Eczema: what is it?

Inflammation of the epidermis

 Epidermal disease
 Hence scaly

 Inflammation
 Hence redness

 Profoundly itchy
What does it look like?
 Red
 Scaly

 Weepy if its infected

 Cracked if it is quite
dry
Secondary changes: infection
 Weepy
 Crusted
 Yellow
Other secondary changes
 Scratch marks
Lichenification
 Thickening of the skin
due to chronic
scratching
Atopic Eczema: what is actually
going on?
 Immunological
abnormalities “atopy”
 THi2 dominant
 Uncontrolled humoral
immunity: IgE
production

 Dry skin
 Dryness indicates loss of the
normal waterproofing of the skin
Eczema: loss of waterproofing of
the skin
 Atopic Eczema
 Most obvious early sign is dryness which is
also the key abnormality to correct during
treatment

 Redness/inflammation, which usually

follows on from the dryness but can
seemingly come and go at will
Atopic Eczema
 Common
 Miserable
 Incredibly itchy
 Life disrupting for
children and families
 Embarrassing
 Destroyer of self
confidence
The treatment of eczema
 Complicated therefore
needs much patient
education
 Multi-faceted
 Child
 Family
 School
 Skin/allergies/
environment
Treatment of atopic eczema in childhood
 treatment of the dry
skin with emollients
 topical steroids
 removal of “flare
factors” eg infection
 Antihistamines (only
occasionally)
 now tacrolimus and
pimecrolimus
Dry skin in eczema
 Actually mild eczema
 Implies loss of barrier
function
 Escalation of fluid loss
 Increased risk of
infection
 Hence emollients are
the key to treatment
Keypoint 1
 Emollients are the cornerstone of
management, and should be used liberally
to all areas on a daily basis, even (perhaps
especially) if the eczema is quiescent.
 Most patients use far too little.
Emollients
 If used correctly will control most children’s
eczema most of the time, because it addresses
the fundamental problem of dry skin and its
resulting poor barrier function.
 Emollients are under-used.
 Many patients are prescribed topical steroids
inappropriately before being offered emollients
 The greasier the better: some sting
Emollients
 Replace detergents and
soaps with emollient soap
substitutes
 Ointments are better
because they are more
hydrating and often less
irritant, but consider patient
preference to improve
compliance.
 Continue emollients even
when eczema settles to
prevent or reduce severity
of relapse.
Emollients
 Use large amounts of ointments/creams, and
encourage liberal application several times a
day, to moist skin (after bath) where possible.
 Prescribe in large quantities to aid compliance
and be more cost effective.
 Pump dispensers may be helpful to reduce
infection risks.
 Typical doses: 250g/week for child, 500g/week
for adult.
 These may be better tolerated if warmed.
 Wet wraps/ Comfifast Suits
 Efficient means of delivering emollients
 Occludes and therefore protects the skin
 Maintains a constant temperature and
therefore reduces the tendency to scratch

 Don’t suit every child

 Avoid till infection is controlled
Topical steroids
 Use the least potent
steroid which is effective,
intermittently, to avoid
systemic side effects
(growth suppression) and
local side effects (skin
thinning and contact
dermatitis)
 Ensure all steroids are
used in correct amounts
 Topical steroids
 Avoid potent steroids around the eye (risk
of cataracts) and on the face (risk of
atrophy/telangectasia)
 A short course of potent steroids may abort
a severe episode
 Potent and very potent steroids must be
used intermittently, eg for a few days to
each body site, every few weeks.
 Topical steroids
 Modern steroids (eg Fluticasone propionate,
Mometosone furoate) are potent but less
likely to be associated with side effects
 Ointments (oil-based) are more effective than
creams, although creams and lotions (water-
based) are useful when the skin is inflamed
 Educate parents/patients that side effects are
related to the potency of the steroid, the
amount used and site of application
Advise the steroid ladder
 4 rungs
 Dermovate
 Betnovate
Cutivate/Elocon
 Eumovate/ Haelen
 Hydrocortisone
Infection
 Common
 S Aureus
 Occasionally also
Strep
 Caused by reduced
waterproofing of the
skin

 Is it herpes?
When the infection has been
treated
 Having discarded old
creams
 Emollients, emollients,
emollients

 Advice about what to look

for which may indicate
returning infection
 And what to do
 Potassium permanganate
 Fucidin
 Infected eczema
 If there is early relapse after use of antibiotics, or
recurrence of infection, perform skin and nasal swabs
in child and family to check for S.Aureus carriage.
Consider treatment with topical antibiotic cream.

 Topical antibacterial/steroid mixes may be useful for

the flexures and in the presence of recurrent infection,
but should not be used other than for short periods.
Eczema Herpeticum
 Grouped vesicles
 Later umbilicated
lesions

 Often secondary
impetigo
Referral
• Refer all children with severe or refractory
 eczema, or those requiring frequent courses

of potent steroids or antibiotics, to

dermatology.

• Children with eczema in an unusual
distribution should also be referred, as they

may need patch testing to exclude a contact
eczema.
• The following require same-day referral
to dermatology: cases of eczema
herpeticum; erythroderma; systemic
upset secondary to severe eczema.
Referral
 Where there are co-existing medical problems,
such as failure to thrive or worrying reactions to
food, referral decisions will depend on the relative
severity of each problem
 In most cases, particularly in young children, the
child should be referred to a general or specialist
paediatrician, who can co-ordinate involvement of
other services, including paediatric dietetics, as
appropriate.
Other interventions
• Sedative oral antihistamines – given for
 short periods at night only may help to

interrupt the scratch-itch cycle. Avoid in

children under 3 months. Note the
potential detrimental impact on school

performance.
• Measures to prevent bacterial infection
– daily baths; avoid sharing of flannels,
towels; wash such items on hot wash cycle of
 washing machine; don’t leave tubs of

ointments open.
• Avoid mammalian pets.
 Atopic eczema in childhood: occupational
advice

 avoidance of jobs involving wet hands eg

hairdressing
 avoidance jobs involving hand contact with
oils eg engineering
 avoidance contact with animals
 The prescription of aqueous
cream for mod to severe eczema
 Ok for washing
 Not greasy enough for
much else
Type of emollient is important
 Does it sting?
 Preservatives sting so
ointments are best
 Some brands sting
often
 Patient choice in the
end
 When skin is really dry
everything stings at first
Mild steroid induced “perioral
dermatitis”
 Common especially in
health care workers
 Stop all steroids
 Treat as acne rosacea
in the interim