic dermatitis, endogenous eczema, constitutional eczema, atopic allergic dermatosis) - a more severe pathological condition than limited neurodermatitis, with more pronounced inflammation of the zoo, itching, and zodiac disease, with a more pronounced inflammation of the skin, itching, with a zoo occupying the entire skin as erythroderma. Often affects the skin of the eyelids, lips, hands and feet. Unlike a limited form, it develops predominantly in childhood, often combined with other manifestations of atopy, which gives grounds in these cases to consider this disease as an atopic allergic dermatosis. Sometimes cataract (Andogh's syndrome) is found, often - common ichthyosis. In children, lesions of the skin by the type of allergic ekzematizirovannogo may be a manifestation of the syndrome Wiskott-Aldrich syndrome, an inherited recessive X-linked and exhibit, in addition, thrombocytopenia, bleeding, disglobulinemiey, increased risk of infectious and malignant diseases, especially lymphohistiocytic system.

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

Complications and consequences

Neurodermatitis is complicated by recurrent bacterial, viral and fungal infections, especially in individuals who use hormonal ointment for a long time. Bacterial complications include folliculitis, furunculosis, impetigo, and hydradenitis. The causative agent of these complications is usually Staphylococcus aureus, less commonly, White Staphylococcus aureus or Streptococcus, the source of which are foci of chronic infection. The development of complications are accompanied by chills, fever, sweating, increased redness and itching. Peripheral lymph nodes are enlarged, painless.

One of the most serious complications that can accompany the disease is the herpetiform eczema of Kaposi, the mortality rate of which varies from 1.6% to 30%. The causative agent is a herpes simplex virus, mainly type 1, which causes lesions of the upper respiratory tract and skin around the nose and mouth. Less common is a virus of the 2nd type, which affects the mucous membrane and skin of the genital organs. The disease begins acutely 5-7 days after contact with a patient with herpes simplex and manifests itself with chills, fever up to 40 ° C, weakness, adynamism, prostration. After 1-3 days, rash appears small, up to the size of a pinhead, bubbles filled with serous, less often hemorrhagic contents. Subsequently, the vesicles turn into pustules and acquire a typical appearance with a umbilical depression in the center. In the process of the evolution of elements, bleeding erosion is formed, the surface of which is covered with hemorrhagic crusts. The face of the patient acquires a “mask-like” look. The lesion of the mucous membranes proceeds according to the type of aphthous stomatitis, conjunctivitis, keratoconjunctivitis.

Kaposi eczema can be complicated by the development of streptococci and staphyloderma, pneumonia, otitis media, sepsis. After 10-14 days the rash begins to regress, and in their place are small superficial scars.

Fungal complications include candidal heylitis, onychia, and paronychia. Rarely, atopic dermatitis is complicated by an atopic cataract that develops in no more than 1% of patients (Andogh's syndrome).

[31], [32], [33], [34], [35], [36]

Diagnostics of the neurodermatitis

A dermatologist diagnoses atopic dermatitis by examining the affected skin. To exclude other diseases, he can take a sample of the affected skin for a skin biopsy.

[37], [38], [39], [40], [41], [42], [43]

Differential diagnosis

Neurodermatitis must be differentiated from chronic eczema, lichen planus, nodular pruritus. Chronic eczema is distinguished by the true polymorphism of the precipitated elements represented by microvesicles by microerosias, microcoriocles with marked weeping in the form of “serous wells” accompanied by itching. This allergic dermatosis is characterized by itching, which is ahead of the appearance of papular rash. Eczema is also characterized by the localization of lesions in limited areas of the skin. Dermographism for eczema is red, with this allergic dermatosis - white.

Lichen planus is characterized by scattered polygonal papules of lilac color with a umbilical depression in the center, located on the inner surface of the upper extremities, the anterior surface of the legs, torso. Sometimes the mucous membranes of the oral cavity and genitals are affected. When smearing papules with vegetable oil, a reticulated pattern (Wickham mesh) is revealed.

The nodular and nodular pruritus is characterized by a rash of papules of a hemispherical shape, not prone to fusion and grouping and accompanied by severe itching.

[44], [45], [46], [47], [48], [49]

Treatment of the neurodermatitis

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

Neurodermatitis must be treated, observing the following principles:

• Enterosorption using polyphenane, enterosorbent, activated coal. Diuretics (triampur, veroshpiron) Fasting days (1-2 days per week). The appointment of low molecular weight drugs and plasma substitutes (gemodez, reopolyglukine and others.).
• Neurodermatitis requires rehabilitation of foci of chronic bacterial and parasitic infections.
• Restoration of disturbed functions of the gastrointestinal tract with the normalization of digestion and absorption (depending on the revealed deviations). Correction of dysbacteriosis with antibiotics, staphylococcal bacteriophage, lactobacterin, bifidumbacterin, bifikolom. In case of enzyme deficiency (according to coprogram data) - pepsidin, pancreatin, panzinorm, mezim-forte, festal, digestal. When biliary dyskinesia - no-spa, papaverine, platifillin, halidor, sunflower oil, sulphate magnesia, decoction of corn stigmas, xylitol, sorbitol.
• Nonspecific hyposensitizing effects have a diet, antihistamines (zaditen, tavegil, suprastin, phencarol, etc.), prescribed by short courses.
• In immune deficiency, sodium nucleinate, methyluracil, T-activin is used. As non-specific stimulants use vitamins A, C, PP and group B.
• For the correction of disorders of the central and vegetative nervous system, pirroxan butyroxan, stugerone (cinnarizine), valerian tincture, tranquilizers (names, seduxen) are used.
• To restore hemocoagulation disorders and microcirculation, infusion therapy is used (hemodez, reopolyglukine), trental, chimes, complamin.
• In order to restore the function of the adrenal glands, patients with long-term illness are prescribed etizol, a solution of ammonium chloride, glycers, inductothermia in the adrenal region.
• Pastes and ointments (zinc, dermatol, ASD, 3rd fraction, birch tar) are used as external therapy. It is not recommended to apply hormonal, especially on the skin of the face.
• Ultraviolet irradiation according to a sparing technique (in sub-erythemic doses), currents of d'Arsonval inductothermia in the adrenal region, diathermy in the region of the cervical sympathetic ganglia.
• Patients with severe forms of allergic dermatosis are shown selective phototherapy (PUVA therapy), hyperbaric oxygenation, and ultraviolet blood irradiation.
• Spa treatment. Patients are shown heliotherapy in the southern seaside resorts, Matsesta and other sulphide applications and baths.

[50], [51], [52], [53], [54]

Clinical examination

Clinical examination subject patients with all clinical forms of disease. When professional orientation of patients should take into account the contraindications of professions associated with prolonged and excessive emotional stress, contact with inhalants (perfumery, pharmaceutical, chemical, confectionery production), mechanical and chemical irritants (textile, fur enterprises, hairdressing), strong physical effects (noise, cooling).

[55], [56], [57], [58], [59]

Forecast

Limited neurodermatitis has a more favorable prognosis than diffuse, although with the latter, in the majority of patients, the process regresses with age, sometimes remaining in the form of focal manifestations according to the eczema of the hands. Some authors point to the possible connection of the disease with Sesari syndrome.

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