Eczema

Eczema, a chronic inflammatory skin disease, impacts approximately 20% of children and 3% of adults, manifesting as

pruritus
eczematous lesions (dry, scaling and crusted areas of skin)
when chronic may be associated with lichenification (thickening) and pigmentary changes
relapsing course
varying frequency and periods of remissions

Also referred to as atopic eczema or atopic dermatitis

Background:

Onset Characteristics:
- Typically begins between 3-6 months
- 60% of cases emerging before age 1
- 90% by age 5.
Associations: Elevated serum IgE levels and a personal or immediate family history of atopy (type I allergies, allergic rhinitis, and asthma).

Diagnosis:

Diagnostic Approach: Diagnosis relies on patient history and clinical examination.
Criteria: Key criteria involve pruritus, eczema, chronic or relapsing history, typical morphology, and age-specific patterns.

4. Diagnostic Features (American Academy of Dermatology):

Essential Features (Must be Present):
- Pruritus
- Eczema (acute, subacute, chronic)
- Chronic or relapsing history
- Typical morphology and age-specific patterns
Important Features (Adding Support):
- Early age of onset
- Atopy
- Raised IgE levels
Associated Features (Suggestive but Nonspecific):
- Various dermatological responses
- Ocular/periorbital changes
- Regional findings

5. Diagnostic Criteria (Hanifin and Rajka, UK Working Party):

Major Criteria (Must Have 3):
- Pruritus
- Dermatitis affecting flexural surfaces in adults or face and extensor surfaces in infants
- Chronic or relapsing dermatitis
- Personal or family history of cutaneous or respiratory allergy
Minor Criteria (Must Have 3):
- Facial features
- Triggers (emotional, environmental, food, skin irritants)
- Various complications (skin infections, impaired immunity, etc.)

Differential Diagnosis:

- Atopic dermatitis
- Irritant contact dermatitis (detergents, solvents, friction)
- Allergic contact dermatitis (nickel, perfume, rubber)
- Dermatitis herpetiformis (coeliac disease)
- Cow’s milk protein allergy
- Seborrhoeic dermatitis (scalp)
- Scabies
- Tinea
- Psoriasis
- Localised herpetic infections
- Immunodeficiency (Cutaneous T cell lymphoma)
- Dry skin
- Molluscum dermatitis
- Miliaria
- Zinc deficiency

Differential diagnosis of eczema (not exhaustive)
Other inflammatory dermatoses	Seborrhoeic dermatitis, psoriasis, contact allergy or irritation, pompholyx, napkin dermatitis, nummular eczema, lichen simplex, pityriasis lichenoides acuta and chronica, pityriasis alba
Ichthyoses	Ichthyosis vulgaris, autosomal recessive congenital ichthyosis, X-linked ichthyosis, Netherton syndrome
Infections and infestations	Scabies, tinea corporis, pityriasis versicolor, pityriasis rosea, HIV
Immunodeficiencies	Severe combined immunodeficiency, Omenn syndrome, hyper-IgE syndrome, Wiskott-Aldrich syndrome, IPEX syndrome
Immunological disorders	Dermatitis herpetiformis, juvenile dermatomyositis, graft-vs-host disease
Malignancies	Cutaneous T-cell lymphoma (mycosis fungoides)
Metabolic disorders	Zinc deficiency, pyridoxine deficiency, biotin deficiency, niacin deficiency, phenylketonuria, cystic fibrosis, neutral lipid storage disease
Other	Urticaria pigmentosa, Epidermolysis bullosa pruriginosa

Assessment:

Identification of Triggers:
- Irritants (soaps, detergents, chlorine in swimming pools)
- Skin infections (Staphylococcus aureus, Streptococcus pyogenes, herpes simplex)
- Contact allergens
- Food and inhalant triggers
- Stress
Assessment of ciurrent and previous Treatments:
- History should cover:
  - Bathing/showering frequency
  - Use of soap, soap-free cleansers, shampoos
  - Use of bath additives
  - Emollient/moisturiser—frequency of application, quantity used per week
  - Topical steroids—types, sites of application, quantity used per week
  - Any adverse reaction to topical agents eg stinging
  - Antihistamine, antibiotic use
- Underuse of topical treatments is a common cause of treatment failure in eczema.

Impact of Eczema:

Areas of Focus:
- Psychosocial impact
- Skin infections
- Absenteeism from school/activities
- Sleep quality
Formal Measures: CDLQI, POEMS.

Physical Examination:

Components:
- Diagnostic features of eczema or other potential diagnoses
- Extent and severity of eczema
- Evidence of secondary infection
- Growth and development monitoring in children
Formal Measures: SCORAD, EASI.

Investigations: – Instances for Consideration: Some cases may require investigations to confirm the diagnosis and rule out other potential conditions.

Holistic Assessment (NICE Guidelines 2007):

Skin and physical severity
Impact on quality of life and psychosocial well-being
Cultural practices and beliefs of the child and family

Factors Considered: –

Skin and physical severity		Impact on quality of life and psychosocial wellbeing
Clear	Normal skin, no evidence of active eczema	Clear	No impact on quality of life
Mild	Areas of dry skin, infrequent itching (with or without small areas of redness)	Mild	Little impact on everyday activities, sleep and psychosocial wellbeing
Moderate	Areas of dry skin, frequent itching, redness (with or without excoriation and localized skin thickening)	Moderate	Moderate impact on everyday activities and psychosocial wellbeing, frequently disturbed sleep
Severe	Widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation)	Severe	Severe limitation of everyday activities and psychosocial impact, nightly loss of sleep

Outpatient Management:

Prescribed Elements:
- Advice on trigger/irritant avoidance.
- Guidance on bathing and soap substitutes.
- Emollients (moisturizers).
- Topical corticosteroids/calcineurin inhibitors.
- Antibiotics and antihistamines if necessary.
- Instructions on recognizing infections.
- A clear plan for regular health professional reviews.

Bathing Recommendations:

Frequency: Once or twice daily.
Water Conditions: Warm water, baths lasting no more than 10 minutes.
Products: Emollients or emollient washes instead of soap and shampoo.
Additional Consideration: Antiseptic baths (bleach baths) or triclosan bath oils may be beneficial.

Emollients/Moisturizers:

Usage: Provided for daily moisturizing, washing, and bathing.
Quantity: Children should receive 250–500g of emollient weekly. adult patients may use up to 500 g/week or more
Application Technique: Emollients are best applied when skin is moist (after bathing) but can and should be applied at other times as well. Ideally, they should be applied every 4 hours or at least 3 to 4 times per day.
Container Considerations: Prefer pump containers or tubes to prevent contamination.

Topical Corticosteroids:

Benefits and Harms Discussion: Prioritize a discussion with family/caregivers, emphasizing benefits over potential harms.
Potency Selection: Use the fingertip unit ( FTP) as a guide to the amount of topical steroid to use different areas of the body. Tailored to eczema severity, with mild, moderate, and potent categories.
- Mild potency
  - For mild eczema
  - For infants <12 months
  - For the face and neck
- Moderate potency
  - For moderate eczema
  - For short term 5–7 day use in the axillae and groin and for severe facial flares
- Potent
  - For severe eczema
  - Not recommended for use on the face and neck
  - Do not use super potent topical corticosteroids in children (or potent in children under the age of 12 months) without specialist dermatological advice
Topical corticosteroids should only be applied to areas of active eczema, and stopped when the eczema has gone.
Emollients should be continued.
Topical corticosteroids should be applied in a thin layer to the affected area once or twice daily.
They can be applied before or after emollients.
- Diluting topical corticosteroids in emollient or other products has not been shown to reduce potency.
Long term continuous use of topical steroids can rarely result in side effects
- skin thinning
- adrenal suppression with widespread application.
It is recommended that children using topical steroids are reviewed regularly and treatment stepped down in frequency as possible.
Children requiring continuous use of topical steroid should be reviewed by a dermatologist.
Long term maintenance use of topical steroids 2 days per week (‘weekend treatment’) seems safe and effective

Topical Calcineurin Inhibitors:

Consideration: Second-line therapy for eczema unresponsive to topical corticosteroids.
Discussion with Caregivers: Risks and benefits should be thoroughly discussed.
Specialist Involvement: Recommended, and not to be used without dermatological advice.

Antihistamines:

Routine Use Not Recommended: Not for routine use. Oral non-sedating antihistamines may provide relief for some patients, particularly those with concomitant urticaria or allergic rhinitis.
Consideration for Trial: Short-term use (<1 month) for moderate-severe eczema or associated urticaria.
Review: Evaluate benefits every 3 months.

Antibiotics:

Topical Use: Limited to localized areas (<5 cm) for up to 7 days.
Systemic Use: A 7-day course of oral flucloxacillin is most appropriate for treating Staphylococcus aureus.
Other: Soaking for 10 minutes twice weekly in dilute bleach bath (sodium hypochlorite) may reduce the severity of eczema and skin infections.

Reassessment After 7–14 Days:

Considerations for No Improvement:
- Incomplete adherence to treatments.
- Ongoing exposure to irritants.
- Inadequate application of corticosteroid.
- Secondary skin infection.
- Contact allergy or incorrect diagnosis.

Treatment of refractory eczema
Wet dressings	Application of wet dressings in combination with topical corticosteroids helps with skin barrier recovery, as it increases the efficacy of the corticosteroid and protects the skin from persistent scratching. Overuse of wet dressings can cause skin maceration, folliculitis and secondary skin infections.
Phototherapy	Most commonly used phototherapy modality is narrow-band UVB. Photochemotherapy with PUVA should be restricted to patients with severe widespread eczema.Broadband UVB, and UVA1 where available may also be useful.
Systemic immunomodulatory agents	Methotrexate, ciclosporin, mycophenolate mofetil, azathioprine, interferon-gamma and systemic corticosteroids have shown to provide benefit for patients with severe refractory eczema.Use is limited by their potentially serious adverse effects.
Hospitalisation	Patient is removed from environmental allergens, irritants, and stressors.Patient education and compliance with therapy are intensified.
Allergen immunotherapy	Possible consideration in selected eczema patients with associated aeroallergen sensitivity.

Referral for specialist advice
Referral for inpatient care	Eczema herpeticum is suspectedEczema is severe and not responding to treatment Bacterially infected eczema is not responding to appropriate treatmentFor education, support and respite in select cases
Referral for eczema nurse advice	Where the patient and caregivers would benefit from advice and support regarding correct use of treatment
Referral for specialist dermatologist advice	The diagnosis is uncertain Eczema on the face has not responded to treatmentContact dermatitis is suspected Eczema is causing significant psychological or social problems Eczema is associated with severe or recurrent infections The family or child would benefit from specialist advice on treatment Where phototherapy or systemic treatment is required
Referral for psychological advice	Children with ongoing psychological or social impact despite appropriate medical advice
Referral for specialist paediatric advice	Children with suspected immediate food hypersensitivity Children with poor growth Children with severely restricted diets