Atopic Eczema

1
Atopic Eczema

• Nice guide lines 2007

2
Diagnosis

• Itching plus 3 or more of
• Visible flexural dermatitis involving skin
  creases, cheeks or extensor surfaces
• History of flexural dermatitis involving skin
  creases, cheeks or extensor surfaces
• History of dry skin in last year
• History of atopic disease (asthma rhinitis
  eczema) in first degree relative aged lt 4yrs
• Onset under 2 yrs (use only in those gt 4 yrs at
  diagnosis

3
Assessment of severity

• Clear normal skin no evidence of active atopic
  eczema
• Mild areas of dry skin, frequent itching -
  small areas of redness
• Moderate - areas of dry skin, frequent itching,
  redness, - excoriation and localised thickening.
• Severe widespread areas of dry skin, incessant
  itching, redness (- excoriation, extensive skin
  thickening, bleeding, oozing, cracking.

4
Impact on quality of life

• None no impact on quality of life
• Mild little impact on everyday activities,
  sleep and psychosocial well being
• Moderate - Moderate impact on everyday
  activities, psychosocial well being, frequently
  disturbed sleep
• Severe severe limitation of everyday activities
  and psychosocial well being, loss of sleep every
  night

5
Holistic approach

• Take account of
• Physical severity of eczema
• Impact on quality of life
• Psychosocial functioning
• Any loss of sleep
• No direct correlation between physical severity
  of eczema and impact on quality of life

6
Management

• Identify trigger factors
• Irritants soaps and detergents
• Contact allergens
• Food allergens
• Inhalant allergens
• Skin infections
• Refer for specialist advice when necessary

7
Stepped treatment

• Tailor treatment to severity
• Start with emollients should be used even when
  skin clear
• Mild disease emollients mild steroid creams
  1 hydrocortisone
• Moderate disease emollients moderate steroid
  creams. Topical calcineurin inhibitors, bandages.
• Severe disease potent steroid creams (short
  periods only) topical calcineurin inhibitors,
  bandages, phototherapy, systemic therapy

8
Management

• Use topical antibiotics steroid for localised
  infection for no longer than 2 weeks
• Non-sedating antihistamines if eczema is severe
  or severe itching or urticaria
• Sedating antihistamines children aged gt 6/12
  during acute flares if sleep disturbance for
  child or carers.
• Recognise indications for referral

9
Indications for referral

• Immediate (same day)
• if eczema herpeticum suspected
• Urgent (within 2 weeks)
• If severe and not responded to optimal treatment
  for 1 week
• Treatment of bacterial infected eczema has failed

10
Indications for referral

• Routine referral
• Diagnosis uncertain
• Eczema on face not responded
• Eczema is associated with sever recurrent
  infections
• Contact allergic eczema suspected
• Causing serious social or psychological problems
  for child or carers
• Eczema not controlled to the satisfaction of
  carers or child

11
Education and information

• Explain cause and course of disease
• Demonstrate quantities and frequency of
  treatments
• Inform symptoms and signs of bacterial infections
• How to recognise eczema herpeticum
• Ask about use of complementary therapies explain
  have not be assessed for safety. Should continue
  to use emollients as well as complimentary
  therapies

12
Overcoming

• Discuss parental anxieties about treatments
  explain benefits of steroids outweigh possible
  harms
• Written care plans including management of flare
  ups and infections
• Explain when topical steroids and other
  treatments are indicated