Eczema
Questionnaire/history:
Triggers?
Irritants?
- Use of soaps and detergents.
- Clothing?
--- Synthetic?
--- Wool clothing (more irritant than cotton)?
--- Dyes in cotton clothing?
Heat?
--- Long hot bath/shower?
Contact allergens?
--- Perfumes?
--- Topical medications?
--- Metal?
--- Latex?
Inhalant allergens?
- Seasonal flares?
(Note: Particularly in children > 3 years and adults with facial eczema especially around the eyes and if eczema associated with asthma or allergic rhinitis)
Additional stresses?
- Emotional upset?
- Lack of sleep?
- Concurrent illness?
Food allergy/dietary factors?
- Milk?
- Egg?
- Wheat?
- Soy?
- Peanut?
(Note: The above account for ~75% of food-induced atopic eczema)
Scratching?
Infection?
Past medical history?
- Atopy?
Family history?
- Atopy?
Current medication?
Known drug allergies?
Examination:
Ill-defined patches or erythema?
Location?
- Facial (common in infants)?
- Flexural areas?
- More widespread (more in older age groups)?
In people with darker skin:
- Extensor surfaces?
- Discoid patches?
- Follicular involvement?
Investigations:
(Notes: Most people do NOT need allergy testing, with PCDS stating that 'Most children with mild-moderate eczema that respond well to treatment do not have a food allergy.In such patients, and in the absence of any close temporal link between a particular food causing a flare of eczema, investigations and dietary restrictions are not recommended. Irrespective of the clinical context, if there appears to be a close temporal link between a food and the symptoms the diagnosis can be confirmed by dietary exclusion, often without the need for any investigations.')
Patch testing if seasonal flares, particularly if facial eczema especially around the eyes and if eczema associated with asthma or allergic rhinitis?
Management:
Referral:
- Refer acutely/admit if eczema herpeticum suspected
- Diagnostic uncertainty
- Severe eczema
- Eczema causing significant social or psychological problems (eg sleep disturbance).
- Eczema only partially responding to standard treatment (eg recurrent secondary infection, very frequent flares 1-2 times/month)
- Steroid atrophy or concerns regarding the amount of topical steroids being used
- Possible cases of contact allergic dermatitis
- Suspected food allergy or inhalant allergy triggering eczema (with immediate symptoms, particularly if infants/young children with gut dysmotility (eg colic, vomiting, altered bowel habit) or failure to thrive)
(Note: A 6-8 weeks trial of extensively hydrolysed or amino acid formula is recommended for bottle-fed infants < 6 months with moderate/severe eczema not responding to optimal treatment)
Advised:
Emollients, ideally QDS
Thicker emollients (eg ointments) better for dryer skin but concordance can be a problem, and they also come in tubs - do not place hands in tubs as this increases the risk of cross-infection, but use a utensil (e.g. clean spoon or spatula) to scoop out the ointment.
Rub emollients gently into the skin until no longer visible, downwards in the direction of the hairs (reduces the risk of folliculitis).
Aqueous cream is generally not recommended due to higher rates of skin reaction
If possible pump dispenser to reduce the risk of cross-contamination and prescription of generous quantities e.g. 500 g pump dispensers.
Current evidence does not support the use of separate bath emollients for children > 1 year as standard emollients (particularly ointments) make effective soap substitutes
Antihistamines are not recommended for routine use in eczema management, however, if there is severe itch or urticaria consider non-sedating antihistamines.
If there is severe itch affecting sleep consider sedating antihistamines (eg adults hydroxyzine 25-50 mg, children chlorphenamine 5-15 mg)
Topical steroids:
Use the lowest appropriate potency and apply only to inflamed skin OD for 1-2 weeks (can be increased to BD if not settling), however, the PCDS note that for flare-ups it is more effective and safer to 'hit hard' using more potent steroids for a few days than to use milder steroids for longer periods of time:
Child face: mild potency eg 1% hydrocortisone (only consider moderate potency steroids for severe flares and for max 3-5 days)
Child trunk and limbs: moderate potency (eg Eumovate (clobetasone butyrate 0.05%) or Betnovate-RD (betamethasone valerate 0.025%))
Adult face: mild or moderate potency (eg Eumovate)
Adult trunk or limbs: potent (eg Betnovate (betamethasone valerate 0.1%), Elocon (mometasone))
Palms and soles: potent or very potent (eg Dermovate (clobetasol propionate 0.05%)
Vulnerable sites (axillae/groins): generally use mild potency steroid; if used, moderate/potent steroids should only be used for short periods (eg 7-14 days)
As a rough guide, adults are likely to need for 1-week use:
- Both hands 15-30 g
- Face and neck 15-30 g
- Both arms 30-60 g
- Both legs 100 g
Skin atrophy is rare if topical steroids are used appropriately but should be avoided around the eyes, and regular use should be avoided on the face
Creams may be preferred, especially on visible areas eg hands/face; ointments may be more effective but are greasy but may be a good option to use at night
Flare-ups (i.e. flares more than every 1-2 months):
Concordance checked?
- Enough emollient used?
- Enough topical steroid used?
Triggers to be addressed?
‘Steroid weekend regime’ considered?
(Note: Once the eczema is under control use the usual topical steroid on two consecutive days (eg Saturday and Sunday) of each week to the areas that tend to flare even if the skin is not inflamed for 3-6 months, then review)
Secondary infection
Questionnaire/history:
Rapidly worsening eczema?
No response to usual treatment?
Systemic features?
- Fever?
- Malaise?
Examination:
Weeping?
Pustules?
Crusts?
Investigation:
Swab if eczema worsening or not responding to standard treatment?
Recurrent infections: skin and nasal swab?
Management:
If eczema continues to flare take swabs and treat as appropriate:
Topical treatment for localised/not severe infections: Fusidic acid 2% TDS for 5-7 days
For more widespread or severe infections use oral antibiotics: 1st line flucloxacillin 500mg QDS 5-7 days, alternative if unsuitable or penicillin-allergic clarithromycin 250-500mg BD 5-7 days, if pregnancy erythromycin 250-500mg QDS 5-7 days
If staph aureus present nasal Bactroban cream BD for 1 week
Resource(s):
Information for patient/carer(s):
British Association of Dermatologists (BAD): eczema (atopic)
National Eczema Society: Itching and scratching