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Management of atopic eczema

Aetiology

  • Both genetic and environmental factors play a role
  • Atopic eczema usually occurs in people who have an ‘atopic tendency’
  • Mutations in the filaggrin gene (resulting in a defect in the skin barrier function) are likely to underlie almost half the cases of atopic eczema. This reinforces the importance of the regular use of emollients to help manage eczema

Triggers

  • Spontaneous flare-ups are often the result of triggers. Although triggers are not the same for everyone, common triggers include:
    • soap and detergents
    • overheating/rough clothing
    • skin infection
    • animal dander
    • aeroallergens (pollens)
    • food
    • house-dust mites and their droppings
    • stress

History

  • Although eczema presents most frequently in childhood it can present at any age, and one-third of all new cases arise in adults
  • A personal or family history of atopy is common
  • Itch is very common
  • Many patients have more troublesome symptoms in winter as a result of central heating drying out the skin
  • Most children out grow atopic eczema as they get older. It is not possible to tell whether children will or will not out grow their eczema, although generally speaking those with more severe eczema are less likely to outgrow it

Clinical findings

  • There is variation in the appearance of eczema related to the presence/absence of infection, the age of the person, their ethnic origin, and the treatments used
  • Distribution—changes with age:
    • the face is a common site in infants
    • this is then followed by flexural involvement
    • in some patients it can become widespread
  • Morphology:
    • ill-defined areas of erythema
    • dry skin with areas of fine scale (scale does not normally develop in flexures due to friction)
    • during flare-ups the skin will appear red, sometimes with vesicles and weepy/crusted patches
    • excoriations
    • lichenification
    • in darker skin, prominent follicular involvement is common
  • Other affected sites:
    • scalp—may be generally erythematous with fine scale. Beware of nits presenting as scalp eczema
    • any body site can be affected

Management

  • At each step it is essential to ensure patient compliance and to make sure that copious amounts of emollients are being used

Step 1: general measures

  • Time is needed by the GP and/or practice nurse to discuss the condition, advise on how best to use emollients and to provide an individual management plan
  • Information for patients:
    • advise on a pre-payment certificate where appropriate
    • useful sources of patient information include:
  • For patients presenting with a flare-up go to step 2, for those presenting with relatively mild eczema go to step 3

Step 2: initial management for patients presenting with a flare-up

  • In both children and adults, it is more effective and safer to ‘hit hard’ using more potent treatments for a few days than it is to use less potent treatments for longer periods of time
  • Use a moderate to potent topical steroid, e.g. betamethasone or mometasone od until flare-ups settle down
  • If the skin appears infected, i.e. a widespread flare-up and/or areas of weeping or crusted eczema, the patient will also need either:
    • an appropriate systemic antibiotic, i.e. flucloxacillin (erythromycin, if allergic) for 1 week
    • or if localised, consider using betamethasone and clioquinol cream or fusidic acid and betamethasone cream without a systemic antibiotic
  • For marked sleep disturbance, consider a sedating antihistamine at night:
    • adults: hydroxyzine 25–50 mg
    • children: chlorpheniramine 5–15 mg
    • there is almost no role for non-sedating antihistamines in the management of eczema, the only exception is patients needing treatment for co-existent hay fever
  • Take a skin swab if not settling
  • Review the patient in 1–2 weeks to discuss long-term management (see step 3 below)

Step 3: long-term management

  • Emollients are the mainstay of therapy and without them it is not possible to manage eczema effectively
  • The more emollients are used, the less topical steroids are needed. Compliance is essential and so always review patients to check they are happy with what has been prescribed—it may be necessary to try a range of emollients before the patient settles on the best combination
  • Moisturisers:
    • base choice on patient preference
    • ointments tend to be less well tolerated by patients, but they are less likely to cause contact allergic dermatitis as they do not contain preservatives (this is for both emollients and topical steroids)
    • encourage appropriate usage by prescribing generous amounts, e.g. 500 g of moisturisers to use regularly (often qds)
    • as with other topical treatments, moisturisers should be gently rubbed into the skin until they are no longer visible. They should be applied downward in the direction of the hairs to lessen the risk of folliculitis
    • warn that they may sting for the first couple of days before soothing the skin
    • to avoid cross infection, patients should use a utensil to dispense the ointment
    • order of application—if topical steroids are also being used, moisturisers can be applied first and allowed to dry for approximately 15–20 minutes before applying the topical steroid
  • Bath/shower formulations:
    • does the patient bath or shower more?
    • patients getting frequent flare-ups may benefit from antiseptic emollients:
      • can occasionally irritate the skin if used too often, in which case it can be used once or twice a week
    • patients complaining of very itchy skin may benefit from antipruritic emollients
    • patients must pat themselves dry after bathing, this is a good time to also apply moisturiser
    • give careful consideration as to whether or not to use these products in patients with poor mobility due to the increased risk of slipping in the bath or shower
  • Soap substitutes:
    • soaps should should be avoided where possible
    • although specific soap substitutes can be prescribed, it is probably more cost effective to use one of the prescribed moisturisers as a wash—ointments in particular can provide an effective wash
  • Topical steroids:
    • use the lowest appropriate potency and only apply thinly to inflamed skin
    • allow moisturisers to dry into skin for approximately 20 minutes before applying the steroid
    • avoid using combined steroid/antibiotic preparations on a regular basis as it will increase the risk of antibiotic resistance
    • amount of steroid needed can be determined by the Finger Tip Unit method
    • strength of steroid is determined by the age of patient, site, and severity:
      • child face: mild potency, e.g. hydrocortisone
      • child trunk and limbs: moderate potency, e.g. clobetasone or betamethasone
      • adult face: mild or moderate potency, e.g. clobetasone
      • adult trunk and limbs: potent, e.g. betamethasone, mometasone
      • palms and soles: potent or very potent, e.g. clobetasol
    • if used appropriately it is uncommon to develop steroid atrophy, however extra care needs to be taken in the following sites:
      • around the eyes—due to the risk of glaucoma
      • face (regular use should be avoided)
      • lower legs in older patients/others at risk of leg ulcers (regular use should be avoided)
    • where there are concerns that the patient may be using too much topical steroid, especially on the sites referred to above, or there are signs of atrophy go to step 5
  • Bandages and dressings:
    • some patients find dry bandages or medicated dressings helpful
    • they can be used on top of emollients and topical corticosteroids for 7–14 days during flare-ups, or for longer periods on chronic lichenified eczema
    • there is no good evidence to support the use of wet wraps, although some patients find them soothing
    • bandages/dressings should not be used on wet, infected eczema

Step 4: management of flare-ups

  • For infrequent flares, e.g. every 4–8 weeks manage as in step 2
  • For more frequent flares:
    • check treatment compliance
    • wab the skin—for frequent infections it is also useful to take nasal swabs and if positive for S.Aureus treat with nasal mupirocin cream bd for 1 week
  • Consider the steroid weekend regimen for both children and adults—betamethasone or mometasone should be applied thinly to inflamed areas od for 2 weeks and then alternate days for a further 2 weeks. Once the eczema is under control, use the treatment on two consecutive days (e.g. Saturday and Sunday) of each week to the areas that tend to flare. The treatment must be applied even if the skin in not inflamed—the aim is to reduce the frequency of flare-ups
  • An alternative to using topical steroids is to use tacrolimus (see step 5)—as above, the eczema first needs to be brought under control by more frequent use of the tacrolimus and then reduced down to twice a week
  • Patients not responding to the above—consider the possibility of a contact allergic dermatitis, which can sometimes be caused by topical therapies. If a given treatment is felt to be causing a reaction the medication could be tested on a small areas of unaffected skin e.g. the outer arm to see if the skin reacts. If the skin does react change to a different treatment
  • If the skin does not settle and the possibility of a contact allergy remains move to step 7

Step 5: treatment with immunomodulators

  • Tacrolimus and pimecrolimus are calcineurin inhibitors; their main benefit is that they are not steroid based and so do not cause skin atrophy
  • Local adverse effects include stinging, burning, itch, irritation, and slight photosensitivity—appropriate sun protection is recommended. Adverse effects are more common with tacrolimus but in many patients are transient
  • Immunomodulators should be temporarily discontinued when the skin is infected
  • When to consider immunomodulators:
    • eczema involving the eyelids and peri-orbital skin
    • patients regularly using topical steroids on the:
      • face
      • lower legs particularly in elderly patients, and others at risk of leg ulcers
  • Any signs of skin atrophy:
    • milder cases, use pimecrolimus cream, if this is ineffective, or if the eczema is of a greater severity, consider tacrolimus ointment:
      • tacrolimus should be allowed to dry into the skin for 30–60 minutes before applying moisturisers, whereas patients using pimecrolimus only need wait 15–20 minutes
  • Possible long-term adverse effects of immunomodulators are not yet known. Risks are likely to be minimal especially when the treatments are used as described above. For patients using larger quantities (i.e. more frequent applications to larger areas), especially tacrolimus, consider referral to a specialist

Step 6: management of scalp eczema

  • Wash with a mild tar-based shampoo. In young children (e.g. ≤18 months of age) it is often better to use an emollient bath oil to wash the hair rather than using a specific scalp treatment
  • Water-based topical steroid scalp application to eczematous areas until flare-ups settle (avoid alcohol-based lotions as they will sting)
  • If a lot of thick scale is present, before commencing topical steroids, remove the scale with coal tar/sulphur/salicylic acid ointment—massage into the scale for 5 minutes and leave on for 2–4 hours before shampooing. Use this for a few days until most of the scale is removed

Step 7: referral to a specialist

  • When to refer:
    • diagnostic uncertainty
    • severe eczema
    • moderate–severe eczema only partially responding to steps 1–5
    • steroid atrophy or concerns regarding the amount of topical steroids/immunomodulators being used
    • possible cases of contact allergic dermatitis

full guideline available from…
www.pcds.org.uk/clinical-guidance/atopic-eczema

Primary Care Dermatology Society. Management of atopic eczema. March 2015