The Treatment And The Treatment And Management of Management of

EczemaEczema

Sharon HulleySharon Hulley

Clinical Nurse Specialist in Clinical Nurse Specialist in

DermatologyDermatology

University Hospital Of Wales, CardiffUniversity Hospital Of Wales, Cardiff

What Is Eczema ?What Is Eczema ?

““Eczema is derived from the Eczema is derived from the

Greek ‘ekzein’ meaning ‘to boil Greek ‘ekzein’ meaning ‘to boil

over’ and is characterised by dry, over’ and is characterised by dry,

itching and inflamed skin” itching and inflamed skin”

(The Skin Care Campaign 1999)(The Skin Care Campaign 1999)

Types Of EczemaTypes Of Eczema

Atopic EczemaAtopic Eczema

Atopic Eczema Increasing

incidence

Affects approximately 1:10 children

Familial tendency

Associated with asthma and hay fever

Diagnostic Criteria For Diagnostic Criteria For Atopic Eczema Atopic Eczema

Inflammatory condition of the superficial Inflammatory condition of the superficial skin, characterised by 3 or more basic skin, characterised by 3 or more basic features:features:– prurituspruritus– lichenification lichenification – chronic relapsing coursechronic relapsing course– Personal or family history of atopy (asthma, Personal or family history of atopy (asthma,

allergic rhinitis, atopic eczemaallergic rhinitis, atopic eczema

Plus 3 or more minor features:Plus 3 or more minor features:– e.g. xerosis, elevated serum IgE, early age of e.g. xerosis, elevated serum IgE, early age of

onset, itch when sweatingonset, itch when sweatingHanifin & Rajka (1980)Hanifin & Rajka (1980)

UK Working Party’s UK Working Party’s Diagnostic CriteriaDiagnostic Criteria

Presence of itchy skin condition, plus Presence of itchy skin condition, plus 3 or more of the following:3 or more of the following:– history of flexural dermatitishistory of flexural dermatitis– onset <2 years (if child is >4 years)onset <2 years (if child is >4 years)– personal or family history of asthma or personal or family history of asthma or

hayfeverhayfever– visible flexural dermatitisvisible flexural dermatitis

Williams HC et al (1994)Williams HC et al (1994)

Diagnostic Criteria for atopic eczema (3)

Must have an itchy skin condition (or reported scratching or rubbing in a child) plus 3 or more of the following :

– History of itchiness in skin creases such as folds of the elbows, behind knees, fronts of ankles or around the neck (or cheeks in children under 4 years)

– History of asthma or hay fever (or a history of atopic disease in a first degree relative in children under 4 years)

– General dry skin in the past year

– Visible flexural eczema (or eczema affecting the cheeks or forehead and outer limbs in children under 4 years)

– Onset in the first 2 years of life (not always diagnostic in children under 4 years)

(McHenry et al 1995)

DiscoidDiscoid

Discoid EczemaDiscoid Eczema

Presents as well demarcated round Presents as well demarcated round oval or annular red scaly plaques.oval or annular red scaly plaques.

Can be vesicular and crusty or dry Can be vesicular and crusty or dry and scaly.and scaly.

Usually affects older people. Patients Usually affects older people. Patients may also have a background of may also have a background of atopic eczema.atopic eczema.

Pompholyx Pompholyx (palmar/plantar)(palmar/plantar)

Irritant ContactIrritant Contact

Allergic ContactAllergic Contact

ErythrodermicErythrodermic

Varicose / VenousVaricose / Venous

Craquele / CraquelatumCraquele / Craquelatum

Aim Of Eczema TreatmentAim Of Eczema Treatment

To treat and control the symptoms of To treat and control the symptoms of itching, pain and discomfortitching, pain and discomfort

Reduce inflammation Reduce inflammation

Replace lost moisture Replace lost moisture

Inhibit scratching and thus infection Inhibit scratching and thus infection

Improve the quality of life for the patient Improve the quality of life for the patient and their familyand their family

How Do We Treat Eczema?How Do We Treat Eczema?

Moisturisers / Emollients (soap Moisturisers / Emollients (soap substitute, bath oil, topical)substitute, bath oil, topical)

Ointment - dry skinOintment - dry skin

Cream or lotion - wet skinCream or lotion - wet skin

Appropriate quantitiesAppropriate quantities

Effects of an emollientEffects of an emollient

20 minutes after an emollient application

Prior to emollient application

How Do We Treat Eczema?How Do We Treat Eczema?

Appropriate strengths of steroidAppropriate strengths of steroid

Which Strength Of Topical Which Strength Of Topical Steroid ?Steroid ?

Mild EczemaMild Eczema

Mild - ModerateMild - Moderate

ModerateModerate

Moderate - SevereModerate - Severe

SevereSevere

1% Hydrocortisone1% Hydrocortisone

Clobetasone butyrateClobetasone butyrate

Betamethasone 0.025%Betamethasone 0.025%

BetamethasoneBetamethasone / / Mometasone Furoate 0.1% Mometasone Furoate 0.1%

Clobetasol ProprionateClobetasol Proprionate

How Do We Treat The How Do We Treat The Condition?Condition?

Appropriate quantities of steroidAppropriate quantities of steroid

The Finger Tip UnitThe Finger Tip Unit

1 finger tip unit (ftu) = 0.5g 1 finger tip unit (ftu) = 0.5g

Topical Steroid Quantities Topical Steroid Quantities (child)(child)

Twice daily application of Twice daily application of steroid all over:steroid all over:

– 6 month old = 9.5g daily = 6 month old = 9.5g daily = 66.5g weekly66.5g weekly

– 4 year old = 19.25g daily = 4 year old = 19.25g daily = 134.75g weekly134.75g weekly

– 7 year old = 24.5g daily = 7 year old = 24.5g daily = 171.5g weekly171.5g weekly

Topical Steroid Quantities Topical Steroid Quantities (adult)(adult)

Face & Neck 2 ftu = 1gFace & Neck 2 ftu = 1g

Back & Front 7 ftu = 3.5gBack & Front 7 ftu = 3.5g

Arm 3 ftu x2 = 3gArm 3 ftu x2 = 3g

Hand (both sides) 1 ftu x2 = Hand (both sides) 1 ftu x2 = 1g1g

Leg (not incl. foot) 6 ftu x2 Leg (not incl. foot) 6 ftu x2 = 6g = 6g

Foot 2 ftu x2 = 2gFoot 2 ftu x2 = 2g

total per once daily total per once daily application = 16.5gapplication = 16.5g

Per week = 115.5gPer week = 115.5g

How Do We Treat The How Do We Treat The Condition? (cont’d)Condition? (cont’d)

BandagesBandages

Antibiotics (topical / oral)Antibiotics (topical / oral)

Treatment regimeTreatment regime

Avoid provoking factors if possibleAvoid provoking factors if possible

What If That Doesn’t Work?What If That Doesn’t Work?

Review treatmentReview treatment– steroid not strong enoughsteroid not strong enough– not enough emollientnot enough emollient– infection not addressedinfection not addressed– consider bandagingconsider bandaging

Topical immunomodulatorsTopical immunomodulators

NICE Recommendations For NICE Recommendations For Use Use

Of Topical ImmunomodulatorsOf Topical Immunomodulators Treatment with both Protopic & Elidel Treatment with both Protopic & Elidel

must be initiated by physicians must be initiated by physicians (including G.P’s) with a special interest (including G.P’s) with a special interest and experience in dermatology.and experience in dermatology.

Prior to commencing - careful Prior to commencing - careful discussion with patients and/or discussion with patients and/or parents of potential risks and benefits parents of potential risks and benefits of all seconds-line treatment options.of all seconds-line treatment options.

Mode Of ActionMode Of Action

Calcineurin inhibitors.Calcineurin inhibitors.

Suppression of T-lymphocyte Suppression of T-lymphocyte responses.responses.

Availability Of Protopic & Availability Of Protopic & ElidelElidel

Protopic (Tacrolimus) 0.03% & 0.1% Protopic (Tacrolimus) 0.03% & 0.1% OintmentOintment – 30g (0.03% & 0.1%)30g (0.03% & 0.1%)– 60g (0.03% & 0.1%)60g (0.03% & 0.1%)

Elidel (Pimecrolimus 1%) CreamElidel (Pimecrolimus 1%) Cream– 30g30g– 60g 60g – 100g 100g

Licensed Indications For Licensed Indications For Protopic (Tacrolimus) 0.03% & Protopic (Tacrolimus) 0.03% &

0.1% Ointment0.1% Ointment

Children 2-16 years 0.03% Children 2-16 years 0.03%

Adults & adolescents over 16 years Adults & adolescents over 16 years 0.1%.0.1%.

Treatment of moderate to severe atopic Treatment of moderate to severe atopic eczema unresponsive to conventional eczema unresponsive to conventional therapy.therapy.

NICE NICE Indications For Protopic Indications For Protopic (Tacrolimus) 0.03% & 0.1% (Tacrolimus) 0.03% & 0.1%

OintmentOintment Not recommended for the treatment of Not recommended for the treatment of

mild atopic eczema or as a first-line mild atopic eczema or as a first-line treatment.treatment.

Treatment of moderate to severe atopic Treatment of moderate to severe atopic eczema in adults & children over 2 years eczema in adults & children over 2 years of age.of age.

Failed response to topical corticosteroids.Failed response to topical corticosteroids.

At risk of adverse effects from further use At risk of adverse effects from further use of topical corticosteroids e.g. skin atrophy.of topical corticosteroids e.g. skin atrophy.

Application Of Protopic Application Of Protopic (Tacrolimus) 0.1% & 0.03% (Tacrolimus) 0.1% & 0.03%

OintmentOintment

Prior to use, clinical infections at treatment Prior to use, clinical infections at treatment sites should be cleared. sites should be cleared.

Emollients should not be applied to the Emollients should not be applied to the same area within 2 hours of applying same area within 2 hours of applying tacrolimus. tacrolimus.

Body, limbs, face, neck and flexures.Body, limbs, face, neck and flexures.

Twice daily for up to 3 weeks then reduce to Twice daily for up to 3 weeks then reduce to once daily until clear.once daily until clear.

Restart as/when necessary.Restart as/when necessary.

Side EffectsSide Effects

More CommonMore Common– Burning or tingling sensation Burning or tingling sensation – Pruritus Pruritus – Erythema Erythema

Less CommonLess Common– Folliculitis Folliculitis – Herpes simplex infection Herpes simplex infection – Acne Acne – Increased sensitivity to hot and cold Increased sensitivity to hot and cold – Alcohol intolerance Alcohol intolerance – Lymphadenopathy has also been reportedLymphadenopathy has also been reported

Licensed Indications For Licensed Indications For Elidel (Pimecrolimus) CreamElidel (Pimecrolimus) Cream

Children over 2 years & adults. Children over 2 years & adults.

Acute treatment of mild to moderate atopic Acute treatment of mild to moderate atopic eczema (including flares).eczema (including flares).

NICE NICE Indications For Elidel Indications For Elidel (Pimecrolimus) Cream(Pimecrolimus) Cream

Not recommended for the treatment of mild Not recommended for the treatment of mild atopic eczema or as a first-line treatment.atopic eczema or as a first-line treatment.

Treatment of moderate atopic eczema on Treatment of moderate atopic eczema on face & neck in children aged 2-16 years of face & neck in children aged 2-16 years of age.age.

Failed to respond to topical corticosteroids.Failed to respond to topical corticosteroids.

At risk of adverse effects from further use of At risk of adverse effects from further use of topical corticosteroids e.g. skin atrophy.topical corticosteroids e.g. skin atrophy.

Application Of Elidel Application Of Elidel (Pimecrolimus 1%) Cream(Pimecrolimus 1%) Cream

Prior to use clinical infections at treatment Prior to use clinical infections at treatment sites should be cleared. sites should be cleared.

Not to be applied to areas affected by acute Not to be applied to areas affected by acute cutaneous viral infections. cutaneous viral infections.

Twice daily until symptoms resolve.Twice daily until symptoms resolve.

Re-start as/when necessary.Re-start as/when necessary.

Side EffectsSide Effects More CommonMore Common

– Burning sensation Burning sensation – Pruritus Pruritus – Erythema Erythema

Less CommonLess Common– Skin infections (including folliculitis and rarely Skin infections (including folliculitis and rarely

impetigo, herpes simplex and zoster and impetigo, herpes simplex and zoster and molluscum contagiosum)molluscum contagiosum)

– Papilloma (rarely) Papilloma (rarely) – Local reactions such as pain, paraesthesia, Local reactions such as pain, paraesthesia,

peeling, dryness, oedema and worsening of peeling, dryness, oedema and worsening of eczemaeczema

Any questions?Any questions?