Eczema

Eczema: what is it? Inflammation of the epidermis Epidermal disease Hence scaly Inflammation Hence redness Profoundly itchy

What does it look like? Red Scaly Weepy if its infected Cracked if it is quite dry

Secondary changes: infection Weepy Crusted Yellow

Other secondary changes Scratch marks

Lichenification Thickening of the skin due to chronic scratching

Atopic Eczema: what is actually going on? Immunological abnormalities “atopy” THi2 dominant Uncontrolled humoral immunity: IgE production Dry skin

Dryness indicates loss of the normal waterproofing of the skin

Eczema: loss of waterproofing of the skin

Atopic Eczema Most obvious early sign is dryness which is also the key abnormality to correct during treatment Redness/inflammation, which usually follows on from the dryness but can seemingly come and go at will

Atopic Eczema Common Miserable Incredibly itchy Life disrupting for children and families Embarrassing Destroyer of self confidence

The treatment of eczema Complicated therefore needs much patient education Multi-faceted Child Family School Skin/allergies/ environment

Treatment of atopic eczema in childhood treatment of the dry skin with emollients topical steroids removal of “flare factors” eg infection Antihistamines (only occasionally) now tacrolimus and pimecrolimus

Dry skin in eczema Actually mild eczema Implies loss of barrier function Escalation of fluid loss Increased risk of infection Hence emollients are the key to treatment

Keypoint 1 Emollients are the cornerstone of management, and should be used liberally to all areas on a daily basis, even (perhaps especially) if the eczema is quiescent. Most patients use far too little.

Emollients If used correctly will control most children’s eczema most of the time, because it addresses the fundamental problem of dry skin and its resulting poor barrier function. Emollients are under-used. Many patients are prescribed topical steroids inappropriately before being offered emollients The greasier the better: some sting

Emollients Replace detergents and soaps with emollient soap substitutes Ointments are better because they are more hydrating and often less irritant, but consider patient preference to improve compliance. Continue emollients even when eczema settles to prevent or reduce severity of relapse.

Emollients Use large amounts of ointments/creams, and encourage liberal application several times a day, to moist skin (after bath) where possible. Prescribe in large quantities to aid compliance and be more cost effective. Pump dispensers may be helpful to reduce infection risks. Typical doses: 250g/week for child, 500g/week for adult. These may be better tolerated if warmed.

Wet wraps/ Comfifast Suits Efficient means of delivering emollients Occludes and therefore protects the skin Maintains a constant temperature and therefore reduces the tendency to scratch Don’t suit every child Avoid till infection is controlled

Topical steroids Use the least potent steroid which is effective, intermittently, to avoid systemic side effects (growth suppression) and local side effects (skin thinning and contact dermatitis) Ensure all steroids are used in correct amounts

Topical steroids Avoid potent steroids around the eye (risk of cataracts) and on the face (risk of atrophy/telangectasia) A short course of potent steroids may abort a severe episode Potent and very potent steroids must be used intermittently, eg for a few days to each body site, every few weeks.

Topical steroids Modern steroids (eg Fluticasone propionate, Mometosone furoate) are potent but less likely to be associated with side effects Ointments (oil-based) are more effective than creams, although creams and lotions (water-based) are useful when the skin is inflamed Educate parents/patients that side effects are related to the potency of the steroid, the amount used and site of application

Advise the steroid ladder 4 rungs Dermovate Betnovate Cutivate/Elocon Eumovate/ Haelen Hydrocortisone

Amount of steroid to apply (in Finger Tip Units) by body site and age 5 3.5 4.5 2.5 2 6 to 10 y 3.5 3 3 2 1.5 3 to 5 y 3 2 2 1.5 1.5 1 to 2 y 1.5 1 1.5 1 1 3 to 6 m Post trunk Ant trunk Leg and foot Arm and hand Face and neck Age

Amount of steroid to prescribe per week (grams) by skin involved and age 60 90 170 Adult 55 85 135 16 y 45 65 120 12 y 35 50 90 8 y 20 35 60 4 y 15 20 45 1 y 15 20 35 6/12 Trunk Arms and legs Whole body Age

Infection Common S Aureus Occasionally also Strep Caused by reduced waterproofing of the skin Is it herpes?

When the infection has been treated Having discarded old creams Emollients, emollients, emollients Advice about what to look for which may indicate returning infection And what to do Potassium permanganate Fucidin

Infected eczema If there is early relapse after use of antibiotics, or recurrence of infection, perform skin and nasal swabs in child and family to check for S.Aureus carriage. Consider treatment with topical antibiotic cream. Topical antibacterial/steroid mixes may be useful for the flexures and in the presence of recurrent infection, but should not be used other than for short periods.

Eczema Herpeticum Grouped vesicles Later umbilicated lesions Often secondary impetigo

Referral Refer all children with severe or refractory eczema, or those requiring frequent courses of potent steroids or antibiotics, to dermatology. Children with eczema in an unusual distribution should also be referred, as they may need patch testing to exclude a contact eczema. The following require same-day referral to dermatology: cases of eczema herpeticum; erythroderma; systemic upset secondary to severe eczema.

Referral Where there are co-existing medical problems, such as failure to thrive or worrying reactions to food, referral decisions will depend on the relative severity of each problem In most cases, particularly in young children, the child should be referred to a general or specialist paediatrician, who can co-ordinate involvement of other services, including paediatric dietetics, as appropriate.

Other interventions Sedative oral antihistamines – given for short periods at night only may help to interrupt the scratch-itch cycle. Avoid in children under 3 months. Note the potential detrimental impact on school performance. Measures to prevent bacterial infection – daily baths; avoid sharing of flannels, towels; wash such items on hot wash cycle of washing machine; don’t leave tubs of ointments open. Avoid mammalian pets.

Atopic eczema in childhood: occupational advice avoidance of jobs involving wet hands eg hairdressing avoidance jobs involving hand contact with oils eg engineering avoidance contact with animals

Particular problems in general practice

Less than ideal prescribing of emollients: quantity Emollients are the mainstay of treatment for eczema Long term as it is a preventative treatment Emollients 250g per week for a baby, 500g for a big teenager MINIMUM

The prescription of aqueous cream for mod to severe eczema Ok for washing Not greasy enough for much else

Type of emollient is important Does it sting? Preservatives sting so ointments are best Some brands sting often Patient choice in the end When skin is really dry everything stings at first

Choice of emollient Start with something simple and cheap Creamy paraffin Oily cream BP £2.20p/500g 50/50 WSP/Ung Emuls £1.50p/500g Diprobase £6.92p/500g Modulate if not tolerated in one way or another

Alternative emollients Aveeno £18.00 Double Base Epaderm £6.50 Unquentum M £9.55 Eucerin £35.20

Not enough Tubifast prescribed 3m lengths Baby Green line 12m/week Yellow line 3m/week Older child Blue line 12m/week Yellow/beige 6m/week Actifast cheaper

Inappropriate prescription of topical steroids Use of Betnovate rather than the newer steroids such as Elocon Use of too potent steroids in the long term Over use of Fucibet Use of potent steroids on the face Use of too weak steroids

Mild steroid induced “perioral dermatitis” Common especially in health care workers Stop all steroids Treat as acne rosacea in the interim

Eczema

More Related Content

What's hot

Viewers also liked

Similar to Eczema

More from Mohammed Al-Issa

Recently uploaded

In this document

Eczema