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Nummular Dermatitis

(Discoid Dermatitis)

By Mercedes E. Gonzalez, MD, Clinical Assistant Professor;Medical Director, University of Miami, Department of Dermatology, Miller School of Medicine;Pediatric Dermatology of Miami

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Nummular dermatitis is inflammation of the skin characterized by coin-shaped or discoid eczematous lesions. Diagnosis is clinical. Treatment may include topical corticosteroids and ultraviolet light therapy.

Nummular dermatitis is most common among middle-aged and older patients and is often associated with dry skin, especially during the winter. Dermatophytid (identity, or id) reactions may manifest as nummular dermatitis. The cause is unknown.

Symptoms and Signs

Discoid lesions often start as patches of confluent vesicles and papules that ooze serum and form crusts. Later they become dry, scaly, lichenified, and sometimes annular (central clearing). Lesions are often intensely pruritic. They can number from 1 to about 50 and tend to be from 2 to 10 cm in diameter. They are often more prominent on the extensor aspects of the extremities and on the buttocks but also appear on the trunk. Exacerbations and remissions may occur, and when they do, new lesions tend to reappear at the sites of healed lesions.

Diagnosis

  • Clinical evaluation

Diagnosis is clinical based on the characteristic appearance and distribution of the skin lesions. Tests for bacteria and fungi may be done to rule out infection.

Treatment

  • Supportive care

  • Antibiotics

  • Corticosteroids (most often topical, but sometimes intralesional or oral)

  • Ultraviolet light therapy

No treatment is uniformly effective. Oral antibiotics (eg, dicloxacillin or cephalexin 250 mg qid) may be given, along with use of tap water compresses, if weeping and pus are present. Mid- to high-potency corticosteroid cream or ointment should be rubbed in 2 times daily. An occlusive dressing with a corticosteroid cream under polyethylene film or with flurandrenolide-impregnated tape can be applied at bedtime. Intralesional corticosteroid injections may be beneficial for the few lesions that do not respond to therapy.

In more widespread, resistant, and recurrent cases, ultraviolet B radiation alone or oral psoralen plus ultraviolet A (PUVA) radiation may be helpful. Occasionally, oral corticosteroids are required, but long-term use should be avoided; a reasonable starting dose is prednisone 40 mg every other day. Corticosteroid alternatives for recalcitrant disease include cyclosporine and methotrexate.

Key Points

  • The etiology of nummular dermatitis is unknown, but the disorder is most common in middle-aged and older patients.

  • Pruritic discoid lesions form in patches of confluent vesicles and papules that later become dry and lichenified.

  • Diagnosis is clinical.

  • Treatment includes supportive care (eg, corticosteroid cream) for the itching, antibiotics for infection, and ultraviolet light therapy for widespread, resistant, and recurrent lesions.

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* This is the Professional Version. *