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EczemaThe basics

Objectives

At the end of this lecture you should Be more familiar with the presentation of eczema Have better understanding of the stages of eczema Be able to formulate a plan of care for a patient with

eczema Have some new strategies for helping your patients

manage their eczema.

Eczema

This is a skin barrier dysfunction

Can be aggravated by stress

Is worsened in very dry climates

Is generally a lifelong condition which means… We have to teach our patients how to best live with the skin

they are in. Proper care helps lessen the need for prescription

medications: Topical calcineurin inhibitors, steroids, antihistamines

Eczema

Typical locations, typical appearanceAffects young to oldCan be infected or not (these are not)Images – typical atopic eczema, eczema craquele, ichthyosis, Infant eczema

lichenification

Stages of severity

http://www.coolhealthtips.com/category/diseases-and-conditions/skin-diseases/page/2

Superinfection

http://derm-imaging.org/wp-content/uploads/DSCN9420-e1297246010546.jpg

Eczema – preventing rash

Cleansers not soaps – soaps have detergents You scrub a greasy skillet with detergent, eczema patients

need to conserve their body oils !

Warm, not hot, showers or baths

PAT dry with a wadded up towel, don’t rub !

Apply emollient while still slightly damp

Cotton is your friend – towels, clothing, bed-sheets, etc. Is least irritating to the skin

Topicals

Humectants hold water on the skin

Emollients fill the crevices between the corneocytes and help restore barrier function

Occlusives applied correctly are a great way to lock in moisture. They’re especially helpful because they don’t contain preservatives which some patients are sensitive to.

Humectants

Ammonium Lactate

Butylene glycol

Gylcerin

Propylene glycol

Urea

Others

These products should be applied immediately after a bath or shower while the skin is still damp.

Occlusives

Petrolatum

Lanolin

Beeswax

Paraffin

Mineral oil

These tend to be hot and sticky but when applied correctly are and are very helpful in keeping the skin healthier

Ok, so when is a prescription necessary ?

When the non-medicated topical treatments fail

When the patient cannot be consistent in the application of the OTC products

When a flare of eczema breaks thru despite good skin care

When eczema has become inflamed and weepy

When eczema has become infected

Topical non-steroidals

Elidel cream(pimecrolimus)

Protopic ointment ( tacrolimus )

Expensive but effective

Low side effect profile (*Black box warning in the US)

Variable dosing depending on whether using for a flare or for long term suppression / maintenance

Cannot use in patients less than 2 years old

Topical steroids

Generally class II, III, IV for the body (never, ever, ever for face, intertriginous areas, or for genitals)

If eyelids are involved – may use OTC hydrocortisone cream twice a day for THREE DAYS ONLY ! (most eyelid dermatitis is irritation from or allergy to nail polish, hair spray, or eye make-up)

Used correctly they are very safe, the problem is convincing the patient to use them correctly. THAT is why there are so many sizes to choose from when dispensing.

Topical antibiotics

Polysporin (otc)

Triple antibiotic (otc)

Altabax (retapamulin)

Bactroban (mupirocin)

DO NOT recommend Neosporin as topical neomycin is a well known sensitizer.

Systemic Antibiotics

Amoxicillin

Cephalexin

Others as necessitated due to individual patient (allergies, chronic medications, etc)

A 7 – 10 day course is usually prescribed when extensive areas of skin are involved

The bleach bath

¼ cup (250ml) bleach in a bathtub of water. Bathe in this twice a week for two weeks after skin is mostly healed.

Eczema infection is usually caused by the patients own skin flora.

Dilute bleach helps to eradicate skin flora and reduce incidence of infection.

Rinse under the shower after bathing, pat dry, apply topical medications.

The bleach bath

Cautions Bleach etches fiberglass tubs. Ask what they have. If your patient has a fiberglass bathtub, have them

mix 1 tsp (5ml) bleach in a litre of water. Use a spray bottle or a washcloth to apply to the skin. Wait a few minutes and then bathe as normal.

Caution patients to NOT overdo on this therapy. It CAN cause harm but not if directions are followed.

Tricks of the trade

When applying an ointment - wet hands, place small amount of ointment in palm and scrub hands together. Place hands on area to be treated and apply the thin film of ointment. This application method helps with compliance.

For the itch, especially with children, lightly patting or pinching the itchy area can override the itch sensation and bring relief without the scratching that can tear skin

Trim fingernails short

EDUCATE that this is likely a lifelong process but that you will help the patient learn to live with the skin they’re in.

Review

It is my hope that you all now Are more familiar with the presentation of eczema Have better understanding of the stages of eczema Feel more confident in formulating a plan of care for a

patient with eczema Have some new strategies for helping your patients

manage their eczema.

References

Most photographs are on the Dermnetnz.org site. Those that are not, are credited with the website from which they were taken.

Dermetnz.org also has an excellent tutorial on the dermatoses: http://dermnetnz.org/doctors/dermatitis/