CASE REPORT

NUMMULAR DERMATITIS TREATED WITH CORTICOSTEROID AND

ANTIBIOTIC
Muhlis1, Fitriyani Sennang1, Wiwiek Dewiyanti1, Ni Ketut Sungowati2
1
Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin
Sudirohusodo Hospital Makassar
2
Department of Pathology Anatomy Medical Faculty of Hasanuddin University / Wahidin
Sudirohusodo Hospital Makassar

ABSTRACT
Nummular dermatitis characterized by shaped lesions form of currency
(coin), demarcated, with a papulovesicular efflorescense, usually easily broken
down (oozing). Unknown aetiology, possibly multi-factor. Suspected infection
played a role in nummular dermatitis, with the discovery colonies of
Staphylococcus and Micrococcus increased in the abnormality, although
clinically not found signs of infection. Reported one case of nummular dermatitis
on a 25-years-old woman treated with corticosteroid, antibiotic, antihistamine,
showed clinical improvement.
Key words: Antibiotic, corticosteroid, nummular dermatitis

Address for correspondence : Muhlis, dr., Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin Sudirohusodo
Hospital Makassar 177 Jl. Katimbang kel. Paccerakang Makassar, South Sulawesi, Indonesia 90245 Muhlis@gmail.com

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Muhlis
INTRODUCTION
Nummular dermatitis, also known
as nummular eczema, discoid eczema.
Nummular dermatitis characterized by
single lesions, dermatitis plaque that is
round or oval with clear boundaries, there
are usually papules and vesicles, and
frequent excoriation. 1
Nummular dermatitis often occurs
in adults. Men are more often affected
than females. Highest incidence occurs in
men at the age of 50 to 65 years, whereas
in women 15 to 25 years. 2
The pathogenesis of the disease is
unknown, thought to be caused by many
factors. Involved in pathogenesis of
nummular dermatitis infection seen from
the increased colonization of
Staphylococcus and Micrococcus in lesion
area. The existence of these organisms is
still unclear role in the disease process.3 In
fact, a hypersensitivity reaction to the
bacteria or infection itself can begin to
form plaques nummular, but never
adequately investigated. Local physical
trauma or chemical trauma also play a role
in some cases, nummular dermatitis
sometimes develops on old wounds or
scars.1
In one study found 68 percent of
an internal focus of infection, including
dental, upper respiratory tract and lower
respiratory tract.1 Most patients with
nummular dermatitis had no history of
atopy or a family history of atopy, although
nummular plaque can also be seen in the
specific allergy atopic dermatitis.3 Specific
allergic not common, but can be ignored in
some cases of severe or persistent if the
patch test is not done.1 Stress emotional
role in some cases, but it is unlikely to be
the cause .1 Reported a case of nummular
dermatitis in female patient aged 25 years
old was diagnosed nummular dermatitis
74
nummular dermatitis treated with coticosteroid and antibiotic
based on history, clinical signs, and
histopathologic examination. She was
given antibiotic and corticosteroid therapy
and showed clinical improvement.
CASE REPORTS
A woman aged 25 years old came
to clinic of dermatovenereology Tadjuddin
Chalid hospital with complaints rash itchy
redness on the left leg since 2 months
ago. Initially lesion coin-shaped
erythematous patches, and spread into
larger patches. No fever. Patient had
cavitation (caries) teeth since 1 year ago.
History of allergies was denied, family
history of suffering from the same
complaint denied, a history of similar
disease not previously exist, history of
previous treatment loratadine taken once a
day for ten days, erythromycin tablets 400
mg taken four times a day, neomycin
sulfate ointment 0.5% but no
improvement. On physical examination
found the patient's general condition is
good. Blood pressure 120/80 mm Hg,
pulse rate 80 beats / min, breathing 18
times / min and body temperature 36.80C.
Dermatological examination on inferior
extremity sinistra showed erythematous
patches, size of lesion approximately 5
cm in diameter (palm-sized),
hypopigmentation patches and
hyperpigmentation patches . Based on
history taking and dermatological
examination, diagnosis was nummularis
dermatitis. Differential diagnosis of this
patient with contact dermatitis and tinea
corporis. Skin biopsy was performed.
Therapy after biopsy cefadroxil 500 mg
twice a day, mefenamic acid 500 mg
three times a day. Histopathological
examination showed irregular psoriasiform
epidermal hyperplasia, hyperkeratosis,
parakeratosis with crusting, mild
spongiosis, granulosum layer is thick
enough, the upper dermis there are quite
IJDV Vol.2 No.2 2013

dense lymphocytic inflammation infiltrates DISCUSSION

with 1-2 eosinophils. Histopathological Nummular dermatitis or nummular
examination conclusions chronic spongi- eczema is characterized by coin-shaped
otic dermatitis, can support a nummular plaques or oval and discrete.4 Definite
dermatitis. etiology is unknown but several factors
cause of suspected.5 Nummular dermatitis
This patient was given oral
characterized by demarcated plaque,
methylprednisolone 8 mg three times a
shaped like coins, fragile papulovesicular ,
day, erythromycin 500 mg four times a
wet and a crusting. Crusts can cover the
day , cetirizin once a day, mometason
entire surface of the lesion, the skin
furoat cream and mupirocin cream applied
around the lesion is generally normal, but
morning and afternoon. On day 30, skin
can also xerotic. Pruritus is variations from
lesions showed good result. Dermato-
mild to severe.8 This corresponding with
logical examination showed hyperpig-
our case, patient’s complaint itchy red-
mented macular on inferior extremity
ness rash on the left leg .
sinistra.

75
Muhlis
Nummular dermatitis arise about 2 out of
1000 people in the United States and is
more common in adults is rare in children.
Men are more often affected by the age of
55 to 65 years. Earlier in women exposed
at ages 15 to 25 years. The peak age of
onset in childhood is 5 years.9 This
corresponding to the case where patient
suffering from the disease at age 25 years.
Differential diagnosis with nummular
dermatitis, allergic contact dermatitis and
tinea corporis. Nummular dermatitis
characterized by single lesion, dermatitis
plaques that are round or oval with clear
boundaries, there are usually papules and
vesicles, and can experience excoriation,
measuring 4 to 5 cm in diameter.1,3 The
only form of allergic contact dermatitis
lesions erythema plaques, and vesicles
with papules, erosion, but sometimes only
hyperpigmented macules. Distinguish be
examined patch test or prick test. Tinea
corporis skin lesions showed scales,
erythema usually mild, especially visible
on the edges of the lesion.
Histopathologic examination in
acute lesions found spongiosis,
intraepidermal vesicles, whereas the
inflammatory cells of lymphocytes and
macrophages around the blood vessels.
Chronic lesions are found irregular
acanthosis, hyperkeratosis, hypergranu-
losis and, perhaps mild spongi-osis. Upper
dermis fibrosis, lymphocytes infiltrates
and macrophages around blood vessels.3
In this case the results of the examination
showed irregular epidermal hyperplasia,
hyperkeratosis, parakeratosis with crus-
ting, mild spongiosis, granulosum layer is
thick enough, the upper dermis there
quite dense lymphocytic inflammation
infiltrates with 1-2 eosinophils.
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nummular dermatitis treated with coticosteroid and antibiotic
Histopathological examination conclusions
chronic spongiotic dermatitis, can support
a nummular dermatitis. Numularis
dermatitis treatment wherever possible
seek the causes or factors that provoke.
When dry skin, moisturizer or emollient
given. In lesions can be treated with
topical anti-inflammatory medication, such
as tar preparations, glucocorticoids,
tacrolimus, or pimecrolimus. If the lesions
are exudative, preferably compressed first,
if found to secondary infection, systemic
antibiotics are given. Systemic corticos-
teroids are given only in cases of severe
and refractory, in the short term. Pruritus
can be treated with antihistamines. The
case was given erythromycin 500 mg four
times a day. Corticosteroids have specific
and nonspecific effects associated with
different mechanisms of action, including
its anti-inflammatory, immunosuppressive,
anti-proliferative, and vasoconstriction.
Most of the effects of corticosteroids on
cell mediated by the binding of
corticosteroid to its receptor in the cytosol,
followed by translocation of the drug-
receptor complex to a region of DNA
known as a core element of corticosteroid
responsive, and able to stimulate or inhibit
transcription of genes adjacent to the thus
regulate the inflammation.3 Corticosteroids
are estimated using a potent anti-
inflammatory by inhibiting the release of
phospholipase A2, an enzyme responsible
for the formation of prostaglandins,
leukotrienes, and other derivatives of
arachidonic acid pathway. Some corticos-
teroids are as effective immunesup-
pressive effect. Corticosteroids suppress
the production and effects of humoral
factors involved in the inflammatory
response, inhibiting leukocyte migration to
inflammatory sites and disrupt the function
of endothelial cells, granulocytes, mast
cells, and fibroblas.3
IJDV
Anti-proliferative effects of topical
corticosteroids are mediated by the
inhibition of DNA synthesis and mitosis.
The mechanism that induces vasocon-
striction of corticosteroids is still not
entirely clear. It is thought to be related to
the inhibition of natural vasodilators such
as histamine, bradykinin, and
prostaglandins. Topical steroids cause the
capillary vessels in the superficial dermis
vasoconstriction, thus reducing erythema.
The ability of corticosteroids given to
agents cause vasoconstriction usually
correlates with anti-inflammatory potential
therapy.3 This case was given oral
methylprednisolone 8 mg three times a
day, mometasone furoat cream and
mupirocin cream applied every morning
and afternoon. Oral antihistamines are
useful as sedatives, reducing itching and
is very useful at night. The case was given
cetirizin 10 mg once a day.
Patients should be given education about
the development or the course of the
disease that can recurrence.
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