Eczema

Question 1

What dysfunction does eczema cause?

Answer 1

Unclear why eczema occurs but the end result is dysfunction of the barrier function of the skin.

Question 2

What are the different types of eczema?

Answer 2

Eczema can be grouped into endogenous – atopic, seborrheic, varicose and discoid or exogenous – allergic contact or irritant contact.

Question 3

How does eczema present?

Answer 3

Erythematous macula rash
Poorly defined and not scaly
Pruritic and associated excoriations
Typically spares the nappy area

Question 4

How long does atopic eczema normally last?

Answer 4

Most children grow out of atopic eczema by the age of 13.

Question 5

What are the risk factors for atopic eczema?

Answer 5

Atopy – asthma and hay fever
Genetic
Infection – staph colonises lesions
Allergens – unusual for there to be a clear trigger

Question 6

How is atopic eczema diagnosed?

Answer 6

Itchy skin or parental reports of scratching with >3 of:
Onset before 2 years
Past flexural involvement
History of dry skin
Personal history of atopy or 1st degree relative
Visible flexural dermatitis

Question 7

What is adult seborrhoaeic dermatitis?

Answer 7

Erythematous scaly rash usually affecting scalp (dandruff), eyebrows, nasolabial folds, cheeks and flexures. Otitis externs and blepharitis may develop. Thought to be caused by overgrowth of skin yeasts (Malassezia). Can be severe if HIV +ve and also associated with Parkinson’s.

Question 8

What is seborrhoaeic dermatitis also know as in children?

Answer 8

In children this is also known as cradle cap but may also affect the nappy area, face and limb flexures.

Tends to resolve spontaneously by 8 months.

Question 9

How should seborrhoaeic dermatitis be managed?

Answer 9

Over the counter preparations such as head and shoulders

Mild topical steroids/antifungal preparations such as Daktacort or ketoconazole.

Question 10

What is allergic contact dermatitis?

Answer 10

This is a type IV hypersensitivity reaction.

Question 11

What are common causes of allergic contact dermatitis?

Answer 11

Common causes include nickel, chromates, lanolin, rubber, plants and topical drugs. These are often found in jewellery, watches, coins, keys, cement, cosmetics and hair dyes etc.

Question 12

How does the rash appear in allergic contact dermatitis?

Answer 12

Rashes are often well defined where the contact ended and have a good history associating them with contact. Secondary spread via autosensitisation is frequent.

Question 13

How should allergic contact dermatitis be investigated and managed?

Answer 13

Investigate with patch testing
Manage by avoiding allergens
Use a topical steroid appropriate for management of the immediate rash.

Question 14

Which eczema presentation should be referred straight to hospital and what is the presentation?

Answer 14

Important to report any weeping wounds around the mouth – eczema herpeticum caused by a primary infection by herpes simplex 1 or 2. This will be seen as monomorphic punched-out erosions (circular, depressed, ulcerated lesions) usually about 1-3mm in diameter. Admitted and treat with IV aciclovir.

Question 15

How is mild eczema defined?

Answer 15

Areas of dry skin and infrequent itching and small amounts of erythema

Question 16

How is mild eczema managed?

Answer 16

Generous volume of Emollients

Topical hydrocortisone – use for another 48 hours after flare is controlled

Question 17

How is moderate eczema defined?

Answer 17

Areas of dry skin frequent itching and redness +/- excoriation and localized skin thickening

Question 18

How is moderate eczema managed?

Answer 18

Generous volume of Emollients
Topical Low dose Betnovate or Eumovate
If itching or urticaria – non-sedating antihistamine e.g. cetirizine, loratadine or fexofenadine

Question 19

How is severe eczema defined?

Answer 19

Areas of dry skin, frequent itching, redness +/- excoriations, extensive skin thickening, bleeding, oozing, cracking, and altered pigmentation.

Question 20

How is severe eczema managed?

Answer 20

Generous volume of Emollients
Topical Betnovate
Is eczema causing psychological distress – oral prednisolone
If itching or urticaria – non-sedating antihistamine e.g. cetirizine, loratadine or fexofenadine
If itching or urticaria that affects sleep – sedating antihistamine e.g. chlorphenamine

Question 21

How should refractory eczema be managed?

Answer 21

Chronic eczema that is not simply a flare up
Maintenance topical steroid alongside emollients (not for face, genital or axillae)
Topical calcineurin inhibitors such as tacrolimus and pimecrolimus as second line option

Question 22

What advice should you give patients regarding emollient use?

Answer 22

Use liberally as many times a day as possible and even when eczema isn’t active. Use 10:1 emollient to steroid and apply emollient first then wait 30mins before steroid.
Give soap substitute such as dermo-500

Question 23

What advice should you give patients about steroid use?

Answer 23

Use for exacerbations and only on active lesions
Use for about a week in a flare and 4-6 weeks in chronic disease
Fingertip rule – 1 FTU (fingertip unit) = 0.5g which is sufficient to treat a skin area about twice that of the flat of an adult hand.

Question 24

How should secondary bacterial infection of eczema be managed?

Answer 24

If extensive coverage of infection swabs the skin then prescribe oral antibiotics – flucloxacillin is first line or erythromycin if allergic. If does not respond prescribe according to swab results.
If localised infection, then topical antibiotics – can be separate or combined with corticosteroids and encourage to use for 2 weeks

Question 25

What specific management can be offered to children with severe eczema and itching problems?

Answer 25

In children with severe eczema wet wraps and oral ciclosporin may be used

Break the itch scratch cycle if needed using a sedating antihistamine such as hydroxyzine at night and keep finger nails short. Advise pressing rather than scratching.

Question 26

What is pityriasis alba?

Answer 26

Low grade eczematous rash of unknown cause. It mainly affects children and adolescents and is more noticeable in patients with darker skin. It presents with areas of scaly pink plaques which shed to lead areas of hypopigmentation. Most commonly this is seen on the face but can be elsewhere.

Question 27

What is asteatotic eczema?

Answer 27

Common skin conditions in the elderly presenting with a crazy paving like rash most often on the shins. Occurs due to water loss from the stratum corneum resulting in dry skin. Low humidity environments such as houses with central heating on in the winter and excessive washing with soap can make it worse. Treat with liberal use of emollients.

Question 28

What is discoid eczema?

Answer 28

Also known as nummular eczema (which means coin shaped) presents with bilateral round patches of eczema which is very itchy. Can be triggered by injury.