ECZEMA

Question 1

Causes of atopic eczema?

Answer 1

No single cause:
- strong genetic susceptibility
- filaggrin gene mutations causing skin barrier dysfunction
- T-helper cell dysregulation - predominance of Th2 cells rather than Th1
- environmental factors e.g. early life exposure to irritants, pruritogens etc

Question 2

Genetic factors for atopic eczema?

Answer 2

70% have a positive FHx of atopic disease
80% of children if both parents affected and 60% if only 1 parent affected
Twin studies showed a concordance rate of 85%

Question 3

Filaggrin gene function?

Answer 3

Filaggrin gene is essential for the conversion of keratinocytes to the protein/lipid squames that make up the outermost barrier layer of the stratum corneum
Loss of this function causes skin barrier dysfunction

Question 4

How does skin barrier dysfunction lead to atopic eczema?

Answer 4

Water loss from the skin leads to dryness and itching which makes the skin susceptible to allergens = hyperreactivity and induction of IgE and autoantibodies
This also predisposes skin to colonisation or infection by microbes which also leads to an inflammatory response and further damage to the skin barrier

Question 5

Triggers for atopic eczema?

Answer 5

Soap and detergents
Animal dander
House-dust mites
Extreme temperatures
Rough clothing - synthetics, silk, dyes
Pollen
Certain foods
Skin infections
Stress
Hormonal triggers - premenstrual or pregnancy
Diet - milk, egg, wheat, soy, peanuts

Question 6

Prevalence of atopic eczema?

Answer 6

Prevalence is increasing
Presents most frequently in childhood but can present at any age
Affects 10-30% of children
Up to 90% of cases occur before 5 years of age
Only 30% of those with eczema first develop symptoms as adults

Question 7

Complications of atopic eczema?

Answer 7

Infection - staph aureus, herpes simplex, superficial fungal
Psychological problems - distress, depression, behavioural problems, poor self image, sleep issues
Asthma, allergic rhinitis, food allergy, eosinophilic oesophagitis

Question 8

Typical pattern of atopic eczema?

Answer 8

Episodic disease of flares and remissions - may occur as frequently as 2 or 3 times each month

Question 9

Prognosis of atopic eczema?

Answer 9

Gradual improvement in adult life - clears in 75% of children by 16

Question 10

How commonly do children with eczema go on to develop asthma or hay fever/

Answer 10

Asthma in 30-50%
Hay fever in 30-80%

Question 11

Where is eczema most common in adults?

Answer 11

On the hands

Question 12

Where is eczema most common in children?

Answer 12

Flexure of limbs and creases of face+neck

Question 13

Where is eczema most common in infants?

Answer 13

Face, scalp, extensor surfaces of limbs

Question 14

Signs of chronic eczema?

Answer 14

Lichenified skin
Follicular hyperkeratotic papules (karatosis Pilaris) - extensor upper arms, buttocks, anterior thighs

Question 15

Criteria for eczema?

Answer 15

An itchy skin conditions plus 3 or more of the following:
Visible flexural eczema involving the skin creases or visible eczema on the cheeks/extensor areas in children younger than 18 months
PHx of flexural eczema
PHx of dry skin in the last 12 months
PHx of atopic disease
Onset of signs and symptoms before age 2

Question 16

Severity of eczema?

Answer 16

Mild - areas of dry skin and infrequent itching
Moderate - dry skin, frequent itching and redness
Severe - widespread dry skin, incessant itching and redness
Infected - weeping, crusted, pustules, fever or malaise

Question 17

Managing mild eczema?

Answer 17

Frequent and liberal use of emollients
Mild topical corticosteroid

Question 18

Self-care advice for eczem,a?

Answer 18

Frequent and liberal use of Emollients even when skin is clear
Avoid trigger factors e,g. Soap substitutes
Avoid scratching the eczema - trim nails + anti-scratch mittens

Question 19

Management of moderate eczema?

Answer 19

Emolliennts
Moderately potent topical corticosteroid for on inflamed areas
If severe itch then 1 month trial of non-sedating antihistamine

Consider a minatennce regimen of topical corticosteroids to control areas of skin prone to frequent flares

Question 20

Management of severe eczema?

Answer 20

Emollients
Potent topical corticosteroid
If severe itch - 1 month trial of non-sedating antihistamines or a short course of a sedating antihistamine if affecting sleep
If severe, extensive disease causing psychological distress - short course of oral corticosteroid

Consider maintenance regimen of topical corticosteroids to control areas of skin prone to frequent flares

Question 21

WHAT IS WET WRAPPINH?

Answer 21

large amounts of emollient (and sometimes topical steroids) applied under wet bandages

Question 22

How should you apply emollients and topical steroids?

Answer 22

if a topical steroid is also being used the emollient should be applied first followed by waiting at least 30 minutes before applying the topical steroid

Question 23

Non-sedating antihistamine options?

Answer 23

Cetirizine, loratidine or fexofenadine

Question 24

Steroid ladder: mild

Answer 24

Hydrocortisone

Question 25

Steroid ladder: moderate

Answer 25

Betamethasone valerate 0.025%
Clobetadone butyrate 0.05% (eumovate)

Question 26

Steroid ladder: severe

Answer 26

Betamethasone valerate 0.1% (betnovate)

Question 27

When should you consider admission to hospital for eczema?

Answer 27

If you suspect eczema herpeticum

Question 28

Managing infected eczema?

Answer 28

Antibiotic - flucloxacillin

If localised areas consider topical fusidic acid

Prescribe new supplies of topical emollients/steroids to try to reduce the risk of further infection

Question 29

Most common organism that causes infected eczema?

Answer 29

Staph aureus

Question 30

What causes eczema herpeticum?

Answer 30

Herpes simplex virus 1 or 2

Question 31

What does eczema herpeticum look like?

Answer 31

A rapidly progressing painful rash
Monomorphic punched-out erosions - circular, depressed, ulcerated lesions usually 1-3mm in diameter

Question 32

Management of eczema herpeticum?

Answer 32

Admit to hospital
IV aciclovir

Question 33

Side effects of topical steroids for eczema?

Answer 33

Thinning of the skin - more prone to flares, bruising, tearing, stretch marks and telangiectasia
Systemic absorption is possible

Question 34

Management options for severe non-responsive eczema?

Answer 34

Phototherapy
Immunosuppressants - azathioprine, Ciclosporin, methotrexate

Question 35

Who does periorificial dermatitis most commonly affect?

Answer 35

Women aged 20-45

Question 36

What is periorificial dermatitis?

Answer 36

A relatively common chronic inflammatory skin eruption
Preferentially targets cutaneous orifices e.g. around eyes, nostrils, mouth

Question 37

Types of periorificial dermatitis?

Answer 37

Perioral
Periocular
Perinasal
Genital periorificial dermatitis

Question 38

What often triggers periorificial dermatitis?

Answer 38

Topical or, to a lesser extent, inhaled corticosteroids

Question 39

Where is periorificial dermatitis most common?

Answer 39

Perioral - note the skin immediately adjacent to the vermillion border of the lip is spared

Question 40

Features of periorificial dermatitis?

Answer 40

Clustered, erythematous papules, papulovesicles and papulopastules

Question 41

Management of periorificial dermatitis?

Answer 41

Topical or oral antibiotics

Note: steroids may worsen Sx

Question 42

What is pompholyx?

Answer 42

Aka dyshidrotic eczema
A type of eczema that affects the hands or feet

Question 43

Types of pompholyx?

Answer 43

Cheiropompholyx - hands
Pedopompholyx - feet

Question 44

What can precipitate pompholyx eczema?

Answer 44

Humidity/sweating
High temperatures

Question 45

Features of pompholyx?

Answer 45

Small blisters on palms and soles
Often intensely itchy and may have a burning sensation
Once blisters burst the skin may become dry and cracked

Question 46

Management of pompholyx?

Answer 46

Cool compresses
Emollients
Topical steroids