Eczema

Question 1

What patient advice is needed for emollients?

Answer 1

They are flammable - the thicker the more dangerous, so stay away from flames + careful with smoking

Question 2

What is the epidemiology of eczema?

Answer 2

Atopic eczema is common and increasing in prevalence
- c. 2-20% in developed countries

Family Hx is a common risk factor

80% of cases will present <5yrs old

Question 3

What are some triggers of eczema?

Answer 3

Exogenous factors:

• Irritants e.g. soaps, detergents
• Skin infections = S.aureus, thought to exacerbate
• Contact allergens
• Abrasive fabrics e.g. wool
• Dietary factors e.g. food allergy (more common in children)
• Inhaled allergens e.g. dust mites, pollens, pet dander, moulds

Endogenous factors:

• Genetics affecting the production of filaggrin (= protein that helps convert keratinocytes into the outermost barrier of the skin
• Stress
• Hormonal changes in women e.g. pre-menstrual and pregnancy flares

Question 4

How does eczema present?

Answer 4

Areas affected may shift over lifespan and with scratching, but generally affects skin creases

• Folds of elbows
• Behind the knees

Rash:

• Itchy
• Vesicles or poorly demarcated redness

Skin:

• Dryness*, crusting, scaling, cracking and swelling of skin
• Thickening of chronically affected areas

History of asthma*
Onset in the first 2yrs of life*

• = very suggestive of Dx, itchiness is nearly always present - doesn’t itch, not eczema

Question 5

How can you assess the severity and wellbeing of a child with atopic eczema?

Answer 5

Categorise as:

• Clear - no evidence of active eczema
• Mild - areas of dry skin, infrequent itching +/- redness
• Moderate - areas of dry skin, frequent itching, redness
• Severe - widespread areas of dry skin, incessant itching, redness +/- skin thickening, bleeding, oozing, cracking, pigmentation changes
• Infected - weeping, crusted areas or pustules, or fever and malaise

Validated tools:

• Visual analogue scales (0-10) assessing severity, itch and sleep loss over three previous nights
• Patient-oriented eczema measure (POEM)

In older people:
- Assess for the psychological impact - on ADLs, social and work life, sleep and mood

Question 6

How do you investigate eczema?

Answer 6

Usually a clinical Dx

May perform IgE testing to confirm allergy status of individual (to help avoid specific allergens) or swab for bacteria if patients are not responding to treatment

Question 7

How do you manage eczema?

Answer 7

Patient information:

• Triggers and avoidance
• Recognise symptoms of flares and infections and how to manage
• Keep nails short, avoid soaps/detergents - replace with emollients
• Keep skin hydrated
• Provide psychosocial and occupational support

Emollients:

• Best applied when skin is moist, but should be applied at other times
• Applied liberally and frequently e.g. every 4hrs
• Maximal hydration of skin and as a barrier to reduce infection

Topical steroids:

• Mild - on face and flexures
• Potent - for those with scalp, limbs and truncal involvement; use for 7-14 days max
• Application 1-2x/day
• Review frequently for systemic side effects
• Can have withdrawal flares if used improperly (red skin, burning, peeling, papules/pustules, sweating etc)

Abx:

• Flucox PO 14days (for S.aureus; erythromycin if Pen allergic)
• Penicillin if B-heamolytic strep

Question 8

How do you manage lichenification?

Answer 8

Thickening of skin resulting from repeated sccratching

- Treat with potent CCS

Question 9

What other treatments are available in secondary care?

Answer 9

Tacrolimus:

• A calcineurin inhibitor
• For those who’s eczema is not controlled on maximal corticosteroid treatment, or if there is a risk of corticosteroid induced side effects esp. skin atrophy

Phototherapy

Systemic immunosuppression e.g. ciclosporin, azathioprine

Very potent topical steroids

Short period of hospitalisation to remove the person from environmental antigens or emotional stresses, provide intense education and check compliance with treatment

Question 10

What is eczema herpeticum?

Answer 10

Concomitant infection with herpes simplex virus

Signs appear 5–12 days after contact with an infected individual, who may or may not have visible cold sores

Identified by grouped vesicles and punched-out erosions that may coalesce into large, denuded bleeding areas that extend over the entire body
- Patient is also systemically unwell with fever, malaise

Manage with oral aciclovir 400-800mg 5x daily for 10-14days or until lesions heal