CKS Atopic Eczema

Definition

Atopic eczema is a chronic, itchy, inflammatory skin condition that affects people of all ages, although it presents most frequently in childhood.

Prevalence

Affects about 10–30% of children and about 2–10% of adults.

Around 70–90% of cases occur before 5 years of age, with a high incidence of onset in the first year of life.

Aetiology

Genetic predisposition
Skin barrier dysfunction
Protective effect of breast feeding
Environmental factors (such as exposure to pets, house-dust mites, and pollen)
Immune system dysfunction (such as food allergies)

Complications

• Infection
  Staphylococcus aureus
  Herpes simplex virus infection (may be widespread if eczema herpeticum)
  Superficial fungal infection.

• Psychosocial issues

Diagnosis

An itchy skin condition plus three or more of the following:

Flexural eczema (bends of the elbows or behind the knees) or visible eczema on the cheeks and/or extensor areas in children age <18m.
Personal history of dry skin in the last 12 months.
Personal history of asthma or allergic rhinitis
Onset < age 2y

In children of Asian, black Caribbean, and black African ethnic groups, atopic eczema can affect the extensor surfaces rather than the flexures, and discoid or follicular patterns may be more common.

Management

Assess severity of the eczema

Mild — if there are areas of dry skin, and infrequent itching (with or without small areas of redness)
Moderate — if there are areas of dry skin, frequent itching, and redness (with or without excoriation and localized skin thickening)
Severe — if there are widespread areas of dry skin, incessant itching, and redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking, and alteration of pigmentation)
Infected — if eczema is weeping, crusted, or there are pustules, with fever or malaise.

Assess psychological impact

Provide advice, including skin care measures and need to avoid trigger factors (where possible)

Stepwise approach:

1. Emollients - acute flares and remissions of the condition.
   Eucerin® Intensive
   E45® Itch Relief Cream
   E45® cream and lotion
   Antiseptic, for example Dermol® 
   

2. Topical corticosteroids should be considered for red, inflamed skin.
   Hydrocortisone 1% is available over-the-counter for the treatment of mild-to-moderate eczema not involving the face or genitals.

   For normal skin on the body (not the face, genitals, or axillae):
   Prescribe a strength of topical corticosteroid to match the severity of the eczema, to be used once a day for 7–14 days: (if needed, increase to twice daily.)

   mild eczema mildly potent: hydrocortisone 0.1%, 0.5%, 1.0%, and 2.5% 

   moderate eczema moderately potent: betamethasone valerate 0.025% (Betnovate-RD®) and clobetasone butyrate 0.05% (Eumovate®)

   severe eczema potent: betamethasone valerate 0.1% (Betnovate®)
   very potent: clobetasol propionate 0.05% (Dermovate®) (Dermatologist prescribed)
   
   For flares on the face, genitals, or axillae, consider prescribing a mild potency topical corticosteroid (increase to a moderate potency corticosteroid only if necessary)
   
   For the maintenance treatment (that is, skin other than the face, genitals, or axillae), consider

   Step down treatment
   Intermittent treatment
   Weekend therapy — topical corticosteroid, to be used on two consecutive days per week
   Twice weekly therapy —topical corticosteroid used every 3–4 days

3. If there is persistent, severe itch, or urticaria, a one-month trial of a non-sedating antihistamine (cetirizine, loratadine, or fexofenadine)
   If itching is severe and affecting sleep, consider a short course of a sedating antihistamine (chlorphenamine).

4. If there is severe, extensive eczema, a short course of oral corticosteroids should be considered.

5. Commence antibiotics if secondary bacterial infection (eczema is weeping, crusted, or there are pustules, with fever or malaise)
   treat with flucloxacillin (active against Staphylococcus aureus and streptococcus) 

6. Immediate hospital admission if eczema herpeticum (rapidly worsening, painful eczema; clustered blisters; and punched out erosions)
   treat with combination of aciclovir and broad-spectrum antibiotics.

Referral to a dermatologist

Eczema is not controlled with current treatment
There is recurrent secondary infection.
Treatment advice is needed (such as bandaging techniques).

Dermatologists may initiate treatment with calcineurin inhibitors such as tacrolimus for eczema refractory to topical corticosteroids.

Referral to an immunologist

if a food allergy trigger

Referral to a clinical psychologist

if concern over psychological well-being