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  1. 1. Eczema: what is it? Inflammation of the epidermis <ul><li>Epidermal disease </li></ul><ul><ul><li>Hence scaly </li></ul></ul><ul><li>Inflammation </li></ul><ul><ul><li>Hence redness </li></ul></ul><ul><li>Profoundly itchy </li></ul>
  2. 2. What does it look like? <ul><li>Red </li></ul><ul><li>Scaly </li></ul><ul><li>Weepy if its infected </li></ul><ul><li>Cracked if it is quite dry </li></ul>
  3. 3. Secondary changes: infection <ul><li>Weepy </li></ul><ul><li>Crusted </li></ul><ul><li>Yellow </li></ul>
  4. 4. Other secondary changes <ul><li>Scratch marks </li></ul>
  5. 5. Lichenification <ul><li>Thickening of the skin due to chronic scratching </li></ul>
  6. 6. Atopic Eczema: what is actually going on? <ul><li>Immunological abnormalities “atopy” </li></ul><ul><ul><li>THi2 dominant </li></ul></ul><ul><ul><li>Uncontrolled humoral immunity: IgE production </li></ul></ul><ul><li>Dry skin </li></ul>
  7. 7. Dryness indicates loss of the normal waterproofing of the skin
  8. 8. Eczema: loss of waterproofing of the skin
  9. 9. Atopic Eczema <ul><li>Most obvious early sign is dryness which is also the key abnormality to correct during treatment </li></ul><ul><li>Redness/inflammation, which usually follows on from the dryness but can seemingly come and go at will </li></ul>
  10. 10. Atopic Eczema <ul><li>Common </li></ul><ul><li>Miserable </li></ul><ul><li>Incredibly itchy </li></ul><ul><li>Life disrupting for children and families </li></ul><ul><li>Embarrassing </li></ul><ul><li>Destroyer of self confidence </li></ul>
  11. 11. The treatment of eczema <ul><li>Complicated therefore needs much patient education </li></ul><ul><li>Multi-faceted </li></ul><ul><ul><li>Child </li></ul></ul><ul><ul><li>Family </li></ul></ul><ul><ul><li>School </li></ul></ul><ul><li>Skin/allergies/ environment </li></ul>
  12. 12. Treatment of atopic eczema in childhood <ul><li>treatment of the dry skin with emollients </li></ul><ul><li>topical steroids </li></ul><ul><li>removal of “flare factors” eg infection </li></ul><ul><li>Antihistamines (only occasionally) </li></ul><ul><li>now tacrolimus and pimecrolimus </li></ul>
  13. 13. Dry skin in eczema <ul><li>Actually mild eczema </li></ul><ul><li>Implies loss of barrier function </li></ul><ul><li>Escalation of fluid loss </li></ul><ul><li>Increased risk of infection </li></ul><ul><li>Hence emollients are the key to treatment </li></ul>
  14. 14. Keypoint 1 <ul><li>Emollients are the cornerstone of management, and should be used liberally to all areas on a daily basis, even (perhaps especially) if the eczema is quiescent. </li></ul><ul><li>Most patients use far too little. </li></ul>
  15. 15. Emollients <ul><li>If used correctly will control most children’s eczema most of the time, because it addresses the fundamental problem of dry skin and its resulting poor barrier function. </li></ul><ul><li>Emollients are under-used. </li></ul><ul><li>Many patients are prescribed topical steroids inappropriately before being offered emollients </li></ul><ul><li>The greasier the better: some sting </li></ul>
  16. 16. Emollients <ul><li>Replace detergents and soaps with emollient soap substitutes </li></ul><ul><li>Ointments are better because they are more hydrating and often less irritant, but consider patient preference to improve compliance. </li></ul><ul><li>Continue emollients even when eczema settles to prevent or reduce severity of relapse. </li></ul>
  17. 17. Emollients <ul><li>Use large amounts of ointments/creams, and encourage liberal application several times a day, to moist skin (after bath) where possible. </li></ul><ul><li>Prescribe in large quantities to aid compliance and be more cost effective. </li></ul><ul><li>Pump dispensers may be helpful to reduce infection risks. </li></ul><ul><li>Typical doses: 250g/week for child, 500g/week for adult. </li></ul><ul><li>These may be better tolerated if warmed. </li></ul>
  18. 18. Wet wraps/ Comfifast Suits <ul><li>Efficient means of delivering emollients </li></ul><ul><li>Occludes and therefore protects the skin </li></ul><ul><li>Maintains a constant temperature and therefore reduces the tendency to scratch </li></ul><ul><li>Don’t suit every child </li></ul><ul><li>Avoid till infection is controlled </li></ul>
  19. 19. Topical steroids <ul><li>Use the least potent steroid which is effective, intermittently, to avoid systemic side effects (growth suppression) and local side effects (skin thinning and contact dermatitis) </li></ul><ul><li>Ensure all steroids are used in correct amounts </li></ul>
  20. 20. Topical steroids <ul><li>Avoid potent steroids around the eye (risk of cataracts) and on the face (risk of atrophy/telangectasia) </li></ul><ul><li>A short course of potent steroids may abort a severe episode </li></ul><ul><li>Potent and very potent steroids must be used intermittently, eg for a few days to each body site, every few weeks. </li></ul>
  21. 21. Topical steroids <ul><li>Modern steroids (eg Fluticasone propionate, Mometosone furoate) are potent but less likely to be associated with side effects </li></ul><ul><li>Ointments (oil-based) are more effective than creams, although creams and lotions (water-based) are useful when the skin is inflamed </li></ul><ul><li>Educate parents/patients that side effects are related to the potency of the steroid, the amount used and site of application </li></ul>
  22. 22. Advise the steroid ladder <ul><li>4 rungs </li></ul><ul><ul><li>Dermovate </li></ul></ul><ul><ul><li>Betnovate Cutivate/Elocon </li></ul></ul><ul><ul><li>Eumovate/ Haelen </li></ul></ul><ul><ul><li>Hydrocortisone </li></ul></ul>
  23. 23. Amount of steroid to apply (in Finger Tip Units) by body site and age 5 3.5 4.5 2.5 2 6 to 10 y 3.5 3 3 2 1.5 3 to 5 y 3 2 2 1.5 1.5 1 to 2 y 1.5 1 1.5 1 1 3 to 6 m Post trunk Ant trunk Leg and foot Arm and hand Face and neck Age
  24. 24. Amount of steroid to prescribe per week (grams) by skin involved and age 60 90 170 Adult 55 85 135 16 y 45 65 120 12 y 35 50 90 8 y 20 35 60 4 y 15 20 45 1 y 15 20 35 6/12 Trunk Arms and legs Whole body Age
  25. 25. Infection <ul><li>Common </li></ul><ul><li>S Aureus </li></ul><ul><li>Occasionally also Strep </li></ul><ul><li>Caused by reduced waterproofing of the skin </li></ul><ul><li>Is it herpes? </li></ul>
  26. 26. When the infection has been treated <ul><li>Having discarded old creams </li></ul><ul><li>Emollients, emollients, emollients </li></ul><ul><li>Advice about what to look for which may indicate returning infection </li></ul><ul><li>And what to do </li></ul><ul><ul><li>Potassium permanganate </li></ul></ul><ul><ul><li>Fucidin </li></ul></ul>
  27. 27. Infected eczema <ul><li>If there is early relapse after use of antibiotics, or recurrence of infection, perform skin and nasal swabs in child and family to check for S.Aureus carriage. Consider treatment with topical antibiotic cream. </li></ul><ul><li>Topical antibacterial/steroid mixes may be useful for the flexures and in the presence of recurrent infection, but should not be used other than for short periods. </li></ul>
  28. 28. Eczema Herpeticum <ul><li>Grouped vesicles </li></ul><ul><li>Later umbilicated lesions </li></ul><ul><li>Often secondary impetigo </li></ul>
  29. 29. Referral <ul><li>Refer all children with severe or refractory eczema, or those requiring frequent courses of potent steroids or antibiotics, to dermatology. </li></ul><ul><li>Children with eczema in an unusual distribution should also be referred, as they may need patch testing to exclude a contact eczema. </li></ul><ul><li>The following require same-day referral to dermatology: cases of eczema herpeticum; erythroderma; systemic upset secondary to severe eczema. </li></ul>
  30. 30. Referral <ul><li>Where there are co-existing medical problems, such as failure to thrive or worrying reactions to food, referral decisions will depend on the relative severity of each problem </li></ul><ul><li>In most cases, particularly in young children, the child should be referred to a general or specialist paediatrician, who can co-ordinate involvement of other services, including paediatric dietetics, as appropriate. </li></ul>
  31. 31. Other interventions <ul><li>Sedative oral antihistamines – given for short periods at night only may help to interrupt the scratch-itch cycle. Avoid in children under 3 months. Note the potential detrimental impact on school performance. </li></ul><ul><li>Measures to prevent bacterial infection – daily baths; avoid sharing of flannels, towels; wash such items on hot wash cycle of washing machine; don’t leave tubs of ointments open. </li></ul><ul><li>Avoid mammalian pets. </li></ul>
  32. 32. Atopic eczema in childhood: occupational advice <ul><li>avoidance of jobs involving wet hands eg hairdressing </li></ul><ul><li>avoidance jobs involving hand contact with oils eg engineering </li></ul><ul><li>avoidance contact with animals </li></ul>
  33. 33. Particular problems in general practice
  34. 34. Less than ideal prescribing of emollients: quantity <ul><li>Emollients are the mainstay of treatment for eczema </li></ul><ul><li>Long term as it is a preventative treatment </li></ul><ul><li>Emollients </li></ul><ul><ul><li>250g per week for a baby, 500g for a big teenager MINIMUM </li></ul></ul>
  35. 35. The prescription of aqueous cream for mod to severe eczema <ul><li>Ok for washing </li></ul><ul><li>Not greasy enough for much else </li></ul>
  36. 36. Type of emollient is important <ul><li>Does it sting? </li></ul><ul><ul><li>Preservatives sting so ointments are best </li></ul></ul><ul><ul><li>Some brands sting often </li></ul></ul><ul><ul><li>Patient choice in the end </li></ul></ul><ul><ul><li>When skin is really dry everything stings at first </li></ul></ul>
  37. 37. Choice of emollient <ul><li>Start with something simple and cheap </li></ul><ul><ul><li>Creamy paraffin </li></ul></ul><ul><ul><li>Oily cream BP £2.20p/500g </li></ul></ul><ul><ul><li>50/50 WSP/Ung Emuls £1.50p/500g </li></ul></ul><ul><ul><li>Diprobase £6.92p/500g </li></ul></ul><ul><li>Modulate if not tolerated in one way or another </li></ul>
  38. 38. Alternative emollients <ul><li>Aveeno £18.00 </li></ul><ul><li>Double Base </li></ul><ul><li>Epaderm £6.50 </li></ul><ul><li>Unquentum M £9.55 </li></ul><ul><li>Eucerin £35.20 </li></ul>
  39. 39. Not enough Tubifast prescribed <ul><li>3m lengths </li></ul><ul><li>Baby </li></ul><ul><ul><li>Green line 12m/week </li></ul></ul><ul><ul><li>Yellow line 3m/week </li></ul></ul><ul><li>Older child </li></ul><ul><ul><li>Blue line 12m/week </li></ul></ul><ul><ul><li>Yellow/beige 6m/week </li></ul></ul><ul><li>Actifast cheaper </li></ul>
  40. 40. Inappropriate prescription of topical steroids <ul><li>Use of Betnovate rather than the newer steroids such as Elocon </li></ul><ul><li>Use of too potent steroids in the long term </li></ul><ul><li>Over use of Fucibet </li></ul><ul><li>Use of potent steroids on the face </li></ul><ul><li>Use of too weak steroids </li></ul>
  41. 41. Mild steroid induced “perioral dermatitis” <ul><li>Common especially in health care workers </li></ul><ul><li>Stop all steroids </li></ul><ul><li>Treat as acne rosacea in the interim </li></ul>