Download Notes

Management of Eczema
Practical approach
Heulwen Wyatt R.G.N. R.S.C.N.
Dip. Prof. Prac. (Derm) MSc
Clinical Nurse Specialist in Paediatric Dermatology
Atopic Eczema
• Increasing incidence
• Affects approximately
1:5 children
• Familial tendency
• Associated with
asthma and hayfever
• Most outgrow by the
age of 7yrs
Normal Barrier Function
Increased trans-epithelial water
loss
Role of steroids
Role of Emollients
Moisturisers
• Emollients tend to increase the
efficiency of the epidermis
• Barrier function
Enhance the effects of
emollients with occlusion
- bandages, wet wraps
Bath Oils or Soap Substitutes
• Bath additives – use
daily
• Oily preparations
• Float on water or
emulsion
• Increasingly soap
substitutes preferred
Steroids
•
•
•
•
•
Available in 4 strengths
mild - e.g. hydrocortisone
moderate - e.g. eumovate
potent - e.g. cutivate, betnovate
very potent - e.g. dermovate
• 9 month baby
• Seen 2 months ago
and given 500g
Aqueous cream, 60g
Hydrocortisone 1%
cream.
• Never clear, awake
every night.
• What would you
prescribe?
Treatment
• Swabs, Flucloxacillin
• Eumovate ointment
200g for 4 week
peroid
• 1kg emollient
• Soap substitute or bath
oil
• TIP - split base of
earlobe first sign
eczema in many
babies - avoid soaps
Aqueous Cream
• Not suitable as a moisturiser
• Only prescribe as a soap substitute
Facial Eczema in Children
• Calm down skin with
steroids
• Immunomodulators
• Reduce stinging by using
both steroids and
immunomodulators for
five days
• Remember – Tomato
sauces and baby wipes!!
How would you approach
management?
• 2 year old with
extensive low grade
eczema
• Skin very dry
• Mum states he’s
allergic to all
moisturisers as skin
goes red and he
screams
• Refuses to go in bath
Top Tips
• Explain that very dry
skin takes pale scaly
apearance
• Any water based
emollients may sting
dry skin
• Ointment soap
substitute before bath
Don’t
• Don’t alter diet
• Don’t use soaps
• Don’t bother with
housedust mite
measures
• Don’t advise
allergy tests
Olive Oil
• Contraindicated on
the skin
• Damages the
barrier function of
stratum corneum
• Use mineral oil or
sunflower oil
• 7yr old with eczema
since aged 1
• Used Eumovate
ointment daily for 2
weeks
• Scratching at night
• Has ointment
emollient but won’t
use it as makes skin
feel sticky.
Treatment
•
•
•
•
Viscopaste bandages
Coban or actifast
Offer variety of emollients - cream form
Antibiotics?
Occlusive bandages
• Hands before
treatment and one
week after treatment
with occlusive
bandages, eumovate
and flucloxacillin
Hands
• Viscopaste to
individual fingers or
wet mitts over
emollients
Generalised severe eczema
• If good compliance and appropriate
treatment, consider wet wraps
• TIP - check for scabies!
Wet Wraps
• Steroids and emollients under
damp bandages
• Ready made garments
Prognosis
• Poor:
• Severe disease in
childhood, family
history, asthma,
rhinitis, late onset
(after 2 yrs),
atypical pattern,
hand involvement,
xerosis
STEROIDS - cream or ointment?
• Ointment (oil based) - steroid
of choice. Less additives.
Helps re-hydrate the skin.
• Cream (water
based) - use
on weeping
eczema or
when cosmetic
acceptability is
an issue.
Steroid Quantities
• 1 finger tip unit (f.t.u.)
= 1/2g = 2 adult
hand’s worth of
eczema
Steroid quantities
•
•
•
•
Twice daily application of steroid all over
6 month old = 9.5g daily = 66.5g weekly
4 year old = 19.25g daily = 134.75g weekly
7 year old = 24.5g daily = 171.5g weekly
Typical Daily Routine
•
•
•
•
•
•
•
•
07.20 Wash (soap substitute)
07.30 Steroid to all patches
08.00 Moisturiser all over
12.00 Moisturiser all over
15.30 Moisturiser all over
18.30 Bath with oil / soap substitute
18.45 Steroid to all patches
19.15 Moisturiser all over
Typical Month’s Prescription
• Example •
•
•
•
•
extensive flare of moderate
eczema in a 3 year old
Moisturiser - 1.5kg
Soap substitute - 500g
Bath oil - 500mls
Steroid - 300g
+/- antibiotics, bandages etc
What would you do?
• Known eczema patient.
• Flare last three days.
Treated with cutivate.
Generally unwell.
Eczema Herpeticum
•
•
•
•
•
Dermatology emergency
Stop steroids
Acyclovir - oral or iv
Opthalmic opinion
Admit if unwell
Happy customers