Atopic Dermatitis And Eczema Flashcards
What is atopic eczema?
Atopic eczema is a chronic, relapsing, inflammatory skin condition characterised by an itchy red rash that favours the skin creases such as the folds of the elbows or behind the knees.
What are the environmental trigger factors for atopic eczema?
Irritants – e.g., soaps and detergents (including shampoos, bubble baths, shower gels and washing-up liquids).
Skin infections: Staphylococcus aureus is believed to be an important exacerbating factor in atopic eczema.
Contact allergens.
Extremes of temperature and humidity. Most patients improve in summer and are worse in winter. Sweating induced by heat or exercise can provoke an exacerbation.
Abrasive fabrics – e.g., wool.
Dietary factors aggravate atopic eczema in about 50% of children but much less frequently in adults.
Food allergy should be suspected in children with atopic eczema who have reacted previously to a food, with immediate symptoms, or in infants and young children with moderate or severe atopic eczema that has not been controlled by optimum management, particularly if associated with gut dysmotility (colic, vomiting, altered bowel habit) or failure to thrive.
Inhaled allergens – e.g., house dust mites, pollens, pet dander and moulds. Inhaled allergy should be suspected in children with seasonal flares of atopic eczema, associated asthma and rhinitis, or children aged over 3 years with atopic eczema on the face.
What are the endogenous trigger factors for atopic eczema?
It is thought that genetic mutations affect the production of filaggrin. Filaggrin is a protein critical to the conversion of keratinocytes to the protein/lipid squames that compose the stratum corneum, the outermost barrier layer of the skin. Therefore, in at least some patients with atopic eczema, there is a genetic predisposition that increases their sensitivity to external environmental triggers.
Stress may exacerbate atopic eczema, which itself may be a cause of psychological distress.
Hormonal changes in women – e.g., premenstrual flare-ups, deterioration in pregnancy.
What is the diagnostic criteria for atopic eczema?
Must have an itchy skin condition (or report of scratching or rubbing in a child) plus three or more of the following:
History of itchiness in skin creases such as folds of the elbows, behind the knees, fronts of ankles, or around the neck (or the cheeks in children aged 18 months or under).
History of asthma or hay fever (or history of atopic disease in a first-degree relative in children aged under 4 years).
General dry skin in the preceding year.
Visible flexural eczema (or eczema affecting the cheeks or forehead and outer limbs in children aged under 4 years).
Onset in the first two years of life (not always diagnostic in children aged under 4 years).
•If it does not itch it is very unlikely to be eczema.
Presentation of atopic eczema
The distribution tends to vary with age and the appearance of persistent lesions may alter with scratching.
A tendency to dry skin persists throughout life.
Acute flare-ups vary in appearance from vesicles to areas of poorly demarcated redness.
Other possible features include crusting, scaling, cracking and swelling of the skin.
Repeated scratching often leads to thickening of chronic lesions.
During infancy, atopic eczema primarily involves the face, the scalp and the extensor surfaces of the limbs. It is usually acute. The nappy area is usually spared.
In children and in adults with long-standing disease, eczema is often localised to the flexure of the limbs.
Adults: often generalised dryness and itching.
Chronic eczema on the hand may be the primary manifestation.
Healthcare professionals should be aware that in Asian, black Caribbean and black African children, atopic eczema can affect the extensor surfaces rather than the flexures, and discoid (circular) or follicular (around hair follicles) patterns may be more common.
Presentation of bacterial infection of eczema
Crusting, weeping, pustulation and/or surrounding cellulitis with erythema of otherwise normal-looking skin.
A sudden worsening of the condition.
Presentation of eczema herpeticum
Areas of rapidly worsening, painful eczema.
Clustered blisters consistent with early-stage cold sores.
Punched-out erosions (circular, depressed, ulcerated lesions) usually 1-3 mm that are uniform in appearance (may coalesce to form larger areas of erosion with crusting).
Possible fever, lethargy or distress.
How do you assess severity and well-being in a child with atopic eczema?
In assessment of severity, psychological and psychosocial well-being and quality of life, take into account the impact of atopic eczema on parents or carers, as well as the child and provide appropriate advice and support. The following assessment tools can be used below):
Visual analogue scales (0-10) capturing the child/parent/carer’s assessment of severity, itch and sleep loss over the previous three days and nights.
Patient-oriented Eczema Measure (POEM).
Children’s Dermatology Life Quality Index (CDLQI).
Infants’ Dermatitis Quality of Life Index (IDQOL).
Dermatitis Family Impact (DFI) Questionnaire.
Differentials for atopic eczema
Psoriasis Contact dermatitis Seborrhoeic dermatitis Fungal infections Lichen simplex chronicus Scabies and other infestations.
Investigations for atopic eczema
Investigations are rarely required to establish the diagnosis.
Most children with mild atopic eczema do not need clinical testing for allergies
Estimation of immunoglobulin E (IgE) and specific radioallergosorbant tests (RASTs) only confirm the atopic nature of the individual.
Swabs for bacteriology are particularly useful if patients do not respond to treatment, in order to identify antibiotic-resistant strains of S. aureus or to detect additional streptococcal infection.
Associated diseases of eczema?
Associated with asthma, hay fever and allergic rhinitis.
Which information should you provide the patient and family about atopic eczema?
Provide information about the condition, the factors that may provoke it, the role of different treatments and their effective and safe use. It is important to emphasise the correct quantities of topical treatments to use. Use written information to reinforce information discussed.
Include information on how to recognise flares of atopic eczema (increased dryness, itching, redness, swelling and general irritability).
Information should also include how to recognise the symptoms and signs of bacterial infection with staphylococcus and/or streptococcus (weeping, pustules, crusts, atopic eczema failing to respond to therapy, rapidly worsening atopic eczema, fever and malaise).
Provide support: living with skin disease, especially the potential psychosocial difficulties, can be very difficult.
Provoking factors should be identified and avoided when practical. Avoid anything that is known to increase disease severity: advise avoidance of extremes in temperature and humidity, avoid irritating clothes containing wool or certain synthetic fibres (use non-abrasive clothing fabrics, such as cotton).
Advise keeping nails short and avoid use of soaps or detergents; replace with emollient substitutes (use gloves when unable to avoid handling irritants such as detergents).
Keep the skin hydrated: use of baths and bath additives and reduction of water loss by the use of sufficient appropriate emollient therapy, used liberally.
Management of atopic eczema
A stepped approach should be used for managing atopic eczema in children, i.e. tailoring the treatment step to the severity of the atopic eczema. Management can then be stepped up or down, according to the severity of symptoms
Treatment includes emollients, topical steroids, antibiotics and bandages.
What is the basis of atopic eczema management?
Emollients should form the basis of atopic eczema management and should always be used, even when the atopic eczema is clear.
These are best applied when the skin is moist but they should also be applied at other times.
They should be applied as liberally and frequently as possible and continual treatment with complete emollient therapy (combinations of cream, ointment, bath oil and emollient soap substitute) will help to provide maximal effect.
Ideally the frequency of application of emollients should be every 4 hours or at least 3-4 times per day.
They should be prescribed in large quantities, with the recommended quantities used in generalised eczema being 500 g/week for an adult and 250 g/week for a child.
Intensive use of emollients will reduce the need for topical steroids.
Should you use potent steroids on the face?
Mild corticosteroids are generally used on the face and on flexures; potent corticosteroids are generally required for use on adults with discoid or lichenified eczema or with eczema on the scalp, limbs and trunk.
It is recommended that topical corticosteroids for atopic eczema should be prescribed for application only once or twice daily.
Use mild potency for mild atopic eczema, moderate potency for moderate atopic eczema and potent for severe atopic eczema.
Use mild potency for the face and neck, except for short-term (3-5 days) use of moderate potency for severe flares.
Use moderate or potent preparations for short periods only (7-14 days) for flares in vulnerable sites such as the axillae and groin.
Do not use very potent preparations in children, without specialist dermatological advice.
