Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries...

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Emma King and Liz Moore Dermatology Nurse Consultants Dermatology Department The Royal Children’s Hospital Melbourne, Australia 9345 5510 Practical Eczema Management

Transcript of Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries...

Page 1: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Emma King and Liz MooreDermatology Nurse ConsultantsDermatology DepartmentThe Royal Children’s HospitalMelbourne, Australia9345 5510

Practical Eczema Management

Page 2: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Topics discussed

Diagnosis of eczema

Incidence

Aggravators

History and assessment

Treatments

Clinical Cases

Contact details and clinics

Page 3: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Diagnostic criteriaUK Diagnostic criteria Sampson et al

Must have:itchy skin

Major Featuresfamily history of atopyitchtypical picture, facial, flexures, lichenificationnapkin, facial/mouth/nose area free

Plus three or more of the following:Involvement in flexuresPersonal history of atopyGenerally dry skinOnset under 2 years of ageVisible eczema, forehead, extensors

Minor FeaturesXerosis/ichthyosis/hyperlinear palmsperiaricular fissureschronic scalp scaling

Page 4: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

How common is eczema?

VERY! 10-20% of children in developed countries (Harper et al, 2000)

Incidence has trebled over the last 30 years (Harper et al , 2000)

80% of children will develop eczema in 1st year

50% of children will clear by 2 years of age

85% of children will clear by 5 years of age

About 5% of children with eczema will continue into adulthood

Positive correlations of eczema with higher social classes and air pollution has been confirmed (Simpson, Hanifin, 2005)

Page 5: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Factors influencing poor prognosis

Onset after 2 years of age (Vickers)

Severe eczema in infancy

Atypical location for age of the patient

Eczema to extensors, wrists and hands to be more prone to persistence of eczema

Severity and duration of eczema are correlated to the incidence of asthma

Biparental history of atopy have shown to be unfavourable

(Harper, Oranje, Prose. 2000)

Page 6: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Effects on Life

Intractable itch

Sleep depravation

Disruption to family life

School/work absenteeism

Parental marriage problems

Teasing

Chronic disease

Low self esteem

Page 7: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

What aggravates eczema?

Heat

Dry skin and environment

Prickle

Allergies

Irritants

Infection

Page 8: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

What makes eczema hot and itchy?

Too many clothes

Hot baths >29 degrees

Too many blankets

Hot cars

Sport/running around

Heaters

Hot school classrooms

Page 9: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

What makes eczema dry and itchy?

Soap, use bath oils or washes

Air blowing heaters

Swimming pools

Their dry skin

Australia!!!!

Therefore apply moisturiser from top to toe regularly and more often when flaring

Page 10: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

What prickles eczema and makes it itchy?

Animal hair/dander

Woolen clothes/fabric

Sharp seams

Tags

Sand pits

rough fabrics

Page 11: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

What irritants aggravate eczema?

SalivaChemicalsDetergentsWater

Page 12: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Taking a good historyFirst appointment is important in managing the eczema effectively and gain the trust of the patient and family

Family history

Coexisting atopic disease

Immunization

Allergies, tests, diet manipulation and adequacy

Growth

Previous treatments used and outcomes

Most distressing element

Sleep disturbance

Environmental aggravators, assess heat/prickle/dryness

Effect on family life, school

Parents expectations from treatment

YOUR expectation from treatment

Page 13: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Assessment

Completely undress childLook for (SCORAD http://adserver.sante.univ-nantes.fr/Scorad.html )

Extent %Infection /3Broken skin /3Erythema /3Lichenification /3Xerosis /3Sleep pattern /10Itch /10

Page 14: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Eczema Treatments- 2 types

Every dayavoid aggravatorsmoisturiserbath oil

Flaring Treatmentsevery day treatmentsplus

steroid ointmentswet dressingscool compressesantibiotics

Page 15: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

When to begin flaring treatments

Page 16: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Topical Treatments

Steroids use aggressively when flaringFace- hydrocortisone 1% or Elidel, bdBody- Elocon or Advantan fatty ointment, nocte

Emollients- use often every dayDermeze, hydraderm, aqueous cream, QV cream, QV Kids balmBath oils

Page 17: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Bath oils and washes

QV bath oil, wash and shower balm

Every day

Hamiltons oil and wash Every day

Dermaveen oil and wash Every day

QV Flare up Antiseptic oilDo NOT use in wet dressings

Oilatum bath oil Every day

Oilatum plus bath oil Antiseptic oilDo NOT use in wet dressings

Page 18: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Diagnosis?

Page 19: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)
Page 20: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Why apply wet dressings?

Reduce itch

Treat Infection

Moisturise the skin

Protect the skin

Promote sleep

Page 21: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

When to use a wet dressingWithin 24 hours if cortisone ointments are not clearing the eczema

Child is waking at night

Itchy

Skin is thickened

If there is blood on the sheets

Page 22: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Before After

Page 23: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Case One,History

11 month old

2 month past history of eczema

currently using

hydrocortisone 0.5% to face tds

johnsons baby soap

sorbolene lotion

2 layers of clothing to bed

heater in the bedroom

doona and woolen underlay

Diet; breast fed, full diet, NKA

Page 24: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Case One,Clinical signs

Erythema

itchy

waking every 1-2 hours overnight

weeping

general flare

Page 25: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Case one,What is the diagnosis?What is the plan?

Infected atopic eczema

admission

remove crusts/weeping

oral keflex

cool compressing 1 hourly , apply dermeze post

wet dressings to limbs bd

Page 26: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Case one,plan continued

bath oil

dermeze to face

dermeze to limbs qid

hydraderm to trunk qid

wet t-shirt when red or itchy

sigmacort 1% or elidel bd, prn

elocon nocte to limbs and trunk prn

Page 27: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Case one,Discharge plan

Sigmacort 1% bd to face, prn

Elocon nocte to limbs and trunk, prn

keflex for 10days total

dermeze, face, qid

cool compress prn

wet dressings nocte

hydraderm to body qid

bath oil

follow up 1 -2 weeks

Page 28: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Case two,History

13 month

Eczema since 3 months of age

Elocon nocte

hydraderm qid

bath oil

avoiding allergic foods

not overheated

Page 29: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Case two,What is the problem?

Waking at night 1-2 times eczema persisting

Page 30: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Case two,The plan

Continue treatmentwet dressings nocte until CLEARreview 3 weeks

Page 31: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Case three

Extremely itchy even when not flaring

Rash fluctuates

Persisting

Waking at night

No infection

Rash persisting despite compliant treatment

Urticarial

Worsens after eating some foods

Page 32: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Case threeEczema with food allergies

Referral to allergist and dietitianGeneral eczema treatmentReview as necessary

Page 33: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

What is the diagnosis?

Page 34: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Bacterial infected eczemaREMOVE CRUSTSOral keflex/ 10 days if wellIV flucloxacillin ONLY if unwell or febrileGeneral Eczema Care

Admission prn

Page 35: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

How would you treat?Topical elidel, bd, until improved and then hydrocortisone 1% bd, prnDermeze 4-6/dayCool compress qidAvoid aggravators

Page 36: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Contact Details

Emma King or Liz Moore, 9345 5510

Dermatology Registrars, 9345 5510

Outpatient Clinics, Mon, Tues, Wed, Thurs.

Eczema Workshops, Mon and Wed

Page 37: Practical Eczema Management common is eczema? VERY! 10-20% of children in developed countries (Harper et al, 2000) Incidence has trebled over the last 30 years (Harper et al , 2000)

Eczema Herpeticum

NO TOPICAL STEROIDS

remove crusts

+/- oral/IV acylovir

most often oral keflex

admission prn


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