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Introduction

Eczema is a common inflammatory skin condition characterised histologically by spongiosis with varying degrees of acanthosis, and a superficial perivascular lymphohistiocytic infiltrate.

The clinical features may include itching, redness, scaling and clustered papulovesicles. The condition may be induced by a wide range of external and internal factors acting singly or in combination. The terms eczema and dermatitis are generally regarded as synonymous.

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Aetiology

  • Both genetic and environmental factors play a role
  • Atopic dermatitis usually occurs in people who have an ‘atopic tendency’. This means they may develop any or all of three closely linked conditions; atopic dermatitis, asthma and hay fever (allergic rhinitis). Often these conditions run within families with a parent, child or sibling also affected
  • Current evidence points to mutations in the filaggrin gene being likely to underlie almost half the cases of atopic eczema. Filaggrin is critical to the conversion of keratinocytes to the protein / lipid squames that compose the stratum corneum, the outermost barrier layer of the skin. A primary defect in the skin barrier function therefore appears to underlie atopic eczema, and immunological changes are probably secondary to enhanced antigen penetration through a deficient epidermal barrier. The relevance of this finding is that it 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 there are a number of common ones:

  • Soap and detergents
  • Overheating / rough clothing
  • Skin infection
  • Animal dander (fur, hair) and saliva—if resulting from a pet, symptoms often improve when patients spend time in a different environment for a few days
  • Aeroallergens (pollens) —reactions to airborne allergens may cause a worsening of symptoms (often facial) over spring / summer in those sensitised. This is most commonly seen in older children and adults
  • Food —primarily in infants and young children (refer to the related chapter on Food allergy)
  • House-dust mites and their droppings—sensitised patients may notice a worsening of facial eczema when they wake up
  • 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 outgrow atopic eczema as they get older. In approximately 65% of children the eczema has gone by the time they are seven years of age and in approximately 74% of children the eczema will have disappeared by 16 years of age. It is not possible to tell whether children will or will not outgrow their eczema, although generally speaking those with more severe eczema are less likely to outgrow it

Clinical findings

There is quite a lot of 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

Treatment overview

  • Complete emollient therapy to the whole skin every day —the correct use of moisturisers, and soap substitutes 
  • Steroid creams/ointments for a flare (red/itchy areas of skin)—apply thinly to affected areas of skin. Patients often require a milder and a stronger (potent) steroid treatment to be kept at home. The milder treatment is used for mild flares, and on thinner areas of skin (e.g. face, skin folds and lower legs), the stronger treatment can be used for short spells during more troublesome flares and on thicker areas of skin
  • The weekend steroid regimen— patients with frequent flares often benefit from applying steroid creams/ointments on two consecutive days a week once a flare has settled (see step 4)
  • Immunomodulator cream/ointment— should be considered on areas of thin skin (e.g. the face) if too much steroid cream is being used (see step 5)
  • Provide a written management plan (see step 1) and advise on a pre‑payment certificate for prescriptions
  • Know when to refer (step 7)

Step-by-step treatment

Step 1: general measures

  • As with other chronic skin conditions 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
  • Provide a patient information leaflet (for an example, please refer to original guideline) and a written management plan for the patients/carers:
  • Advise on a pre-payment certificate where appropriate
  • At each step it is essential to ensure patient compliance and to make sure that copious amounts of emollients are being used
  • 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. Betnovate® or Elocon® OD until things settle down
  • For marked sleep disturbance consider the short-term use of a sedating anti-histamine at night e.g. adults—Atarax® (hydroxyzine) 25–50 mg, and children—Piriton® (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 one to two weeks to discuss long-term management (see step 3 below)

Step 3: long-term management

Emollients—Complete emollient therapy

Emollients are the mainstay of therapy and without them it is not possible to manage eczema effectively. Good evidence shows that 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
    • Most patients prefer creams and gels. The most important factor is to find one that the patient likes and is happy to use
    • 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
    • Ointments come in tubs and so can easily become cross infected with bacteria from the skin—patients must not place hands into tubs but instead use a utensil to scoop out the ointment
    • Order of application—if topical steroids are also being used, moisturisers can be applied first and allowed to dry for 15–20 minutes before applying the topical steroid
    • Adults—to view a video clip on the correct application of moisturisers, please refer to the original guideline
    • Children—to view a video clip on the correct application of moisturisers, please refer to the original guideline
  • Bath / shower formulations
    • In general, there is no good evidence to support the use of specific products to use in the bath/shower
    • Patients should be encouraged to have short showers/baths and not have the water over hot
    • The same emollients used to moisturise with can be used as a soap substitute should the patient so wish
    • For the occasional patient, who gets frequent skin infections, the use of a specific antiseptic emollient may be beneficial e.g. Dermol® 600 Bath Emollient or Dermol 200® Shower Emollient, and Emulsiderm® Liquid Emulsion. Dermol® can occasionally irritate the skin if used too often, in which case it can be used once or twice a week
    • Patients must pat themselves dry after bathing, this is a good time to also apply moisturiser
    • Careful consideration must be given as to whether or not to use emollients to wash with in patients with poor mobility due to the increased risk of slipping in the bath or shower
  • Hand eczema and soap substitutes
    • Although patients like soaps as they make a lather, they damage the skin barrier and so 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 20 minutes before applying the steroid
  • Avoid using combined steroid / antibiotic preparations on a regular basis (e.g. Fucibet® and Fucidin® H cream) 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 to be determined by the age of patient, site and severity:
    • Child face: mild potency e.g. 1% hydrocortisone
    • Child trunk and limbs: moderate potency e.g. Eumovate® (clobetasone butyrate 0.05%) or Betnovate-RD® (betamethasone valerate 0.025%)
    • Adult face: mild or moderate potency e.g. Eumovate®
    • Adult trunk and limbs: potent e.g. Betnovate® (betamethasone valerate 0.1%), Elocon® (mometasone)
    • Palms and soles: potent or very potent e.g. Dermovate® (clobetasol propionate 0.05%)
  • If used appropriately it is uncommon to develop steroid atrophy, however extra care needs to be taken in the following sites:
    • Around the eyes: unless used very infrequently topical steroid preparations should be avoided due to the risks of glaucoma
    • The face—the regular use of topical steroids should be avoided
    • Lower legs in older patients / others at risk of leg ulcers—the regular use of topical steroids 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
  • To view a video on the correct application of topical steroids, please refer to original guideline

Bandages and dressings

  • Some patients find dry bandages (e.g. Clinifast® or Tubifast® bandages) or medicated dressings (e.g. Viscopaste) 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 
  • To view a video clip on how to use bandages, please refer to original guideline

Step 4: management of flare-ups

  • For infrequent flares, e.g. every four to eight weeks, manage as in step 2
  • For more frequent flares
    • Check treatment compliance
    • Consider the steroid weekend regimen for both children and adults—Betnovate® or Elocon® should be applied thinly to inflamed areas OD for two weeks and then alternate days for a further two 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 Protopic® ointment (an immunomodulator—see step 5)—as above the eczema first needs to be brought under control by more frequent use of the Protopic and then reduce down to twice a week
    • In general, antibiotics have a limited role in eczema, however, if the eczema continues to flare swab the skin and treat if results are relevant. For frequent infections it is also useful to take nasal swabs and if positive for S. aureus treat with nasal Bactroban® cream BD for one 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 area of unaffected skin e.g. the outer arm to see if the skin reacts. If the skin does react change to a different treatment. Of note, the topical steroid Synalar® appears less likely to cause allergic reactions than some of the other topical steroids. If the skin does not settle and the possibility of a contact allergy remains move to step 7

Step 5: treatment with immunomodulators

  • The topical immunomodulators, Protopic® (tacrolimus) and Elidel® (pimecrolimus) are calcineurin inhibitors
  • Their main benefit is that they are not steroid based and so do not cause skin atrophy
  • Formulations
    • Protopic 0.03% ointment and Elidel cream are licensed for ages 2 years and above
    • Protopic 0.1% ointment is licensed for ages 16 years and above
  • Local adverse effects include stinging, burning, itch, irritation and slight photosensitivity—appropriate sun protection is recommended. Adverse effects are more common with Protopic 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
    • Patients regularly using topical steroids on the lower legs in elderly patients and others at risk of leg ulcers
    • Any signs of skin atrophy
  • In milder cases use Elidel cream, although if this is ineffective or in the first instance the eczema is of a greater severity consider Protopic ointment. As with topical steroids it is preferable to apply the immunomodulators at night, although Elidel may be additionally used in the morning 
  • While short-term data has showed no serious adverse effects, the possible long‑term adverse effects of immunomodulators are not yet known—however the risks are likely to be minimal especially when the treatments are used in the ways described above. For patients using larger quantities (ie more frequent applications to larger areas), especially of Protopic, referral to a specialist is advisable

Step 6: management of scalp eczema

  • Wash with a mild tar-based shampoo. In young children (e.g. 18 months and under) 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, e.g. Betacap® OD-BD to eczematous areas until settles (avoid alcohol based lotions as they will sting)
  • If a lot of thick scale is present, before commencing topical steroids, remove the scale with Sebco® ointment—massage in to the scale for five minutes and leave on for two to four hours before shampooing. Use this for a few days until most of the scale is removed

Step 7: referral to a specialist

The following patients should be referred to a specialist:

  • 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 

Other resources

Patient support group—The National Eczema Society

The eczema written action plan developed by the Centre for Academic Primary Care in Bristol

Atopic Skin Disease —how habit reversal works with optimal topical treatment in the management of chronic atopic eczema

Eczema management plan

Understanding eczema

If you have not been given an information leaflet on eczema one can be found at www.bad.org.uk—there is a link to patient information leaflets on the right side of the page, then look for atopic eczema.

Emollients

  • Emollient moisturisers must be applied at least twice a day (morning and evening), even if the skin is not red and itchy. One of these applications can be after a bath/shower
  • Use large amounts (patients with moderate-severe eczema need up to 500 g a week)
  • Moisturisers come as gels, creams and ointments. Ointments are most effective if the skin is very dry
  • You can mix and match, e.g., some people use cream during the day and ointments at night. If the ointment comes in a tub first scoop it out with a spoon so as not to contaminate the tub
  • Moisturisers can also be used to wash with but take care as they can be slippery. You may be prescribed a different emollient to use in the bath/shower if your eczema gets frequently infected
  • Please watch a video on how to apply emollients (refer to section at bottom—‘important information’)

 

Name of emollient/s to use as moisturiser:

Name of emollient to use as wash (if different):

Steroid creams and ointments

  • Should be used on red or itchy areas of skin
  • They should be applied at least 15 minutes after the moisturiser has been applied (some patients put their moisturiser on early evening and steroid on at bedtime)
  • Please watch a video on how to apply steroids using the fingertip method (refer to section at bottom)
  • You may be provided with two steroid creams—a milder one that can be used more often if needed, and a stronger one that can be used for a few days if the eczema flares (gets worse)
  • In general, less steroid cream should be used on areas of thinner skin, e.g., the face (see next section) the body folds, genitalia and in older patients the lower legs

 

Name of milder steroid (once to twice a day if needed):

Name of stronger steroid to use for a flare:

Facial eczema

  • You may be advised to use the same treatments on the face as you do on your body
  • If you find that you are having to use a steroid cream/ointment on your face on a regular basis you may be prescribed a non-steroid treatment known as an immunomodulator cream/ointment to be used on a more regular basis, and the steroid can then just be used for a few days during a flare

 

Name of immunomodulator:

Scalp eczema

  • You may be prescribed a steroid scalp application. This can be used once a day when the scalp is itchy. The scalp application should be put on dry scalp and left in (ie wash hair at the other end of the day)

 

Name of scalp application:

Important information

  • If you pay for your prescriptions ask the pharmacist if it would be cheaper to have a pre-payment certificate
  • Videos on how to apply moisturiser and steroid cream – refer to www.pcds.org.uk, click on A-Z of skin conditions, look for Eczema – atopic eczema, the videos are under step 3 of the management section
  • There are no shortcuts to managing eczema, the more you put in the more comfortable your skin will be

full guideline available from…

www.pcds.org.uk/clinical-guidance/atopic-eczema

Primary Care Dermatology Society. Eczema - atopic eczema. April 2019.

www.pcds.org.uk/ee/images/uploads/general/Eczema_management_sheet_July_2018.docx

Primary Care Dermatology Society. Eczema management plan. July 2018.