Adult Eczema—Primary Care Treatment Pathway

Overview

This Guidelines summary covers the assessment and management of adult eczema.

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

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  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