Eczema, also known as atopic dermatitis, is a skin condition characterized by a defective skin barrier that causes dryness, cracks, and easy penetration of allergens. The stratum corneum lipid layer is defective, resulting in water loss from the skin and increased susceptibility to irritants. Topical corticosteroids are commonly used to treat flare ups, while emollients are the foundation for long term management by helping repair the skin barrier. Proper skin cleansing and moisturization are also important to prevent exacerbation of eczema symptoms.

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Moch Kurniawan
Defective skin barrier function
• Eczema is an inflammatory condition
of the skin
• In normal, healthy skin, the epidermis
acts as a protective barrier
• The stratum corneum consists of
dead skin cells held together by lipids
and proteins
• In eczema, the lipid layer is defective
causing:1
– Water loss
– Cracks in the outer layer of skin
(stratum corneum)
– Penetration of allergens and irritants
1. Cork MJ. (1997) The importance of skin barrier function. Journal of Dermatological Treatment (1997) 8, S7-13

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Allergy 2006: 61: 969–987

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www.eczemahelp.ca
*Robin Marks, Anne Plunkett, Kate Merlin, Nicole Jenner, Atlas of Common Skin Disease. Department of Dermatology, St Vincent’s
Hospital, Melbourne, Australia, 1999.
Prevalence of Atopic Dermatitis over all ages

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Color Textbook of Pediatric Dermatology, 4th Edition.
Infantile type Childhood type Adult type
Face, scalp, trunk,
extensor surfaces
of extremities
Flexural folds of ext
(antecubital, popliteal fossa)
neck, ankles
Upper arms, back,
wrists, hands,
fingers, feet, toes

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Atopic eczema
affects quality of life
Adapted from Jenner N et al. AustralasJ Dermatol 2004; 45(1): 16–22.
36
28
15
21
40
45
0 5 10 15 20 25 30 35 40 45 50
Spent >10 min/day applying treatments
Influenced the clothes they wore
Problems with treatment
Felt embarassed by their skin
Using 4 or more products
Itchy, sore, painful or stinging
Percentage of Patients (n = 85)
Therapeutic objectives for atopic
dermatitis
Reduce signs and
symptoms;
Prevent or
reduce
recurrences
Provide long-term
management by
preventing exacerbation;
Modify the
course of the
disease
Dr C. Ellis et al British Journal of Dermatology 2003; 148 (Suppl. 63): 3–10

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The Consensus Conference on
Pediatric Atopic Dermatitis
Role of Emollients
• Useful as first-line
agents
• Ointment preferred
over creams
• Frequent
application
recommended
because of their
short duration of
action (6 hours)
General Measures
• Avoidance of
irritating fabrics
such as wool or
synthetic in favor of
cotton clothing
Topical Steroids
• Once or twice daily
use of low- to
medium-potency
topical steroids as
first-line therapy for
disease
exacerbations
• Once controlled,
topical steroids
should be
withdrawn or
tapered to less
potent or less
frequent (twice
weekly) application
• Steroids can be used
safely if monitored
appropriately
Oral Steroids
• Avoid use of
systemic steroids
because of their
side effects
Topical non-steroidal
immunosuppressive
therapies (eg, tacrolimus
and pimecrolimus)
• Useful as
intermittent,
second-line therapy
for moderate to
severe AD
(tacrolimus) or mild
to moderate AD
(pimecrolimus)
• Not approved for
children less than 2
years of age
• Coordinated with
sun protection
because of concerns
Source: Eichenfield LF, HanifinJM, Luger TA, et al. Consensus Conferenceon PediatricAtopic Dermatitis. J Am Acad Dermatol. 2003;49:1088-1095.

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Cleansing
Moisturisation
Treatment

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Emollients
The most fundamental step in fighting
atopic eczema is re-hydration
The principle mode of action of emollients
is improving the depleted lipid barrier of
the skin thus reducing skin water loss
Reduce eczema flare ups and the need of
topical steroids
PrimaryCare DermatologySociety & British Association of Dermatologists. Guidelinesfor the management of atopic eczema. October 2009.
Cork MJ. (1997) The importance of skin barrier function. Journal of DermatologicalTreatment (1997) 8, S7-13
Prodigy – Quick Reference Guide. Emollients. [Online]. (URL www.prodigy.nhs.uk/Eczema-atopic). (Accessed 11 December 2006).
3 Stages of Emollient use in skin repair

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Emollients must be applied regularly
and frequently…
• Every day, even when the skin
looks clear
• In conjunction with other
treatments during flare-ups
• Every 3-4 hours
• Helping patients to build
emollient application into their
daily routine can make it easier
for them to adhere to
…and in the right quantities
• To get the most out of emollients,
patients need to know how much
they should use
• Illustrating how much emollient
your patients should apply can be
helpful
• Most pumps dispense
approximately 4g
Adapted from Dunning G. Nursing Times 2005; 101 (4): 55-56

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Complete emollient therapy
• Giving patients a combination of different
formulations and sizes can encourage them
to use them regularly, frequently and
in sufficient volume, for example:
– An ointment tub for use on severe areas
or at night
– A large cream pump dispenser for daily
moisturising and washing
– A smaller tube of cream or ointment for use
when out and about
– A bath substitute as an alternative to cosmetic
wash products
Prescribing emollients in sufficient
volume
• 250-500g per week for children3
– Between 2-4 500g pump dispensers per month
• 600g per week for adults1
– 4 x 500g pump dispensers per month
• Pump dispensers are a good way to help patients:
– Use the correct volumes
– Reduce cross contamination
1. Primary Care Dermatology Society & British Association of Dermatologists. Guidelines for the management of
atopic eczema. October 2009.
3. NICE (2007) Clinical Guideline 57, London, December 2007

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Cleansing
Skin cleansing
• Ordinary soap can dry the skin and worsen itching.
• Ordinary soap contains sodium lauryl sulphate (SLS)
which further aggravate and irritate skin.
• Ordinary soap can cause flare up and block the
effects of the treatment.
• The key to cleansing in children with atopic
dermatitis is to be gentle due to the damaged,
fragile stratum corneum.

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Skin cleansing
• Cleansing, with water, soap or a liquid cleanser, will
affect the moisture skin barrier
• Soap will bring about the greatest changes to the
barrier and increase skin pH
• Liquid facial cleansers are gentler, effecting less
disruption of the barrier, with minimal change to skin
pH, and can provide people with a cleanser that is a
combination of surfactant classes, moisturizers and
acidic pH in order to minimize disruption to the skin
barrier
Skin Therapy Letter • Editor: Dr. Stuart Maddin • Vol. 8 No. 3 • March 2003
Skin cleansing
• The dry skin of eczema is not caused by a lack
of oil in the skin, but because the skin barrier
is damaged, so that the skin cannot retain
water.
• This is why a skin regimen focused on bathing
and moisturizing is your first defence against
eczema flare-ups
www.eczemahelp.ca

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Skin cleansing
• Moisturising, mild pH-neutral or acidic cleansers
should be used
• The use of bath oils free of fragrances and
emulsifying agents is also recommended.
• Soaps and bubble baths should be avoided.
• Bathing time should not exceed 15 to 20 minutes
• Immediately after showering or bathing, a
moisturiser should be applied.
http://skincare.dermis.net/content/e04erkrankt/e617/e620/index_eng.html
IRRITANTS
Sodium Lauryl Sulfate (SLS)
&
Sodium Laureth Sulfate (SLES)

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The skin's natural moisturizing factors are
amino acids
The skin's natural moisturizing
factors are amino acids

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 Very mild and hypoallergenic.
 Weakly acidic, similar to the pH level of the
skin, leaving the skin without a taut feeling.
 Mild and gentle to the hair without leaving it
dry and coarse.
Amisoft is less irritant than SLS / SLES
0
1
2
3
0 1 2 3 4 5
Days
Reading
Sodium Lauryl
Sulfate
Amisoft
Water
A five day human patch test
N=72 (age : 19-72, 30 men & 42 women)
Score Symptoms
0 No reaction
0.5 Slight erythema
1.0 Clear erythema &
hardening
2.0 Erythema &
vesiculation or
dryness
AJINOMOTO Co., Inc. AminoScience Lab. 2003.09.16.

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Prevention
•help soften the skin and lock
in moisture
•should be applied after
bathing and frequently
throughout the day
Apply emollients
and moisturizers
•If the results of the patch
testing indicate an allergy,
the patient should avoid all
items that contain the
allergen (substance causing
the allergy)
Avoid allergens
•The dermatologist will talk
about options for avoiding
the substance(s) that is
irritating the skin.
Avoid irritants
•If the patient wears gloves at
work, it is important to
realize that substances on the
hands can get inside the
gloves and irritate the skin,
especially when more than
one substance gets inside the
gloves
Change work habits
Effective formulations for all types of skin

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www.eczemahelp.ca
The role of topical steroids
• Topical steroids are widely used to relieve
acute symptoms and clear flare-ups
• They come as creams and ointments, and in
a range of strengths
– So that patients can be given one that is ideal for
the severity and location of their eczema
• Topical steroids should be applied to inflamed
areas only and used twice a day at most
• They should be used sparingly and only
for as long as is necessary to clear up the flare
– Fingertip units can be a useful way for patients to measure
doses

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Prescribing topical steroids
• Topical steroids are usually prescribed using a step-wise
approach:3
– Starting with the correct potency based on the severity of eczema
– Stepping down as the severity decreases
– Or stepping up as required
• The face and neck should normally only be treated with mild
steroids – adverse effects are more likely in areas where the
skin is thinner
3. NICE (2007) Clinical Guideline 57, London, December 2007
Akdis et al. J ALLERGY CLIN IMMUNOL JULY 2006

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DERMATOLOGYNURSING/December2006/Vol. 18/No.6

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