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What is eczema?

Eczema (also known as atopic eczema or atopic dermatitis) is a common, chronic, relapsing, inflammatory skin disorder. The skin function is impaired leading to porous and dry skin that easily becomes inflamed, susceptible to infection and itchy. Chronically scratched skin may become thickened (lichenified)

Assessment

An holistic approach is essential

  • History of itchy rash often with onset in childhood
  • Relevant family/social history – eczema, asthma, hayfever, smokers, pets
  • Distribution and clinical signs
  • Impact on quality of life and sleep
  • What treatments are being and have been used; how long for; what helped and what did not

Management principles - ABC rule

A  A void triggers; soaps or anything that lathers, cigarette smoke, irritant clothing

B  B land moisturisers; an absolute essential part of treatment. Should be fragrance free. Applied ideally 3-4 times a day; prescribe adequate quantities (at least 500g/week); patient choice improves concordance; bath additives are not recommended; use emollients to wash (apply before wetting the skin). Ideally wash hair over the sink to avoid shampoo on skin causing irritation

C  C ontrol inflammation

  • Topical steroids matched to severity and anatomical site – mild (face & flexures), moderate, potent
  • Topical steroids use once daily for 1-6 weeks until settled, decreasing to twice weekly use for maintenance if frequent flares
  • Step-up use to daily during a flare, then wean back down for maintenance therapy (reduces frequency of flares)
  • Calcineurin inhibitors (e.g. topical tacrolimus or pimecrolimus) are useful as second line and particularly useful in delicate sites (eyelids, face, flexures)

Other considerations

  • No evidence of benefit with non-sedating anti-histamines
  • Sedating anti-histamines short-term may aid sleep and break the itch-scratch cycle
  • Directing to patient support groups e.g. National Eczema Society
  • Complications – suspect infections in rapidly deteriorating eczema (bacterial or viral), take swabs, consider oral antibiotics or antivirals. Avoid long-term use of combination topical agents (e.g. clotrimazole or fucidic acid with a topical steroid)
  • No good evidence for alternative therapies

When to refer

  • Diagnostic uncertainty
  • Failure to respond to treatment
  • Cutaneous atrophy from chronic topical steroid use
  • Suspicion of allergic contact dermatitis (especially if new onset of eczema of face and hands) for patch testing
  • Refer urgently: severely infected eczema eg bacterial or HSV in a systemically unwell adult or erythroderma (>90% body surface)
Table 1: Clinical features and specific treatment of five adult eczema types
TypeClinical featuresSpecific treatment
Stasis (Varicose) Eczema
  • Bilateral erythematous, scaly, pruritic, rash of lower legs, often oedematous
  • Commonly misdiagnosed as bilateral cellulitis which is extremely rare. Cellulitis is unilateral, associated with ascending erythema, patient may have systemic signs of infection
  • May co-exist with contact dermatitis from dressings
  • Full emollient regimen
  • Consider potent steroid 2-4 weeks then step down to twice weekly maintenance or use tacrolimus 0.1%
  • Consider paste or compression bandages
Discoid Eczema
  • Multiple round shaped plaques that are sometimes weepy with exudative crusts
  • Often misdiagnosed as impetigo, or more commonly, a fungal infection. Scrape any scale and send mycology if in doubt
  • Usually extremely itchy
  • Full emollient regimen
  • Potent topical steroids 4-6 weeks
  • May need super-potent topical steroids up to 2 weeks
  • Consider maintenance therapy twice weekly 
Pompholyx 
  • Extremely itchy clear vesicles on hands and feet
  • Full emollient regimen
  • Super-potent topical steroids for 2 weeks. May need to use under occlusion with clingfilm overnight
  • Then twice weekly maintenance regimen
  • Treat any co-existing athlete’s foot after confirming with skin scrapings
Contact Dermatitis
  • Worsening eczema at defined sites secondary to a contact allergen
  • Full emollient regimen
  • Take detailed history e.g. occupational and recreational
  • Consider potent steroid 2-4 weeks then step down to twice weekly maintenance or use tacrolimus 0.1%
  • Refer for patch testing if contact allergen cannot be identified accurately from history
Asteatotic Eczema (also known as eczema craquelé)
  • Often seen in the elderly
  • Dry skin with superficial cracked (dried-up riverbed) appearance
  • Areas of excoriation, erythema and bleeding may be evident due to rubbing or scratching 
  • Full emollient regimen
  • Steroids rarely needed
  • Ideally avoid an overly warm environment 

Want to learn more about this guideline?

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Read the related Guidelines in Practice article

Full guidelines available from: Primary Care Dermatology Societywww.pcds.org.uk/ee/images/uploads/general/Adult_Eczema_Pathway-web.pdf

First included: September 2019.

Further information: National Eczema Societywww.eczema.org