Atopic eczema

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Atopic eczema
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Important documents

• NICE Clinical Guideline 57, Atopic eczema in
  children management of atopic eczema in
  children from birth up to the age of 12 years,
  December 2007
• Clinical Knowledge Summary (PRODIGY) November
  2004 (minor update January 2006)

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What is atopic eczema?

• An itchy inflammatory skin condition with a
  predilection for the skin flexures. It is
  characterised by a poorly defined erythema with
  oedema, vesicles and weeping in the acute stage
  and skin thickening in the chronic stage

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Clinical features and diagnosis

• Reduced skin lipid layer gt increased transdermal
  water loss gt lowered resistance to irritant
  substances
• Associated with other atopic diseases
• Asthma in 30
• Allergic rhinitis in 35
• Children
• Prevalence 15-20
• 75 get it by 6m and 80 start lt 5 yrs
• Clears in 60 by early adolescence
• Typically episodic relapse and remission
• Adults
• Prevalence 2-10
• Genetic component present in 80 when both
  parents affected and 60 when 1 affected

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How common is it?

• 15-20 of children
• 2-10 of adults
• Evidence of a 2-3x increase in prevalence over
  last 30 years
• 30 of skin consultations in primary care
• 10-20 of dermatology referrals
• Unknown cause, multifactorial, recent theory is
  hygiene hypothesis
• Atopic triad
• Interaction between genetic susceptibility and
  environmental triggers

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Diagnosis and assessment of children 12 years

• Diagnose atopic eczema when a child up to the age
  of 12 has an itchy skin condition plus 3 of the
  following
• Visible flexural dermatitis involving skin
  creases (elbows, knees) or visible dermatitis on
  cheeks /or extensor areas in children 18m
• Personal history of flexural dermatitis or
  dermatitis on cheeks /or extensor areas in
  children 18m
• Personal history of dry skin in last 12m
• Personal history of asthma or allergic rhinitis
  (or history of atopy in 1st degree relative of
  children lt 4 years
• Onset of signs or symptoms lt 2 years

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Diagnosis and assessment of children 12 years

• Adopt a holistic approach at each consultation
  considering
• Severity
• Quality of life (everyday activities, sleep,
  psychosocial wellbeing)
• There is not necessarily a direct relationship
  between severity and its impact on quality of
  life
• Areas of differing severity can coexist in the
  same child
• Treat each area separately

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Appearance and distribution

• Distribution varies with age, and the appearance
  of persistent lesions may alter with scratching.
  The tendency to dry skin persists throughout life
• Acute flare ups
• Vary in appearance
• Poorly demarcated areas, sometimes with crusting,
  scaling, scratching and swelling of the skin
• Chronic lesions
• Commonly become thickened (lichenified) as a
  result of repeated scratching
• During infancy
• Primarily involves the face, the scalp, the
  extensor surfaces of the limbs, and is more
  likely to be acute. Nappy area is usually
  preserved
• In children and adults with long standing disease
• Localisation to the flexures of the limbs is more
  likely
• Adults commonly have generalised dryness and
  itching
• Particularly with exposure to irritants

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Principles of management in primary care

• Identify and avoid provoking factors
• Use emollients regularly
• Use topical steroids and oral ABs intermittently
  for flare ups
• Refer selected people to specialist
• Provide information about
• The condition
• Provoking factors
• The roles of different Rxs
• Effective and safe use of Rxs
• Plan treatment considering patients goals vs.
  safety and acceptability of Rx
• Demonstrate use of topical treatments emphasising
  the correct quantities to use

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Principles of management in children 12 years

• Identify potential trigger factors
• Step up or down depending on severity
• Always use emollients even when clear
• Potency of corticosteroids should be tailored to
  severity and body site
• Topical tacrolimus and pimecrolimus are not
  recommended 1st line or for treatment of mild
  eczema
• Offer information on recognition of staph, strep
  or eczema herpeticum treatment
• Spend time educating children and their carers

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Managing dry skin

• Aim of management of eczema between flare-ups is
  to
• Control skin dryness and itching
• Reduce frequency of flare-ups
• Establish a daily skin care regime with
  emollients
• Tailor type, frequency and quantity to patients
  skin requirements and lifestyle
• Avoid irritation of the skin
• Prescribe a soap substitute
• Use gloves when handling irritant substances
• Avoid extremes of temperature and humidity
• Use non-abrasive clothing fabrics eg cotton
• Reapply emollients after wetting the skin

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Managing flare-ups

• Offer information on
• How to recognise flares
• Give instructions on
• How to manage flares according to a stepped care
  plan
• Settle inflammation with topical corticosteroids
• Treat clinically apparent bacterial infection
  with oral ABs
• Treatment
• Start Rx as soon as signs or symptoms appear
• Continue for 48h after symptoms subside
• Refer urgently or admit if
• Severe unresponsive disease
• Eczema herpeticum is suspected

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Managing frequent flare ups

• Settle acute flare up
• Review and emphasise the use of emollients
• Change to one with a higher lipid content
• Apply the emollient more often
• Apply more emollient each time
• Review the factors possibly causing flare ups
• Environmental irritants or stresses?
• Allergen avoidance is difficult but should be
  considered if other measures fail
• Refer to specialist if
• Risk of adverse systemic effects
• Localised adverse effects due to corticosteroid
  use
• Refer to a dietician
• In children with 2-3 flares / month
• Once controlled use topical corticosteroids on 2
  consecutive days / week
• Review after 3-6 months to assess effectiveness

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Management in adults

• Settle chronic lesions
• With potent corticosterioid
• Review and consider
• Use of emollients
• Avoidance of environmental irritants and stress
• Antigen avoidance if appropriate
• Settle further flare ups
• Intermittent use of a topical corticosteroid of
  appropriate potency and duration of use
• Refer to a specialist
• Risk of systemic adverse effects
• Risk of localised adverse effects from
  corticosteroid use

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Managing severe widespread eczema

• Seek specialist help if
• Flare up is widespread, severe, and distressing
  to the patient
• Consider oral prednisolone and antibiotics if
• There is a delay before specialist review
• There is a risk of rebound flare up with oral
  coricosteroids are stopped
• Stay on oral corticosteroids until other measures
  are instituted. Specialist review should occur in
  7 days to prevent prolonged drug use

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Using oral antihistamines in children

• Do not use routinely
• Efforts to reduce dryness and inflammation should
  be promoted ahead of antihistamines
• Offer 1 month trial of non-sedating antihistamine
  to those with severe atopic eczema or those with
  mild or moderate eczema with severe itching or
  urticaria
• Review Rx every 3 months
• Use 7-14 days of a sedating antihistamine if
  sleep disturbance is significant

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When to prescribe an antibiotic

• Treat visibly infected eczema with oral
  antibiotics
• Flucloxacillin or erythromycin
• Topical antimicrobial / corticosteroid
  combinations are not more effective than topical
  corticosteroids alone

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When to refer children up to 12 years

• Diagnosis is uncertain
• Management is not so far satisfactory
• Atopic eczema on the face not responding to
  appropriate Rx
• The child or parent may benefit from specialist
  advice on treatment application (eg bandaging)
• Contact allergic dermatitis is suspected
• There are significant social or psychological
  problems
• There are severe and recurrent infections

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Emollients

• Effects
• Reduce water loss
• Aid softer and suppler skin
• May reduce flare ups
• Reduce need for steroids
• Lack of good quality evidence comparing
  emollients
• Choice depends on patient acceptability
• Use the cheapest that is effective and acceptable