Atopic eczema

1. Atopic eczema

2. 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)

3. 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

4. Clinical features and diagnosis • Reduced skin lipid layer > increased transdermal water loss > 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 < 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

5. 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

6. 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 < 4 years • Onset of signs or symptoms < 2 years

7. 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

8. 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

9. 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 patient’s goals vs. safety and acceptability of Rx • Demonstrate use of topical treatments emphasising the correct quantities to use

10. 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

11. 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 patient’s 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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