management of atopic eczema

Question 1

What is Eczema (dermatitis)

Answer 1

Term to describe a group of skin conditions characterized by red, itchy rashes
No known single cause, is a complex condition involving genetic, immunological and environmental factors, leading to a dysfunctional skin barrier and immune system dysregulation

Question 2

Stages of Eczema

Answer 2

Depend on the degree of inflammation of
the skin:
ACUTE: skin very oedematous producing papules or bullae – “wet eczema”
SUBACUTE: glistening of skin with redness, scaling and crusting. Secondary infection common
CHRONIC: skin red, dry, scaly, slightly thickened with a tendency to crack and fissure – “dry eczema”

Question 3

Clinical Features

Answer 3

Erythema (may be more purple in SOC)
Oedema
Pruritis
Excoriation, lichenification, dryness of skin (white, thickened, flaking, cracked skin)
Epidermal barrier is disordered - secondary infection risk
Hyper and hypopigmentation (more severe in darker skin tones)

Question 4

Types of Eczema

Answer 4

Atopic
Discoid eczema – a type of eczema that occurs in circular or oval patches on the skin
Contact dermatitis – a type of eczema that occurs when the body comes into contact with a particular substance (irritant or allergen)
Varicose eczema – a type of eczema that most often affects the lower legs and is caused by problems with the flow of blood through the leg veins
Seborrhoeic eczema – a type of eczema where red, scaly patches develop on the sides of the nose, eyebrows, ears and scalp
Infantile seborrhoeic dermatitis - often, but not always it affects the scalp as cradle cap
Pompholyx – a type of eczema that causes tiny blisters to erupt across the palms of the hands

Question 5

Atopic Eczema:Clinical Features

Answer 5

• Pruritis
• Facial and flexural eczema in infants
• Flexural eczema in children and adults
• Chronic or relapsing dermatitis
• Personal or family history of atopy
• Localised variants may affect hands, -eyelids or lips

Question 6

Diagnostic Criteria

Answer 6

An itchy condition plus 3 or more of the following:
Visible flexural eczema (or cheeks / extensor area in < 18month old)
Personal history of flexural eczema (or cheek / extensor in <18 month old)
Personal history of dry skin in the last 12 months.
Personal history of asthma or allergic rhinitis
Onset of signs and symptoms beforethe age of 2years (do not use criterion in children <4yrs)

Question 7

Complications

Answer 7

Bacterial infection, e.g impetigo
Viral infections, e.g. eczema herpeticum
Psychosocial, e.g. depression, behavioural problems, sleep disturbance
Other atopic comorbidities, e.g. allergic rhinitis, asthma, food allergy, eosinophilic oesophagitis
Other non-atopic comorbidities, e.g. allergic contact dermatitis, obesity, cardiovascular disease
Sensitive skin

Question 7

Assessing Severity- physical

Answer 7

NICE CKS categorizes eczema as:
Clear —if there isnormal skin and no evidence of active eczema.
Mild —if there areareas of dry skin, and infrequent itching (with or without small areas of redness).
Moderate —if there areareas of dry skin, frequent itching, and redness (with or without excoriation and localized skin thickening).
Severe —if there arewidespread areas of dry skin, incessant itching, and redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking, and alteration of pigmentation).

Question 8

Assessing Severity- PSYCHOLOGICAL IMPACT

Answer 8

To assess the psychological impact of atopic eczema, ask about the effect of eczema on daily activities (school, work, and social life), sleep, and mood.
Categorize the impact of eczema on quality of life and psychosocial well-being as:
None — no impact on quality of life.
Mild — little impact on everyday activities, sleep, and psychosocial well-being.
Moderate — moderate impact on everyday activities and psychosocial well-being, and frequently disturbed sleep.
Severe — severe limitation of everyday activities and psychosocial functioning, and loss of sleep every night.

Question 9

Atopic Eczema: Management- all patients

Answer 9

Non-pharmacological advice
-Emollients and soap substitutes

Question 10

Atopic Eczema: Management - acute control

Answer 10

Topical corticosteroids
-Topical calcineurin inhibitors (2nd line)
-Oral antibiotics (secondary infection)

Question 11

Atopic Eczema: Management - MAINTENANCE THERAPY

Answer 11

-Emollients
-Intermittent topical corticosteroids
-Topical calcineurin inhibitors (2nd line)

Question 12

Atopic Eczema: Management SPECIALIST TREATMENTS (SECONDARY CARE)

Answer 12

Rescue oral corticosteroids
-Phototherapy
-Oral immunosuppressants (e.g. methotrexate, ciclosporin)

Question 13

Non-Pharmacological management

Answer 13

Emollients and soap substitutes
Education and play techniques
Avoidance of trigger factors, e.g fabrics, heat, soaps, food triggers (diary?)
Cotton mittens and filed nails (scratching), gently rub skin with fingers
Bathing versus showering?
Lukewarm (not hot) water 10-15mins
Avoid scrubbing skin
Lightly pat dry
‘Soak and seal’ with emollients
Wraps or dressings may be of benefit

Question 14

Emollients - RATIONALE / MECHANIS

Answer 14

Improve hydration of skin
Prevent scaling and cracking
Restore barrier function

Question 15

Emollients CHOICE & CORRECT USAGE

Answer 15

Apply frequently and liberally (especially after bathing), even when skin is clear
Smooth into ALL skin in line with hair growth (prevents folliculitis)
Quantities
Adults should aim to use approx. 500g/week; child 250g/week
10:1 ratio of emollient : topical treatment
Which formulation / choice is best?
Patient acceptability is key, may need combination of products (little evidence for one over another)
Creams – red, inflamed, weeping, flexural areas (and may be more suitable for daytime)
Ointments – dry, lichenified areas (and may be more acceptable for nighttime use)
Require emollients as soap substitute also
Most emollients contain no active ingredient, those with additional ingredients, e.g. urea (keratin softener, e.g. Eucerin preparations) or antiseptics (e.g. Dermol) are generally not recommended due to increased risk of skin reactions

Question 16

Emollients adverse affects

Answer 16

Skin reactions, usually due to additives, e.g. preservatives, antiseptics (Dermol), lanolin (e45). Not recommended
Ointments have occlusive effect which can cause folliculitis
Aqueous cream – light emollient – no longer recommended, moved to a soap substitute
WARNING – fire risk with emollient products. Counsel
Skin-related adverse effects can be managed by stopping and switching to alternative emollient / formulation

Question 17

Topical Corticosteroids - Acute flare – choice depends on body site, eczema severity, age of patient

Answer 17

For normal skin on the body (not face, genitals, axillae), prescribe potency of topical corticosteroid to match severity of eczema, to be used OD for 7-14 days
Mild eczema = mildly potent topical corticosteroid
Moderate eczema = moderately potent corticosteroid
Severe eczema = potent topical corticosteroid

For face and neck = mild potency, increased to moderate (max 5 days) only if this is insufficient
For axillae & groin = moderate preparations for 7-14 days

Question 18

Topical Corticosteroids - Maintenance therapy

Answer 18

Step down treatment
lowest potency that controls eczema (e.g. class down from that used during flares; mild only if face / genitals / axillae)
Intermittent treatment – twice weekly or weekend

Question 19

Potencies Potency is a result of the formulation as well as the corticosteroid

Answer 19

Mild
- hydrocortisone 0.1-2.5%; Synalar 1 in 10 dilution (Fluocinolone)
Moderate
- Eumovate (clobetasone butyrate 0.05%); Betnovate RD (Betamethasone valerate)
Potent*
- hydrocortisone butyrate 0.1% (Locoid), mometasone furoate 0.1% (Elocon)
Very potent*
- Dermovate, Etrivex (clobetasol propionate 0.05%)

Question 20

Application and prescribing amounts

Answer 20

Apply thinly to all affected areas

One finger-tip unit (FTU) is sufficient to treat a skin area about twice that of the flat of the hand with the fingers together

Wait 15-30 mins after applying emollient

Prescribe formulation suitable to patient or location affected (ointment may be more effective due to increased emollient effect)

Apply at time that suits person

Continue to use emollients frequently and liberally

Question 21

Corticosteroid side effects

Answer 21

Transient burning or stinging
Worsening and spreading of untreated infection.
Thinning of the skin (improves on stopping)
Permanent striae
Acne vulgaris / rosacea
Mild depigmentation (usually reversible)
Excessive hair growth at the site of application

Systemic adverse effects are rare, but may include:
Adrenal suppression
Cushing’s syndrome
Growth suppression in children.

Question 22

Topical Calcineurin Inhibitors

Answer 22

For acute control or as maintenance therapy – second line therapy (NICE)

Inhibit inflammatory cytokine transcription in activated T cells and other inflammatory cells through inhibition of calcineurin (immunosuppressant)

Steroid sparing effect

Adverse effects
Burning sensation, stinging, soreness, pruritis, skin infections

Question 23

Other treatments

Answer 23

Antibiotics (if infected)

Oral antihistamines (only severe itch, not routinely recommended)

Oral corticosteroids (short term rescue therapy)

Severe refractory eczema (specialist)
Phototherapy
oral Immunosuppressants (amber list shared care medicines). e.g. mycophenolate, ciclosporin, azathioprine
oral Alitretinoin (retinoid), baricitinib, dupilumab (biologics) – (red list, hospital only)
Require close monitoring