Eczema

R Lakshman

Eczema

• Genetic defect in epidermal barrier leads to loss of water from skin

• Drying of skin – itching – scratching

• Scratching – local inflammation – worsened by infection, irritants, allergens

• Chronic inflammation – permanently damaged skin

Eczema

• Sleep

• Quality of Life – constant itching

• Bonding between parents and baby

• Personality changes

• Self Esteem issues

• Bullying

• Sensitization – 20% nut allergy, 30% egg allergy, 50% asthma and/or allergic rhinitis

Management of Eczema

• Treatment of flares – usually steroids – 7-14 days and then wean over a further 2 to 4 weeks

• Prevention of flares – – usually general measures – emollients – food exclusion ( CMP, soya, egg) – identification of other allergens (HDM, animal dander,

pollen) – some need once or twice weekly steroids long term

• Looking for associated conditions • Rarely – not simple eczema – immunodeficiency

Do : Assess Severity Skin – Scratching - Sleep

Do: Consider added infection

Vesicles – herpes infection – urgent referral

Crusting, weeping, pus, bright red Not responding to steroid treatment Bacterial infection

Topical Antibiotics (Fucidin resistance)

Oral Antibiotics (Coamoxiclav) x 7 days

IV aciclovir

IV antibiotics

Referral - Admission

Do : Pick the right strength steroid

• Severity of eczema

• Thickness of skin

• Current treatment

• Past treatment

• Always use ointment

HYDROCORTISONE – EUMOVATE- BETNOVATE - ELOCON

FUCIDIN H - FUCIBET – BETNOVATE C

Do – Advise the right amount

• One finger tip unit = 2 palm areas

• Rub in – skin shines

• One application – bedtime adequate

• No emollient before steroid application

• Use only on the eczematous area

Do prescribe the right amount

• One finger tip unit = 0.5 g = 2 palm areas

• Estimate total area of eczema = eg 8 palm areas

• Total requirement per day = 2 g

• Total duration of treatment = 2 weeks

• 14x 2= 28 g needed = 30 g

• Rule of the thumb – prescribe 100 g tubes

Do give a clear management plan

• Topical steroids daily (to eczema areas) only for 7- 14 days till skin clears completely

• Then alternate nights for the same period 7 -14 days

• Then two nights a week for a further 6 weeks or long term

• Short courses and abrupt stop will cause flares

Do Review if things are not getting better

• Eczema should start getting better on day 3-4 of application and be almost clear by day 14

• If eczema not getting better THINK

– ? Inadequate amount applied

– ? Inadequate strength

– ? Infection

– ? Triggers / Allergens

Do Reassure about steroids

• Thinning of the skin a significant problem on face and neck ( less of a problem elsewhere)

• Absorption of steroid only a significant problem if widespread eczema, strong steroids and daily treatment for more than 2 weeks, occlusive dressings

• Untreated eczema can cause permanently damaged skin

• Emollients cannot treat eczema flares

What is too much ? (rule of the thumb only – Teenagers/Adults)

• 500 g of hydrocortisone per week ( 5 x 100g tubes)

• 50 g of Betnovate or Elocon per week (100g tube lasting less than 2 weeks)

• 100g of Eumovate per week

• Doses around the above range long term – many weeks – may lead to adrenal suppression

• half the above doses may cause side effects in smaller children

How much steroid is absorbed ?

• Forearm absorbs 1%

• Armpit absorbs 4%

• Face absorbs 7%

• Eyelids and genitals absorb 30%

• Palm absorbs 0.1%

• Sole absorbs 0.05%

Steroids in eczema

• 1gm of hydrocortisone 1% = 10mg of hydrocortisone

• Absorption varies from 0.1 to 2% (below neck)

• 10mg = 1 mg absorbed

• 10 kg child – pharmacological treatment of inflammation – dose is 150 mg per day

Other steroids

• Eumovate – 20 x as potent as hydrocortisone

• Elocon, Betnovate – 100 x as potent as hydrocortisone

• Dermovate – 600 x as potent as hydrocortisone

Do remember steroid side effects

• Thinning of skin

• Striae

• Prominent dilated veins/ capillaries

• Temporary loss of pigmentation in dark skin

• Easy bruising

• Growth failure

• Adrenal suppression ( esp if other steroids eg for Asthma in addition to topical)

Do not

• Keep potent steroids on repeat prescription unless there are regular planned reviews in hospital or in primary care

Do

• Prescribe liberal amount of emollients

• Expect 500 g tub/pump to last 2 to 3 weeks depending on size of child

• Advice use two times a day and on all skin

• Explain that emollients can reduce flare ups but cannot treat flares ( itching, redness, thickening, crusting)

• Epaderm – Cetraban – Doublebase – Diprobase - Aveeno

Do not

• Apply emollients and topical steroids at the same time

Do consider Referral

• Significant eczema

• Patient/Parents not coping

Eczema Service

• Dr Gudi, Dr Ranasinghe, Dr Lakshman

• Eczema nurse specialist ()

• Education

• Education

• Education

• Allergy review, patch testing

• Support, point of access

Thank you

• Severity – skin, scratch, sleep

• Infection – viral, bacterial

• Treat flares – promptly and properly

• Avoid Flares – Emollient, More Emollient

• Remember Associations – Other allergies

Any Questions