Atopic Eczema 1

Atopic Eczema
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Clinical Features and Diagnosis
Williams HC. N Engl J Med 2005;352:2314-24
Clinical Knowledge Summary (PRODIGY) 2004
NICE. Clinical Guideline 57, Dec 2007
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Reduced skin lipid layer increases transdermal water loss and
lowers resistance to irritant substances.
Associated with other atopic disease.
– asthma in 30% & allergic rhinitis in 35% of children with eczema.
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Prevalence 15-20% children and 2-10% adults.
– Approx 80% start before age of 5 years; 75% get it by age 6 months.
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Present in 80% of children where both parents affected and 60%
where only one parent affected.
Typically episodic – relapse & remission.
Often has genetic component.
Does occur in de novo in later life – 10% of eczema seen in hospital
settings.
Clears in 60% of children by their early adolescence, although
relapses may occur in later life.
1. Overview of management in primary care
Clinical Knowledge Summary (PRODIGY) 2004
General
• Management in primary care is based upon:
– Identifying and avoiding the provoking factors.
– Using emollients regularly.
– Using topical corticosteroids and oral antibiotics intermittently for
flare-ups.
– Referring selected people to a specialist.
• Information about the condition, the factors that may provoke it,
the role of different treatments, and their effective and safe use,
is required to manage eczema effectively.
• Treatment should be planned to balance the individual's goals
of disease control against the safety and acceptability of
treatment. Without this approach, compliance is likely to be poor
and management less than optimal.
• It is important to demonstrate how to use topical
treatments, particularly topical corticosteroids, and to
emphasise the correct quantities to use.
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Overview of management in children ≤12 years
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NICE. Clinical Guideline 57, Dec 2007
Seek to identify potential trigger factors.
Stepped approach to management – tailored to severity. Step up
or down.
Emollients should always be used, even if eczema clear.
Potency of corticosteroids should be tailored to severity, which
may vary according to body site.
Topical tacrolimus and pimecrolimus not recommended for
treatment of mild eczema or as first-line treatments for eczema
of any severity.
Offer information on how to recognise staphylococcal and/or
streptococcal infection and eczema herpeticum.
Advise what to do if infection possible or if eczema worsens
rapidly or doesn’t respond to treatment.
Healthcare professionals should spend time educating children
and their parents or carers about atopic eczema and treatment.
Referral recommendations – see guidance.
Eczema herpeticum – image reproduced with
permission from Danderm www.dandermpdv.is.kkh.dk/atlas/index.htm
2: Managing dry skin
Clinical Knowledge Summary (PRODIGY) 2004
• The aim of management of eczema between flareups is to control skin dryness and itching and reduce
the frequency of flare-ups.
• Establish a daily skin-care regime with
emollients. The type of emollient, its frequency, and
the quantity to apply should be tailored to the
individual's skin requirements and lifestyle.
• Avoid irritation to the skin by prescribing an
emollient soap substitute, and advising the person to:
– Use gloves when unable to avoid handling irritants such as
detergents.
– Avoid extremes of temperature and humidity.
– Use non-abrasive clothing fabrics, such as cotton.
– Reapply emollients after wetting the skin.
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3: Managing flare-ups
Clinical Knowledge Summary (PRODIGY) 2004
NICE Clinical Guideline 57, Dec 2007
• Offer information on how to recognise flares.
• Give instructions on how to manage flares according to
the stepped-care plan (see earlier).
– Settle inflammation with topical corticosteroids.
– Treat clinically apparent bacterial infection with oral
antibiotics.
• Treatment for flares should be started as soon as signs
and symptoms appear. Continue for approximately 48
hours after symptoms subside.
• Urgently refer or admit someone with severe unresponsive
disease, and admit someone if you suspect eczema
herpeticum.
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4: Managing frequent flare-ups  1
Clinical Knowledge Summary (PRODIGY) 2004
• Settle acute flare-up as before.
• Review and emphasise the use of emollients to
improve the skin's barrier function. Increase the
intensity of emollient treatment, if acceptable to the
individual, by all or any of the following:
– Change the emollient to one with a higher lipid content.
– Advise the person to apply the emollient more often.
– Recommend applying more emollient each time.
• Review the factors that might be provoking flareups:
– Are there environmental irritants or stresses that can be
avoided?
– Allergen avoidance is burdensome, but may be considered
when other measures fail.
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4: Managing frequent flare-ups  2
Clinical Knowledge Summary (PRODIGY) 2004
NICE Clinical Guideline 57, Dec 2007
• Refer to a specialist if there is a risk of either
systemic adverse effects or localised adverse effects
due to topical corticosteroid use.
• Refer to a dietitian when you are considering dietary
intervention.
• In children with 2 or 3 flares/month consider topical
corticosteroid for 2 consecutive days/week once the
eczema has been controlled.
– Review within 3 to 6 months to assess effectiveness.
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5: Management in adults
Clinical Knowledge Summary (PRODIGY) 2004
• Settle chronic lesions with a potent corticosteroid.
• Review and consider:
– The use of emollients.
– The avoidance of environmental irritants and stress.
– Antigen avoidance, if appropriate.
• Settle further flare-ups with intermittent use of a
topical corticosteroid of an appropriate potency and
duration of use.
• Refer to a specialist if there is a risk of either
systemic adverse effects or localised adverse effects
due to topical corticosteroid use.
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6: Managing severe widespread eczema
Clinical Knowledge Summary (PRODIGY) 2004
• Seek specialist help if a flare-up is widespread,
severe, and distressing to the individual.
• Consider oral prednisolone and antibiotics if there
is a delay before specialist review.
• There is a risk of rebound flare-up when oral
corticosteroids are stopped. The individual should
stay on the oral corticosteroid until other measures
are instituted. It is, therefore, important that the
specialist sees the individual within 7 days, in order to
avoid prolonged oral corticosteroid use.
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Summary
• Eczema is common.
• Assessment should be based on both severity and quality
of life.
• The mainstay of management is emollients, even when
the eczema is clear.
• A stepwise approach, tailored to severity is recommended.
• Topical steroids should be used as short-term treatment of
flares.
• Treat widespread infectious exacerbations with oral
therapy rather than topical antibiotics. Tell patients how to
recognise infection.
• Refer patients with severe and/or unresponsive disease,
and urgently refer or admit someone if you suspect
eczema herpeticum.
• Education is an important part of treatment.
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