W24 Clinical management of eczema and psoriasis Flashcards
What is Eczema?
a.k.a. Atopic Eczema/Atopic Dermatitis
Chronic inflammatory skin condition
Affects all ages but presents most often in early childhood
Dry, itchy, inflamed skin
Skin can become infected
Episodes of flare up/exacerbation with periods of remission
Atopic – Increased immune response to an allergen or trigger
Common for patients to have Hx of Family Hx of other atopic conditions e.g. asthma
What is the cause of eczema?
(fil)
*Complex condition
* Many factors affect it’s development
* Genetic Link
-70% patients have FH of atopic disease – asthma, hayfever, allergy, eczema
-Mutation of Filaggrin gene in 50% of cases
* Filaggrin – converts keratinocytes to protein/lipid squames that make up stratum corneum
* Loss of Filaggrin function = Dysfunction of skin barrier
Skin barrier dysfunction = water loss, allergen/pathogen entry
Triggers of eczema?
Soap/Detergents/Chemicals
Animal hair
Dust mites
Extremes of Temperature
Clothing
Pollen
Foods
Infection
Stress
What is the Itch-scratch cycle?
- Itch- In people with atopic dermatitis, immune cells in the deeper layers send inflammatory signals to the surface, causing the itchy rash
- Scratch- Scratching breaks down the outer layer of the skin, which allows germs, viruses and allergens to get in
- Release of Inflammatory signals - In response to these invaders, the immune system continues to send even more redness and itching.
- Damaged skin- The more scratching, the more the skin barrier breaks down, and the itch-scratch cycle continues
Diagnosing Eczema
History
Itching
Pattern
Time & age of onset
Hx of rash
Tx tried? & response
Dry skin in last 12 months
Asthma or allergic rhinitis
Diagnosing Eczema:
What are the features of the Rash?
- Dryness
- Itching
- Primary manifestation on hands
- Presence in limb flexures
- Infants -Face, scalp, limbs nappy areas
- Acute – Fluid vesicles, scaling, crusting of skin
- Chronic – Thickened skin due to scratching, Keratosis pilaris
- Weeping, crusting, pustules, fever & malaise – suspect bacterial infection
What is the differential diagnosis of Eczema? (8)
Psoriasis
Allergic Contact Dermatitis
Seborrhoeic Dermatitis
Fungal infection
Scabies
Food allergy
Fungal infection
Management of Eczema
How is it assessed? (brief)
What are the categories of eczema? (5)
Assessment of Severity
Assess severity to determine the best treatment
Examine all areas
Itching??
Categorization
Clear – normal, no active eczema
Mild – Dry skin, infrequent itching
Moderate – Dry skin, frequent itching, redness +/- excoriation & thickening
Severe – Widespread dry skin, incessant itching & redness. Excoriation, extensive thickening, bleeding, oozing, cracking, altered skin pigmentation
Infected – Weeping, crusting, pustules, fever, malaise
What is Eczema Herpeticum?
- Herpes Simplex infection (HSV)
- Widespread lesions
- Usually on face and neck but can extend over whole body
- Possible association with Staph/Strep skin infection
- Cluster of small blisters - itchy and painful
- Blisters are red, purple or black
- Blisters can ooze pus when broken open
- Fever
- Generally unwell
MEDICAL EMERGENCY – URGENT REFERRAL
Psychological impact of eczema
Assess impact of symptoms on school, work, social life, sleep & mood:
None
Mild
Moderate
Severe
Assessment Tools:
Visual analogue scales
Patient Oriented Eczema Measure
Infants Dermatitis Quality of Life
Children’s Dermatology Life Quality Index
Dermatitis Family Impact
Management of Eczema- Self care
Correct use of emollients
Maintenance of skin, reduce risk of flare ups
Avoid exacerbating triggers
Do not change diet unless advised by specialist
Complementary remedies not advised – Homeopathy, Chinese, herbal
Information and support sources – British Association of Dermatologists (BAD), National Eczema Society, Eczema Care Online
Mild Eczema- management
Emollients – Frequent and liberal use, maintain skin moisture
Mild potency topical corticosteroid for red areas e.g. Hydrocortisone 1%
Continue for 48hrs after flare up controlled
Information & advice on maintenance of skin, reducing flare ups
Follow up – if persisting symptoms review emollient use
Moderate Eczema- management
1st line?
2nd line?
- Identify trigger factors or infection
- Emollients – Frequent and liberal use, maintain skin moisture
- Moderate potency topical corticosteroid
Betamethasone val. 0.025% or Clobetasone but. 0.05% - Use mild potency for delicate skin areas Continue for 48hrs post flare up control, max. 5 days use on face
- Occlusive dressings/bandages – specialist recommendation
- Non-sedating antihistamine – to help with itching
=Cetirizine, Loratadine, Fexofenadine - Information & support – maintenance of skin, reducing flare ups
- Consider maintenance regime of topical steroid
- Follow up – persistent symptoms, review emollient use
Topical Calcineurin inhibitors:
2ND Line preventative option
Tacrolimus
Pimecrolimus
Only recommended by Specialist
Dermatologist or GP with Special Interest (GPSI)
Severe Eczema:
What are the steps in management?
- Identify trigger factors or infection
- Emollients – Frequent and liberal use, maintain skin moisture
- Potent/Very Potent topical corticosteroid e.g. Betamethasone val. 0.1%
-Moderate potency for delicate skin areas, max. 5 days use
-DO NOT USE in children under 12 months old - Occlusive dressings/bandages
- Antihistamine to help with itching
-Cetirizine, Loratadine, Fexofenadine, Chlorphenamine (if affecting sleep) - Extensive & distressing – Consider short oral corticosteroid (Pred 30mg 7/7), Refer under 16s to specialist
- Consider topical steroid maintenance regime
Infected Eczema
- If systemically well aim not to routinely offer Abx – limited benefit, risk of resistance
- If offered Abx
-Flucloxacillin 1st line
-Clarithromycin if penicillin allergy
-Poor response - consider alternative, skin swabs - Localised infection – Topical Fusidic Acid
