Eczema

This information is a broad guideline only. Treatment of an individual patient should always be modified according to need and circumstances and may involve a multidisciplinary approach.

Eczema affects 15-20% of school children and 2-10% of adults

Allergen avoidance is ineffective in the vast majority of patients

Diagnostic criteria for atopic eczema

• Must have:
  • an itchy skin condition (or report of scratching or rubbing in a child)
  • plus three or more of the following:
    • history of itchiness in skin creases such as folds of the elbows, behind the knees, fronts of ankles, or around neck (or the cheeks in children under 4 years)
    • history of asthma or hay fever (or 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)
• If it does not itch it is very unlikely to be eczema

Diagnosis and patient assessment

• Enquiry about and discussion of the following:
  • family and personal history of atopy and eczema
  • distribution of disease
  • onset of disease
  • exposure to pets within the household
  • aggravating factors such as exposure to irritants
  • sleep disturbance due to itching/rubbing
  • previous treatments
  • effect on school work, career, or social life
  • most distressing thing for the patient or family
  • patient’s or family’s expectations from treatment and their understanding of optimal use
  • evidence of clinical infection, suggested by the presence of crusting or weeping in bacterial infection, or grouped vesicles and punched out erosions indicative of herpes simplex infection
  • other considerations are the impact on the quality of life, dietary restrictions tried and other medications being taken (e.g. steroids for asthma)
  • a growth chart should be completed and updated in children with chronic severe eczema

Recommendations for referral to secondary care

• Severe infection with herpes simplex (eczema herpeticum) is suspected
• The disease is severe and has not responded to appropriate therapy in primary care
• The rash becomes infected with bacteria (manifest as weeping, crusting or the development of pustules) and treatment with an oral antibiotic plus a topical corticosteroid has failed
• The rash is giving rise to severe social or psychological problems; prompts to referral should include sleeplessness and school absenteeism
• Treatment requires the use of excessive amounts of potent topical corticosteroids
• Management in primary care has not controlled the rash satisfactorily. Ultimately, failure to improve is probably best based upon a subjective assessment by the child or parent
• The patient or family might benefit from additional advice on application of treatments (bandaging techniques)
• Contact dermatitis is suspected and confirmation requires patch-testing (this is rarely needed)
• Dietary factors are suspected and dietary control is a possibility
• The diagnosis is, or has become, uncertain

The general principles of primary care management

• Keep the patient/parent informed
  • explain the condition and its treatment
  • educate the patient on the use of topical treatments with details of application and quantities
  • ideally demonstrate how and when to use
  • back this up with written information and practical advice
• Avoid exacerbating factors
  • avoid anything that is known to increase disease severity where practicable
  • crude lanolin is a weak sensitiser. However, the sensitising potential of hypo-allergenic ultra-purified lanolin has been shown to be minimal
  • advise avoidance of extremes in temperature, avoiding irritating clothes containing wool or certain synthetic fibres
  • advise keeping nails short
  • avoid use of soaps or detergents, replace with emollient substitutes
• Keep skin hydrated
  • use of baths and bath additives
  • reduce water loss by the use of sufficient appropriate emollient therapy used liberally
• Treat secondary infection early
  • use of appropriate topical and oral therapy
• Treat exacerbations
  • use of appropriate topical steroids on acute basis

Use of emollients

• Emollients are best applied when the skin is moist but they can and should be applied at other times
• Many patients underestimate the quantity needed and frequency of application to achieve maximal effect
• Emollients should be applied as liberally and frequently as possible and continual treatment with complete emollient therapy (combinations of cream, ointment, bath oil and emollient soap substitute) will help provide maximal effect
• An additional approach is to add a local anaesthetic substance such as lauromacrogols to the emollient to provide antipruritic activity to help break the scratch-itch cycle
• Ideally the frequency of application of emollients should be every 4 hours or at least 3–4 times per day
• Emollients should be prescribed in large quantities with the recommended quantities used in generalised eczema being 500 g/week for an adult and 250 g/week for a child
• Intensive use of emollients will reduce the need for topical steroids. It should be emphasised to all patients that emollient use in quantity and frequency far outweighs other therapies they may be given
• A general rule of thumb is that emollient use should exceed steroid use by 10:1 in terms of quantities used for most patients
• Education on how to use emollients is essential to ensure maximal rehydration of the skin

Principles of treatment with topical steroids

• As a rough guide, steroid use should be limited to a few days to a week for acute eczema and up to 4–6 weeks to gain initial remission for chronic eczema
• The weakest steroid should be chosen to control the disease effectively; this may include either a step-up approach, low to more potent, or a step-down approach, more potent to less potent
• In each approach, regular review of steroid use in terms of potency and quantity (especially when using potent steroids) is essential
• Very potent steroids should not be used in children with atopic eczema in primary care. Very rarely their use may be indicated in resistant severe eczema on the hands and feet of adults, again with regular review of use
• Patients using moderate and potent steroids must be kept under review for both local and systemic side-effects
• Take care which strength of steroid is entered into your patient’s repeat prescription

Bacterial infection

• Bacterial infection is suggested by:
  • crusting, weeping, pustulation and/or surrounding cellulitis with erythema of otherwise normal-looking skin
  • a sudden worsening of the condition
• Staphylococcus aureus is believed to be an important exacerbating factor in atopic eczema
  • swabs for bacteriology are particularly useful if patients do not respond to treatment, in order to identify antibiotic-resistant strains of S. aureus or detect additional streptococcal infection
• Emollient antimicrobial preparations can help prevent infection
  • tubs of ointment should not be left open
  • simple clean procedures should be used by patients or parents applying the creams, such as using clean spoons to remove cream from the jar
  • pump dispensers may also be useful
• Oral antibiotics are often necessary in moderate to severe infection
  • a 14-day course should be given
  • flucloxacillin oral is usually most appropriate for treating S. aureus
  • erythromycin or one of the new macrolides can be used if there is a penicillin allergy or penicillin resistance
  • penicillin should be given if beta-haemolytic streptococci are isolated
• Steroid-antibiotic combinations are effective in clinical practice although evidence for superiority in efficacy is lacking

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Treatment of eczema protocol

Psoriasis and eczema

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Primary Care Dermatology Society. Guidelines for the Management of Atopic Eczema