Eczema Treatment

Question 1

Overall Treatment

Answer 1

• Conservative: soap substitute, irritant avoidance
• Emollients
• Topical Steroids
• Topical Calcineurin inhibitors
• 3rd line treatments, UV therapy, Dupilumab

Question 2

Conservative measures

Answer 2

– avoid:
anything that is known to increase disease severity
extremes in temperature
irritating clothes containing wool or certain synthetic fibres
use of soaps or detergents; replace with emollient substitutes
– keep nails short

Question 3

Emollients

Answer 3

E.g. E45, diprobase, aveeno, epadem

simple emollients: Ideally, emollients should be applied
every 4 hours or at least 3–4 times per day. Large quantities should be prescribed (e.g. 250g / week), roughly in a ratio of with topical steroids of 10:1. 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. Creams soak into the skin faster than ointments. Emollients can become contaminated with bacteria - fingers should not be inserted into pots (many brands have pump dispensers)

Question 4

What is a fingertip unit?

Answer 4

1 finger tip unit (FTU) = 0.5 g, sufficient to treat a skin area about twice that of 2 palms

Question 5

Steroid Potency

Answer 5

• Mild: Hydrocortisone
• Moderate
  1. Betamethasone 0.025% (Betnovate)
  2. Clobetasone (Eumovate)
• Potent
  1. Fluticasone
  2. Betamethasone 0.1% (Betnovate)
• Very Potent: Clobetasol (Dermovate)

Question 6

How/when to use steroid?

Answer 6

Steroid use should be limited to a few days to a week for acute eczema and up to 4–6 weeks to gain initial remission for chronic eczema

The weakest steroid that controls the disease effectively should be chosen; this may involve either a step-up approach, less potent to more potent, or a step-down approach.

Question 7

Topical Calcineurin Inhibitors

Answer 7

Immunomodulatory agents (e.g. tacrolimus, or pimecrolimus for short-term use) are an alternative to topical steroids. They should only be considered if the
patient is intolerant to or has failed with conventional corticosteroid therapy

Question 8

Other 3rd line treatments

Answer 8

• immunosuppressants: e.g. ciclospirin, azathioprine
• UV phototherapy
• sedating antihistamines may be used (ideally intermittently for exacerbations) to reduce itch and scratch
• new and first biologic for eczema: dupilumab

Question 9

Bacterial infection - treatment

impetiginization of eczema - red, weeping

Answer 9

• Steroid-antibiotic combinations are effective
  in clinical practice - e.g. Fucibet (Fusidic acid and Betamethasone 0.1%)*
• Oral antibiotics are often necessary in moderate to severe infection or if the infection is recurrent or widespread: a 7-day course of flucloxacillin (or macrolide if penicillin allergy or resistance)
• Swabs for bacteriology are useful if patients do not respond to therapy

*avoid long-term use of topical antibiotics such as fucidic acid which leads to bacterial resistance - never use it for more than 2 weeks

Question 10

Other variants of eczema

Answer 10

Seborrheic Dermatitis: distribution on nasolabial folds, eyebrows, scalp, sometimes central chest or back. Fungal infection, treated with topical ketoconazole +/- topical steroid short term

Discoid Eczema (nummular): unknown aetiology, can sometimes happen as part as atopic eczema; Staph infection is common

Venous Eczema: aka varicose eczema associated with chronic venous insufficiency; hyperkeratosis, thickening, oedema, varicose veins

Question 11

Contact Dermatitis - 2 types

Answer 11

Irritant contact dermatitis: non-allergic, commonly back of hand, people who do ‘wet work’ - wash hands a lot, use of detergents. Gets worse on cold weather (worse in winter). Treatment: irritant avoidance, emollients, +/- steroid

Allergic Contact dermatitis: type 4 hypersensitivity; can happen on head following head dyes, or blistering on palms following cleaning products. Tested with ‘patch testing’ (applying patches with test substances in small chambers or discs to a person’s back)

Question 12

Eczema Herpeticum

Answer 12

Caused by herpes simplex virus 1 or 2.

It is more commonly seen in children with atopic eczema and often presents as a rapidly progressing painful rash. On examination, monomorphic punched-out erosions (circular, depressed, ulcerated lesions) and coalescing vesicles are typically seen.
Can lead to erythema multiforme

Treatment with PO or IV aciclovir +/- topical steroids