Eczema

Questionnaire/history:

Pruritus? Visible flexural eczema (antecubital, popliteal fossae, neck, wrrists and ankles)? Personal history of flexural eczema (or for chilfen under the age of 18 months a personal history of eczema affecting the extensor areas or the cheeks)? Atopy or past medical history of atopy (or family history of atopy in a first-degree relative under the age of 4)? Dry skin for the last one year?

Onset of signs or symptoms in the first 2 years of life?

Triggers?

Irritants?

- Soaps and detergents?

- Clothing?

-- Synthetic?

-- Wool?

-- Dyes in cotton clothing?

- Extremes of temperature?

Contact allergens?

- Fragrances?

- Metal? - Rubber?

- Plants?

Inhalant allergens?

- Pets (animal dander)? - House dust? - Mites? - Pollen? Additional stresses? - Emotional upset? - Concurrent illness? - Lack of sleep?

Food allergy/dietary factors?

- Milk?

- Egg?

- Wheat?

- Soy?

- Peanut?

Past medical history?

- Atopy?

Family history?

- Atopy?

Current medication?

Known drug allergies?

Examination:

Signs of acute eczema: Erythema?

Vesicles?

Crusting?

Excoriations? Signs of chronic eczema:

Lichenification?

Xerosis?

Fissuring?

Hyper- or hypopigmentation? Signs of an infection? Impetignisation (weeping, crusting, pustules, rapidly worsening eczema and no response to usual treatment)? Fever? Malaise?

Investigations: Swabs if eczema is worsening or not responding to standard therapy? Skin and nasal swab if recurrent bacterial infection?

Most patients do not need allerg testing.

Trial of an allergen-specific exclusion diet if a food allergy is strongly suspected?

(If the diagnosis can be confirmed by dietary exclusion a referral for any investigations if often not needed.)

6-8-week trial of extensively hydrolysed or amino acid formula for bottle-fed infants < 6 months with moderate/severe eczema not responding to optimal treatment?

Referral if children with atopic eczema have reacted to food with immediate symptoms, or infants/young children with moderate/severe atopic eczema not controlled by optimum management, particularly if associated with gut dysmotilic (colic, vomiting, altered bowel habit) or failure to thrive?

Diagnosis:

Acute eczema? Discoid eczema? Pompholyx eczema?

Stasis dermatitis?

Chronic eczema? Management:

Advised:

Identify triggers and avoid them Avoid scratching (to read booklet from National Eczema Society: Itching and scratching) Emmollients:

Emollients to the whole body, three to four times daily, at least twice daily, to be gently rubbed into the skin (downward in the direction of the hairs) until no longer visible, creams in the day and ointments at night

Pump dispenser (average child will need 500g per week) (to watch video from NHS: How to use emollients)

Emmolients as a soap substitute, do not use soaps or shower gels

Current evidence does not support the use of separate bath emollients for children > 1 year as standard emollients (particularly ointments) make effective soap substitutes

Antihistamines are not recommended for routine use in eczema management, however, if there is severe itch or urticaria they can be considered (eg chlorphenamine for children and hydroxyzine 25-50 mg for adults)

Topical steroids: Apply emollients first and allow them to dry into the skin for 30 minutes before applying the topical steroid.

Lowest appropriate potency and apply thinly only to inflamed skin once daily for 1-2 weeks (can be increased to twice daily if not settling)

Child face: mild potency eg 1% hydrocortisone (only consider moderate potency steroids for severe flares and for max 3-5 days)

Child trunk and limbs: moderate potency (eg Eumovate (clobetasone butyrate 0.05%))

Adult face: mild or moderate potency

Adult trunk or limbs: potent (eg Betnovate (betamethasone valerate 0.1%), Elocon (mometasone))

Palms and soles: potent or very potent (eg Dermovate (clobetasol propionate 0.05%)

Flexures (axillae/groins): generally mild potency, if moderated/potent only for 3-5 days

As a rough guide, adults are likely to need for 1-week use:

- Both hands 15-30 g

- Face and neck 15-30 g

- Both arms 30-60 g

- Both legs 50-100 g

- Trunk 50g

1 Finger tip unit (FTU) (amount of cream squeeze from the tube from fingertip to the first crease) treats an area of skin twice the size of the flat of an adult's hand with fingers together (to watch video from NHS: How to use topical steroids)

Skin atrophy is rare if topical steroids are used appropriately but they should be avoided around the eyes/face, and potent steroids should be avoided in the flexures. 'Steroid weekend regime' for patients with frequent flares (eg every 1-2 months) once eczema is controlled with using the usual steroid on two consecutive days each week (eg Saturday and Sunday) to area that tend to flare with applications even if the skin is not inflamed

Antibiotics:

If eczema continues to flare take swabs and treat as appropriate:

Topical treatment for localised/not severe infections: Fusidic acid 2% TDS for 5-7 days

For more widespread or severe infections use oral antibiotics: 1st line flucloxacillin 500mg QDS 5-7 days, alternative if unsuitable or penicillin-allergic clarithromycin 250-500mg BD 5-7 days, if pregnancy erythromycin 250-500mg QDS 5-7 days

If staph aureus present nasal Bactroban cream BD for 1 week

Referral:

- Refer acutely/admit if eczema herpeticum suspected

- Diagnostic uncertainty

- Severe eczema

- Eczema causing significant social or psychological problems (eg sleep disturbance).

- Eczema only partially responding to standard treatment (eg recurrent secondary infection, very frequent flares 1-2 times/month)

- Steroid atrophy or concerns regarding the amount of topical steroids being used

- Possible cases of contact allergic dermatitis

- Suspected food allergy or inhalant allergy triggering eczema (with immediate symptoms, particularly if infants/young children with gut dysmotility (eg colic, vomiting, altered bowel habit) or failure to thrive)

(Note: A 6-8 weeks trial of extensively hydrolysed or amino acid formula is recommended for bottle-fed infants < 6 months with moderate/severe eczema not responding to optimal treatment)

Flare-ups (i.e. flares more than every 1-2 months):

Concordance checked?

- Enough emollient used?

- Enough topical steroid used?

Triggers to be addressed?

‘Steroid weekend regime’ considered?

Secondary infection?

Resource(s):