Download The Management of Eczema

The Treatment And
Management of Eczema
Sharon Hulley
Clinical Nurse Specialist in Dermatology
University Hospital Of Wales, Cardiff
What Is Eczema ?
“Eczema is derived from the Greek
‘ekzein’ meaning ‘to boil over’ and is
characterised by dry, itching and
inflamed skin”
(The Skin Care Campaign 1999)
Types Of Eczema
Atopic Eczema
Atopic Eczema

Increasing incidence

Affects
approximately 1:10
children

Familial tendency

Associated with
asthma and hay
fever
Diagnostic Criteria For
Atopic Eczema

Inflammatory condition of the superficial skin,
characterised by 3 or more basic features:
–
–
–
–

pruritus
lichenification
chronic relapsing course
Personal or family history of atopy (asthma, allergic
rhinitis, atopic eczema
Plus 3 or more minor features:
– e.g. xerosis, elevated serum IgE, early age of onset,
itch when sweating
Hanifin & Rajka (1980)
UK Working Party’s
Diagnostic Criteria

Presence of itchy skin condition, plus 3 or
more of the following:
– history of flexural dermatitis
– onset <2 years (if child is >4 years)
– personal or family history of asthma or
hayfever
– visible flexural dermatitis
Williams HC et al (1994)
Diagnostic Criteria for atopic eczema (3)

Must have an itchy skin condition (or reported
scratching or rubbing in a child) plus 3 or more
of the following :
– History of itchiness in skin creases such as folds of the
elbows, behind knees, fronts of ankles or around the neck
(or cheeks in children under 4 years)
– History of asthma or hay fever (or a history of atopic
disease in a first degree relative in children under 4 years)
– General dry skin in the past year
– Visible flexural eczema (or eczema affecting the cheeks or
forehead and outer limbs in children under 4 years)
– Onset in the first 2 years of life (not always diagnostic in
children under 4 years)
(McHenry et al 1995)
Discoid
Discoid Eczema

Presents as well demarcated round oval or
annular red scaly plaques.

Can be vesicular and crusty or dry and
scaly.

Usually affects older people. Patients may
also have a background of atopic eczema.
Pompholyx (palmar/plantar)
Irritant Contact
Allergic Contact
Erythrodermic
Varicose / Venous
Craquele / Craquelatum
Aim Of Eczema Treatment

To treat and control the symptoms of itching,
pain and discomfort

Reduce inflammation

Replace lost moisture

Inhibit scratching and thus infection

Improve the quality of life for the patient and
their family
How Do We Treat Eczema?

Moisturisers / Emollients (soap
substitute, bath oil, topical)

Ointment - dry skin

Cream or lotion - wet skin

Appropriate quantities
Effects of an emollient
Prior to emollient application
20 minutes after an emollient application
How Do We Treat Eczema?

Appropriate strengths of steroid
Which Strength Of Topical Steroid ?

Mild Eczema

1% Hydrocortisone

Mild - Moderate

Clobetasone butyrate

Moderate

Betamethasone 0.025%

Moderate - Severe

Betamethasone /

Severe

Mometasone Furoate 0.1%
Clobetasol Proprionate
How Do We Treat The
Condition?

Appropriate quantities of steroid
The Finger Tip Unit

1 finger tip unit (ftu) = 0.5g
Topical Steroid Quantities
(child)

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
Topical Steroid Quantities
(adult)

Face & Neck 2 ftu = 1g

Back & Front 7 ftu = 3.5g

Arm 3 ftu x2 = 3g

Hand (both sides) 1 ftu x2 = 1g

Leg (not incl. foot) 6 ftu x2 = 6g

Foot 2 ftu x2 = 2g

total per once daily
application = 16.5g

Per week = 115.5g
How Do We Treat The
Condition? (cont’d)

Bandages

Antibiotics (topical / oral)

Treatment regime

Avoid provoking factors if possible
What If That Doesn’t Work?

Review treatment
– steroid not strong enough
– not enough emollient
– infection not addressed
– consider bandaging

Topical immunomodulators
NICE Recommendations For Use
Of Topical Immunomodulators

Treatment with both Protopic & Elidel
must be initiated by physicians (including
G.P’s) with a special interest and
experience in dermatology.

Prior to commencing - careful discussion
with patients and/or parents of potential
risks and benefits of all seconds-line
treatment options.
Mode Of Action

Calcineurin inhibitors.

Suppression of T-lymphocyte responses.
Availability Of Protopic & Elidel

Protopic (Tacrolimus) 0.03% & 0.1%
Ointment
– 30g (0.03% & 0.1%)
– 60g (0.03% & 0.1%)

Elidel (Pimecrolimus 1%) Cream
– 30g
– 60g
– 100g
Licensed Indications For Protopic
(Tacrolimus) 0.03% & 0.1%
Ointment
 Children
 Adults
2-16 years 0.03%
& adolescents over 16 years 0.1%.
 Treatment
of moderate to severe atopic
eczema unresponsive to conventional
therapy.
NICE Indications For Protopic
(Tacrolimus) 0.03% & 0.1% Ointment

Not recommended for the treatment of mild
atopic eczema or as a first-line treatment.

Treatment of moderate to severe atopic
eczema in adults & children over 2 years of
age.

Failed response to topical corticosteroids.

At risk of adverse effects from further use of
topical corticosteroids e.g. skin atrophy.
Application Of Protopic (Tacrolimus)
0.1% & 0.03% Ointment

Prior to use, clinical infections at treatment sites
should be cleared.

Emollients should not be applied to the same area
within 2 hours of applying tacrolimus.

Body, limbs, face, neck and flexures.

Twice daily for up to 3 weeks then reduce to once
daily until clear.

Restart as/when necessary.
Side Effects

More Common
– Burning or tingling sensation
– Pruritus
– Erythema

Less Common
–
–
–
–
–
–
Folliculitis
Herpes simplex infection
Acne
Increased sensitivity to hot and cold
Alcohol intolerance
Lymphadenopathy has also been reported
Licensed Indications For Elidel
(Pimecrolimus) Cream

Children over 2 years & adults.

Acute treatment of mild to moderate atopic eczema
(including flares).
NICE Indications For Elidel
(Pimecrolimus) Cream

Not recommended for the treatment of mild atopic
eczema or as a first-line treatment.

Treatment of moderate atopic eczema on face &
neck in children aged 2-16 years of age.

Failed to respond to topical corticosteroids.

At risk of adverse effects from further use of
topical corticosteroids e.g. skin atrophy.
Application Of Elidel
(Pimecrolimus 1%) Cream

Prior to use clinical infections at treatment sites
should be cleared.

Not to be applied to areas affected by acute
cutaneous viral infections.

Twice daily until symptoms resolve.

Re-start as/when necessary.
Side Effects

More Common
– Burning sensation
– Pruritus
– Erythema

Less Common
– Skin infections (including folliculitis and rarely impetigo,
herpes simplex and zoster and molluscum
contagiosum)
– Papilloma (rarely)
– Local reactions such as pain, paraesthesia, peeling,
dryness, oedema and worsening of eczema
Any questions?