Atopic Eczema

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Atopic Eczema
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Clinical Features and DiagnosisWilliams HC. N
Engl J Med 20053522314-24Clinical Knowledge
Summary (PRODIGY) 2004NICE. Clinical Guideline
57, Dec 2007

• Reduced skin lipid layer increases transdermal
  water loss and lowers resistance to irritant
  substances.
• Associated with other atopic disease.
• asthma in 30 allergic rhinitis in 35 of
  children with eczema.
• Prevalence 15-20 children and 2-10 adults.
• Approx 80 start before age of 5 years 75 get
  it by age 6 months.
• Present in 80 of children where both parents
  affected and 60 where only one parent affected.
• Typically episodic relapse remission.
• Often has genetic component.
• Does occur in de novo in later life 10 of
  eczema seen in hospital settings.
• Clears in 60 of children by their early
  adolescence, although relapses may occur in later
  life.

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1. Overview of management in primary care
Clinical Knowledge Summary (PRODIGY) 2004

• General
• Management in primary care is based upon
• Identifying and avoiding the provoking factors.
• Using emollients regularly.
• Using topical corticosteroids and oral
  antibiotics intermittently for flare-ups.
• Referring selected people to a specialist.
• Information about the condition, the factors that
  may provoke it, the role of different treatments,
  and their effective and safe use, is required to
  manage eczema effectively.
• Treatment should be planned to balance the
  individual's goals of disease control against the
  safety and acceptability of treatment. Without
  this approach, compliance is likely to be poor
  and management less than optimal.
• It is important to demonstrate how to use topical
  treatments, particularly topical corticosteroids,
  and to emphasise the correct quantities to use.

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Overview of management in children 12
yearsNICE. Clinical Guideline 57, Dec 2007

• Seek to identify potential trigger factors.
• Stepped approach to management tailored to
  severity. Step up or down.
• Emollients should always be used, even if eczema
  clear.
• Potency of corticosteroids should be tailored to
  severity, which may vary according to body site.
• Topical tacrolimus and pimecrolimus not
  recommended for treatment of mild eczema or as
  first-line treatments for eczema of any severity.
• Offer information on how to recognise
  staphylococcal and/or streptococcal infection and
  eczema herpeticum.
• Advise what to do if infection possible or if
  eczema worsens rapidly or doesnt respond to
  treatment.
• Healthcare professionals should spend time
  educating children and their parents or carers
  about atopic eczema and treatment.
• Referral recommendations see guidance.

Eczema herpeticum image reproduced with
permission from Danderm www.danderm-pdv.is.kkh.dk/
atlas/index.htm
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2 Managing dry skin Clinical Knowledge Summary
(PRODIGY) 2004

• The aim of management of eczema between flare-ups
  is to control skin dryness and itching and reduce
  the frequency of flare-ups.
• Establish a daily skin-care regime with
  emollients. The type of emollient, its frequency,
  and the quantity to apply should be tailored to
  the individual's skin requirements and lifestyle.
  
• Avoid irritation to the skin by prescribing an
  emollient soap substitute, and advising the
  person to
• Use gloves when unable to avoid handling
  irritants such as detergents.
• Avoid extremes of temperature and humidity.
• Use non-abrasive clothing fabrics, such as
  cotton.
• Reapply emollients after wetting the skin.

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3 Managing flare-upsClinical Knowledge Summary
(PRODIGY) 2004NICE Clinical Guideline 57, Dec
2007

• Offer information on how to recognise flares.
• Give instructions on how to manage flares
  according to the stepped-care plan (see earlier).
  
• Settle inflammation with topical corticosteroids.
  
• Treat clinically apparent bacterial infection
  with oral antibiotics.
• Treatment for flares should be started as soon as
  signs and symptoms appear. Continue for
  approximately 48 hours after symptoms subside.
• Urgently refer or admit someone with severe
  unresponsive disease, and admit someone if you
  suspect eczema herpeticum.

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4 Managing frequent flare-ups ? 1Clinical
Knowledge Summary (PRODIGY) 2004

• Settle acute flare-up as before.
• Review and emphasise the use of emollients to
  improve the skin's barrier function. Increase the
  intensity of emollient treatment, if acceptable
  to the individual, by all or any of the
  following
• Change the emollient to one with a higher lipid
  content.
• Advise the person to apply the emollient more
  often.
• Recommend applying more emollient each time.
• Review the factors that might be provoking
  flare-ups
• Are there environmental irritants or stresses
  that can be avoided?
• Allergen avoidance is burdensome, but may be
  considered when other measures fail.

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4 Managing frequent flare-ups ? 2Clinical
Knowledge Summary (PRODIGY) 2004NICE Clinical
Guideline 57, Dec 2007

• Refer to a specialist if there is a risk of
  either systemic adverse effects or localised
  adverse effects due to topical corticosteroid
  use.
• Refer to a dietitian when you are considering
  dietary intervention.
• In children with 2 or 3 flares/month consider
  topical corticosteroid for 2 consecutive
  days/week once the eczema has been controlled.
• Review within 3 to 6 months to assess
  effectiveness.

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5 Management in adults Clinical Knowledge
Summary (PRODIGY) 2004

• Settle chronic lesions with a potent
  corticosteroid.
• Review and consider
• The use of emollients.
• The avoidance of environmental irritants and
  stress.
• Antigen avoidance, if appropriate.
• Settle further flare-ups with intermittent use of
  a topical corticosteroid of an appropriate
  potency and duration of use.
• Refer to a specialist if there is a risk of
  either systemic adverse effects or localised
  adverse effects due to topical corticosteroid
  use.

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6 Managing severe widespread eczema Clinical
Knowledge Summary (PRODIGY) 2004

• Seek specialist help if a flare-up is widespread,
  severe, and distressing to the individual.
• Consider oral prednisolone and antibiotics if
  there is a delay before specialist review.
• There is a risk of rebound flare-up when oral
  corticosteroids are stopped. The individual
  should stay on the oral corticosteroid until
  other measures are instituted. It is, therefore,
  important that the specialist sees the individual
  within 7 days, in order to avoid prolonged oral
  corticosteroid use.

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Summary

• Eczema is common.
• Assessment should be based on both severity and
  quality of life.
• The mainstay of management is emollients, even
  when the eczema is clear.
• A stepwise approach, tailored to severity is
  recommended.
• Topical steroids should be used as short-term
  treatment of flares.
• Treat widespread infectious exacerbations with
  oral therapy rather than topical antibiotics.
  Tell patients how to recognise infection.
• Refer patients with severe and/or unresponsive
  disease, and urgently refer or admit someone if
  you suspect eczema herpeticum.
• Education is an important part of treatment.