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Diagnosis of the condition is done via a physical examination under a slit lamp. Cultures of debris are occasionally collected for bacterial or fungal testing.
Cultures of the eyelid margins can be a clear indicator for patients suffering from recurrent anterior blepharitis with severe inflammation, in addition to patients who are not responding to therapy. Measurements of tear osmolarity may be beneficial in diagnosing concurrent dry eye syndrome (DES), which may be responsible for overlapping symptoms and would allow the physician to decipher between conditions and move forward with the most beneficial protocol for the patient. Consequently, the measurement of tear osmolarity has various limitations in differentiating between aqueous deficiencies and evaporative dry eye. Microscopic evaluation of epilated eyelashes may reveal mites, which have been evident in cases of chronic blepharoconjunctivitis. A biopsy of the eyelid can also determine the exclusion of carcinoma, therapy resistance, or unifocal recurrent chalazia.
A diagnosis of hyposalivation is based predominantly on the clinical signs and symptoms. There is little correlation between symptoms and objective tests of salivary flow, such as sialometry. This test is simple and noninvasive, and involves measurement of all the saliva a patient can produce during a certain time, achieved by dribbling into a container. Sialometery can yield measures of stimulated salivary flow or unstimulated salivary flow. Stimulated salivary flow rate is calculated using a stimulant such as 10% citric acid dropped onto the tongue, and collection of all the saliva that flows from one of the parotid papillae over five or ten minutes. Unstimulated whole saliva flow rate more closely correlates with symptoms of xerostomia than stimulated salivary flow rate. Sialography involves introduction of radio-opaque dye such as iodine into the duct of a salivary gland. It may show blockage of a duct due to a calculus. Salivary scintiscanning using technetium is rarely used. Other medical imaging that may be involved in the investigation include chest x-ray (to exclude sarcoidosis), ultrasonography and magnetic resonance imaging (to exclude Sjögren's syndrome or neoplasia). A minor salivary gland biopsy, usually taken from the lip, may be carried out if there is a suspicion of organic disease of the salivary glands. Blood tests and urinalysis may be involved to exclude a number of possible causes. To investigate xerophthalmia, the Schirmer test of lacrimal flow may be indicated. Slit-lamp examination may also be carried out.
Dryness is a medical condition in which there is local or more generalized decrease in normal lubrication of the skin or mucous membranes.
Examples of local dryness include dry mouth, dry eyes, dry skin and vaginal dryness. These often have specific causes and treatments. It is possible to have dry eyes without any other signs or symptoms, but this usually causes a syndrome of eye symptoms called keratoconjunctivitis sicca.
More generalized dryness can be caused by e.g. dehydration (that is, more general loss of body fluids), anticholinergic drugs and Sjögren syndrome.
The symptoms of phlyctenular keratoconjunctivitis are primarily treated with application of an appropriate corticosteroid eye drop, such as prednisolone acetate (Pred Forte) or loteprednol (Lotemax). Loteprednol is increasingly preferred due to its lower risk of elevating intraocular pressure. The corticosteroid suppresses the immune response, reducing inflammation and improving most symptoms.
The causative agent (i.e. the source of the antigen that triggered the hypersensitive immune response) should also be identified. "Staphylococcus aureus" is usually the primary suspect, along with "Mycobacterium tuberculosis" in areas where TB is endemic, followed by "Chlamydia trachomatis". Active bacterial infections may be treated with a topical antibiotic or a combination antibiotic-steroid eye drop, such as tobramycin/dexamethasone (Tobradex). An oral tetracycline antibiotic (such as doxycycline) may be used in systemic or particularly severe/intractable infections. Erythromycin may be an effective alternative, especially in pediatric cases where the side effects of tetracyclines are unacceptable.
Artificial tears can reduce dryness and discomfort from corneal lesions. Photophobic discomfort can be mitigated with dark sunglasses.
Generous application of bland emollients can improve the rash. However, complete resolution will not occur until the lip licking stops. Breaking the cycle of dryness then licking followed by more dryness is key to treatment. Sometimes, unlike in perioral dermatitis, topical steroids may be used for few days only.
Treatment of herpes of the eye is different based on its presentation: epithelial keratitis is caused by live virus while stromal disease is an immune response and metaherpetic ulcer results from inability of the corneal epithelium to heal:
Dry eyes can usually be diagnosed by the symptoms alone. Tests can determine both the quantity and the quality of the tears. A slit lamp examination can be performed to diagnose dry eyes and to document any damage to the eye.
A Schirmer's test can measure the amount of moisture bathing the eye. This test is useful for determining the severity of the condition. A five-minute Schirmer's test with and without anesthesia using a Whatman #41 filter paper 5 mm wide by 35 mm long is performed. For this test, wetting under 5 mm with or without anesthesia is considered diagnostic for dry eyes.
If the results for the Schirmer's test are abnormal, a Schirmer II test can be performed to measure reflex secretion. In this test, the nasal mucosa is irritated with a cotton-tipped applicator, after which tear production is measured with a Whatman #41 filter paper. For this test, wetting under 15 mm after five minutes is considered abnormal.
A tear breakup time (TBUT) test measures the time it takes for tears to break up in the eye. The tear breakup time can be determined after placing a drop of fluorescein in the cul-de-sac.
A tear protein analysis test measures the lysozyme contained within tears. In tears, lysozyme accounts for approximately 20 to 40 percent of total protein content.
A lactoferrin analysis test provides good correlation with other tests.
The presence of the recently described molecule Ap4A, naturally occurring in tears, is abnormally high in different states of ocular dryness. This molecule can be quantified biochemically simply by taking a tear sample with a plain Schirmer test. Utilizing this technique it is possible to determine the concentrations of Ap4A in the tears of patients and in such way diagnose objectively if the samples are indicative of dry eye.
The Tear Osmolarity Test has been proposed as a test for dry eye disease. Tear osmolarity may be a more sensitive method of diagnosing and grading the severity of dry eye compared to corneal and conjunctival staining, tear break-up time, Schirmer test, and meibomian gland grading. Others have recently questioned the utility of tear osmolarity in monitoring dry eye treatment.
A specific clinical diagnosis of HSV as the cause of dendritic keratitis can usually be made by ophthalmologists and optometrists based on the presence of characteristic clinical features. Diagnostic testing is seldom needed because of its classic clinical features and is not useful in stromal keratitis as there is usually no live virus. Laboratory tests are indicated in complicated cases when the clinical diagnosis is uncertain and in all cases of suspected neonatal herpes infection:
- Corneal smears or impression cytology specimens can be analyzed by culture, antigen detection, or fluorescent antibody testing. Tzanck smear, i.e.Papanicolaou staining of corneal smears, show multinucleated giant cells and intranuclear inclusion bodies, however, the test is low in sensitivity and specificity.
- DNA testing is rapid, sensitive and specific. However, its high cost limits its use to research centers.
- Demonstration of HSV is possible with viral culture.
- Serologic tests may show a rising antibody titer during primary infection but are of no diagnostic assistance during recurrent episodes.
Classification can be either by cause or by extent of the inflamed area.
Cultures are not often taken or needed as most cases resolve either with time or typical antibiotics. Swabs for bacterial culture are necessary if the history and signs suggest bacterial conjunctivitis but there is no response to topical antibiotics. Viral culture may be appropriate in epidemic case clusters.
A patch test is used to identify the causative allergen in the case where conjunctivitis is caused by allergy.
Conjunctival scrapes for cytology can be useful in detecting chlamydial and fungal infections, allergy, and dysplasia, but are rarely done because of the cost and the general lack of laboratory staff experienced in handling ocular specimens. Conjunctival incisional biopsy is occasionally done when granulomatous diseases ("e.g.", sarcoidosis) or dysplasia are suspected.
There is no way to prevent keratoconjunctivitis sicca. Complications can be prevented by use of wetting and lubricating drops and ointments.
The syndrome is marked by the appearance of characteristic lesions, known as phlyctenules, on the cornea and/or conjunctiva. These usually manifest as small (1 - 3 or 1 - 4 mm) raised nodules, pinkish-white or yellow in color, which may ulcerate (or, more rarely, necrose) and are often surrounded by dilated blood vessels. Corneal lesions are usually triangular in shape, with the base at the limbus and the apex pointing towards the center of the cornea.
The diagnosis of lip licker's dermatitis is from the history and inspection of the rash. It is important to distinguish it from allergic contact dermatitis and perioral dermatitis which is characterised by papule in the perioral area, sparing of the vermillion border and worsened by topical steroids.
Normally, exfoliation is restricted to a particular area and normal skin will replace the exfoliated parts, so no treatment is needed. Since keratolysis exfoliativa is caused by friction, detergents, and solvents, these factors should be avoided. Creams, especially those with silicone and lactic acid are also helpful. In severe cases, photochemotherapy is an option.
Keratoconjunctivitis is inflammation ("-itis") of the cornea and conjunctiva.
When only the cornea is inflamed, it is called "keratitis"; when only the conjunctiva is inflamed, it is called "conjunctivitis".
There are several potential causes of the inflammation:
- Keratoconjunctivitis sicca is used when the inflammation is due to dryness. ("Sicca" means "dryness" in medical contexts.) It occurs with 20% of rheumatoid arthritis patients.
- The term "Vernal keratoconjunctivitis" (VKC) is used to refer to keratoconjunctivitis occurring in spring, and is usually considered to be due to allergens.
- "Atopic keratoconjunctivitis" is one manifestation of atopy.
- "Epidemic keratoconjunctivitis" is caused by an adenovirus infection.
- "Infectious bovine keratoconjunctivitis" (IBK) is a disease affecting cattle caused by the bacteria "Moraxella bovis".
- "Pink eye in sheep and goat" is another infectious keratoconjunctivitis of veterinary concern, mostly caused by "Chlamydophila pecorum"
- "Superior limbic keratoconjunctivitis" is thought to be caused by mechanical trauma.
- "Keratoconjunctivitis photoelectrica" (arc eye) means inflammation caused by photoelectric UV light. It is a type of ultraviolet keratitis. Such UV exposure can be caused by arc welding without wearing protective eye glass, or by high altitude exposure from sunlight reflected from snow ("snow blindness"). The inflammation will only appear after about 6 to 12 hours. It can be treated by rest, as the inflammation usually heals after 24–48 hours. Proper eye protection should be worn to prevent keratoconjunctivitis photoelectrica.
Xerostomia is a very common symptom. A conservative estimate of prevalence is about 20% in the general population, with increased prevalences in females (up to 30%) and the elderly (up to 50%).
In most cases exfoliation resolves spontaneously and no lasting damage is seen. On the other hand, some patients experience cracking and even bleeding in extreme cases.
In most patients, the condition lasts only a matter of weeks; in some cases it can last longer (up to six months). The disease resolves completely without long-term effects. Two percent of patients have recurrence.
There is no good evidence that a mother's diet during pregnancy, the formula used, or breastfeeding changes the risk. There is tentative evidence that probiotics in infancy may reduce rates but it is insufficient to recommend its use.
People with eczema should not get the smallpox vaccination due to risk of developing eczema vaccinatum, a potentially severe and sometimes fatal complication.
Experienced practitioners may make the diagnosis clinically. If the diagnosis is in doubt, tests may be performed to rule out similar conditions such as Lyme disease, ringworm, guttate psoriasis, nummular or discoid eczema, drug eruptions, other viral exanthems.The clinical appearance of pityriasis rosea is similar to that of secondary syphilis, and rapid plasma reagin testing should be performed if there is any clinical concern for syphilis. A biopsy of the lesions will show extravasated erythrocytes within dermal papillae and dyskeratotic cells within the dermis.
A set of validated diagnostic criteria for pityriasis rosea is as follows:
A patient is diagnosed as having pityriasis rosea if:
1. On at least one occasion or clinical encounter, he / she has all the essential clinical features and at least one of the optional clinical features, and
2. On all occasions or clinical encounters related to the rash, he / she does not have any of the exclusional clinical features.
The essential clinical features are the following:
1. Discrete circular or oval lesions,
2. Scaling on most lesions, and
3. Peripheral collarette scaling with central clearance on at least two lesions.
The optional clinical features are the following:
1. Truncal and proximal limb distribution, with less than 10% of lesions distal to mid-upper-arm and mid-thigh,
2. Orientation of most lesions along skin cleavage lines, and
3. A herald patch (not necessarily the largest) appearing at least two days before eruption of other lesions, from history of the patient or from clinical observation.
The exclusional clinical features are the following:
1. Multiple small vesicles at the centre of two or more lesions,
2. Two or more lesions on palmar or plantar skin surfaces, and
3. Clinical or serological evidence of secondary syphilis.
Many skin conditions can mimic acne vulgaris and are collectively known as acneiform eruptions. Such conditions include angiofibromas, epidermal cysts, flat warts, folliculitis, keratosis pilaris, milia, perioral dermatitis, and rosacea, among others. Age is one factor which may help distinguish between these disorders. Skin disorders such as perioral dermatitis and keratosis pilaris can appear similar to acne but tend to occur more frequently in childhood, whereas rosacea tends to occur more frequently in older adults. Facial redness triggered by heat or the consumption of alcohol or spicy food is suggestive of rosacea. The presence of comedones helps health professionals differentiate acne from skin disorders that are similar in appearance. Chloracne, due to exposure to certain chemicals, may look very similar to acne vulgaris.
Prophylaxis consists of periodic administration of Vitamin A supplements. WHO recommended schedule, which is universally recommended is as follows:
- Infants 6–12 months old and any older children weighing less than 8 kg - 100,000 IU orally every 3–6 months
- Children over 1 year and under 6 years of age - 200,000 IU orally every 6 months
- Infants less than 6 months old, who are not being breastfed - 50,000 IU orally should be given before they attain the age of 6 months
Most cases are well managed with topical treatments and ultraviolet light. About 2% of cases are not. In more than 60% of young children, the condition subsides by adolescence.
Comedones (blackheads and whiteheads) must be present to diagnose acne. In their absence, an appearance similar to that of acne would suggest a different skin disorder. Microcomedones (the precursor to blackheads and whiteheads) are not visible to the naked eye when inspecting the skin and can only be seen with a microscope. There are many features that may indicate a person's acne vulgaris is sensitive to hormonal influences. Historical and physical clues that may suggest hormone-sensitive acne include onset between ages 20 and 30; worsening the week before a woman's menstrual cycle; acne lesions predominantly over the jawline and chin; and inflammatory/nodular acne lesions.
Several scales exist to grade the severity of acne vulgaris, but no single technique has been universally accepted as the diagnostic standard. Cook's acne grading scale uses photographs to grade severity from 0 to 8 (0 being the least severe and 8 being the most severe). This scale was the first to use a standardized photographic protocol to assess acne severity; since its creation in 1979, the scale has undergone several revisions. The Leeds acne grading technique counts acne lesions on the face, back, and chest and categorizes them as inflammatory or non-inflammatory. Leeds scores range from 0 (least severe) to 10 (most severe) though modified scales have a maximum score of 12. The Pillsbury acne grading scale simply classifies the severity of the acne from 1 (least severe) to 4 (most severe).