Atopic Eczema 2

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Childhood

ECZEMANICE

Guidelines 2007

Dr Ellie Day (ST5 Paediatrics)

July 16th 2010

Royal Surrey County Hospital


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Definition

General term for skin inflammation

Chronic inflammatory itchy skin condition characterisedby:

pruritus dry, scaly skin

erythema

swelling, cracking, weeping, crusting

lichenification

superadded infections

Relapsing & Remitting course

Flare ups


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Pathophysiology

Normal skin has a high water content and is flexible andelastic

epidermis provides barrier function

stratum corneum contains layers of lipid

In Eczema, skin barrier function is disturbed water is more readily able to evaporate

stratum corneum cells dry out & shrink

cracks appear and act as portal of entry

Evidence suggests genetic component resulting in skin

barrier breakdown

8/10 children where both parents have eczema

Pathophysiology still poorly understood

likely multifactoral


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Statistics

Usually occurs before the age of 5 Adult onset possible but uncommon

1 in 6 UK school age children have eczema

2 out of 3 children will outgrow it by teenage years

1 in 20 adults have it

Affects all races

Ratio 1:1.4 (male to female)

Has significant morbidity

Incidence and prevalence on the rise climate change pollution

allergies

diet


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Atopic Eczema

May occur with other atopic diseases;

asthma

allergic rhinitis

acute allergic reactions to food urticaria


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Differential Diagnoses

Seborrheic dermatitis / eczema

yellow, oily, scaly patches

Face, scalp, ears

cradle cap, dandruff

Contact dermatitis / eczema

localised reaction (erythema, itching, burning)

contact with irritant

Allergic Contact dermatitis / eczema

red, itchy, weepy

contact with allergen

Scabies

Ringworm

Psoriatic plaque


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Presentation Age & duration

influencesdistribution and

appearance

Infancy;

face,scalp,extensor

surfaces,nappy

area spared.

Children;

longstandingflare ups

localised to the

flexures


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Morbidity/Mortality

Significant cause of morbidity

Incessant itch and loss of work days in adults

In children,enormous psychological burden to families

and loss of school days Mortality is extremely RARE !


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Diagnostic criteria

An itchy skin condition (or parental report of scratching) inlast 12 months plus any 3 of the following:

History of involvement of the skin creases

History of flexural dermatitis

(or dematitis of cheeks +/or extensor areas in child


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Assessment

Detailed history time of onset / pattern / severity

response to past / current Rx

possible triggers dietary history

growth & development

impact on child & family

history of atopy (personal / family)

Tools POEM / CDLQI / Visual analogue scales

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Management:

General Measures1. Adopt an holistic approach severity

quality of life

impact on activities / sleep

2. Identify and manage trigger factors

irritants

skin infections

food / inhalent allergens

3. General measures keep fingernails short

Avoid perfumed / lathering products

? Role for antihistamines


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Management -a stepped approach

1. EMOLLIENTS

moisturising, washing, bathing combination of products or one for all

2.TOPICAL STEROIDS

Tailor potency to severity & body site Short term use

3. INFECTIVE EXACERBATIONS

Recognition How to access appropriate treatment

Special reference to recognition of eczema herpeticum

4.EDUCATION

Patient & Parents Verbal & Written

Practical demonstrations


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Other Forms of Rx

Antihistamines Not for routine use

trial of non sedating if severe itching

consider 1-2 week trial of sedating if significant sleep

disturbance

Bandages & Dressing

localised medicated or dry dressings

NOT for infected areas

Topical calcineurin inhibitors

tacrolimus and pimecrolimus

NOT for mild eczema or as 1st line

Children aged >2 yrs

Phototherapy & Systemic treatments


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Management -

Dermatological Referral Diagnosis is / has become uncertain

Failure to control

No of flare ups despite treatment

adverse reaction to treatment

Contact allergic dermatitis is suspected

persistent atopic eczema

facial, eyelid, hand eczema

Significant social / psychological problems

Severe and recurrent infections

Perceived benefit from specialist advice


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Emollients 1

In eczema, normal skin barrier function is disturbed Use of regular moisturisers will help to rehydrate &

restore barrier

reduce itching & scratching

prevent skin penetration

reduce inflammatory / infective triggers

Regular use helps prevent flare-ups & need for steroids

LOTIONS are light & non greasy

mildly affected large areas or hairy areas

CREAMS are also non-greasy but thicker

for moist or weeping lesions

OINTMENTS are thick, occlusive and greasy

dry, lichenified or scaly lesions15


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Emollients 2 Mode of action:

Occlusive

Humectant (contain urea, lactic acid...)

Keratolytics (contain urea, lactic acid, glycolic acid

For everyday moisturising, washing & bathing

used more often and in larger amounts than other treatments

used in conjunction with other treatments

used instead of soaps, detergent based products, shampoos

Used on the whole body even when clear

Advise liberal use & prescribe accordingly (250 - 500g

weekly) Review repeat prescriptions at least annually

Examples:

Dibrobase, Doublebase, Epaderm, Cetraban,

Aveeno, Oilatum


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Topical Steroids 1

Suppress inflammation & control / relieve the symptoms indirectly reduce risk of infection

Rebound may occur on discontinuation

Divided into 4 strengths: (depends on steroid & formulation)

MILD- Hydrocortisone 0.1-2.5% [Dioderm]

MODERATE

- Betamethasone valerate 0.025% [Betnovate-RD]

- Clobetasone butyrate 0.05% [Eumovate]

POTENT

- Mometasone furoate 0.1% [Elocon]

- Betamethasone valerate 0.1% [Betnovate]

VERY POTENT

- Clobetasol propionate [Dermovate] 17


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Topical Steroids 2

Benefits outweigh the risks WHEN applied correctly only on active areas

Prescribe a strength of topical steroids to match severityof the eczema & its anatomical location

Avoid potent steroids on face or neck of children under 1 yr

Avoid using for > 2 weeks at a time Avoid prescribing very potent steroids without specialist advice

Do not use potent topical steroids for more than 2 wks inchildren under 1 year

For maintenance step down a potency class from whatwas used for controlling the flare

Exclude secondary infection if no result within 2 weeks

Consider weekend treatment in children with >2 flaresper months

usual steroid 2days/week on weekly basis


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Topical Steroids 2

Choice of steroid combined with other agents alsoavailable

Antimicrobial Fucidin H, Canesten HC, Trimovate, Fucibet

Crotamiton (anti itch) Eurax-Hydrocortisone

Urea (humectant moisturiser) Calmurid HC Salicyclic Acid (keratolytic) Diprosalic

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Infected Eczema Lesions can become infected

staphylococcus +/or streptococcus (usually)

Characterised by:

weeping,

crusts, pustules,

failure to respond to treatment,

fever,malaise and possibly sepsis

Start treatment as soon as possible and continue for 48

hrs after symptoms subside

Topical antibiotics for localised infection

Systemic antibiotics if widespread or not responding

Flucloxacillin (Erythromycin / Clarithromycin)

If coexisting with a flare,consider topical steroid or

steroid/abx combinations (eg fucibet)


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Eczema Herpeticum

Consider HSV infection areas of rapidly worsening, painful eczema

fever, lethargy, distress

clustered cold sore - like blisters

punched out erosions which may coalesce & crust

not responding to usual treatment

Treat with systemic aciclovir immediately

+/- antibiotics

Consider opthalmological / dermatological advice


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NICE Guidelines 2007

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ALLERGY

Consider food allergy

immediate reaction to a food

moderate / severe uncontrolled atopic eczema

above + history of gut dysmotility or failure to thrive Consider inhalent allergy

seasonal flares

associated asthma, rhinitis

>3 yrs with facial eczema consider allergic contact dermatitis

previously controlled

reaction to topical treatments

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ALLERGY 2

Offer 6-8 week trial of extensively hydrolysed or amino

acid formula in bottle fed infants < 6 months with

uncontrolled > moderate eczema

Avoid partially hydrolysed, soya protein or other speciesmilk if suspect CMPI

It is not known if altering a breastfeeding mothers diet is

effective in reducing the severity of symptoms but can

consider a trial if strongly suspect

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Acknowledgements

NICE Guideline- CG57

emedicine.org

Cks.nhs.uk

Atopic Eczema 2

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