pauline brown clinical nurse specialist eczema/allergies northland dhb child health centre debbie...
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Pauline BrownClinical Nurse Specialist Eczema/Allergies
Northland DHBChild Health Centre
Debbie RickardChild Health Nurse Practitioner Candidate
Capital coast DHB
This sessionWhat is eczema?Who it affects and prevalenceNon-allergic triggersEczema and Atopy (allergy)The skin barrierGene-environment interactionsReasons for treatmentsCosts and stresses on familiesPathophysiology of skin and eczemaComplications of eczema – bacteria, fungus, virusNurse led clinics DebbieBasic Skin treatments/management concepts DebbieManagement infant/pre-school PaulineManagement in the school age/adolescent/adult – Debbie
What is eczemaEczema is a chronic, inflammatory skin
condition that is characterised by DrynessDeep-seated itchRedness and inflammationSometimes areas can be weepy or oozing
IncidenceThe incidence of eczema has increased
steadily in westernised countries, over the past 40 years (Cork et al 2006, p3 ISAAC study, lancet, 2006)
It is believed that up to 1 in 4 children may be affected and there is no cure. (Gold & Kemp, 2005)
It affects around 30% of preschool-age children, 15% of school-age children and 9% of adolescents
60 % of the children will have onset before the age of 1 year (Krakowski, Pediatrics, 2008)
Historically it is poorly understood and frequently under treated.
Name Confusion?Eczema has been historically thought of as an
allergic disease hence the name Atopic Dermatitis (inflammation of the skin due to allergies) (Cork et al, Exchange, NES 2006)
However, more recently it has been suggested that we should be dividing the condition of ‘eczema’ into 2 terms
(Darsow etal European Task Force on Atopic Dermatitis, JEADV, 2010, Ricci etal, Am J Clin Derm, 2009, Cork et al, Exchange, NES 2006)
Atopic - having allergic tendencies (extrinsic)
Non atopic – not having allergic tendencies (intrinsic)
Eczema - AtopicAtopy, or the tendency to be sensitised or allergic
approximately 1/3rd of all individuals with eczema has either;
IgE (immediate hypersensitivity) (example hayfever, asthma, food allergies)
or Cell-mediated (delayed type hypersensitivity). (example
contact dermatitis to nickel, dyes etc.)
Cell mediated allergy does not show on skin prick testing or RAST
(Cork et al 2006)
Eczema – Non Atopic2/3rds have non allergic eczemaTrigger (things that irritate) factors include:
Soap based products, body wash chemicalsHeat, dry air or heatingStress and anxietyWoolly/rough clothes/fabricsCertain food chemicals or
colourings/preservatives (intolerances and not allergy)
Some infections/bacterial, viral, fungalteething
However................
Regardless of the classification, it is thought that the primary problem is the skin barrier
Functions of the skinSkin cells (keratinocytes) divide at the bottom of the epidermis to make a new supply of skin cells
The new cells mature as they move up through the skin
At the top of the skin, the skin barrier (stratum corneum) is formed
The barrier protects the body from the environment and prevents the penetration of irritants and allergens
The skin cells in the stratum corneum are locked together by structures call corneodesmosomes and the skin cells are surrounded by lipid bi-layers.(Cork et al, Exchange, NES 2006)
The skin barrier
The stratum corneum can be viewed as a brick wall
Comparing skin cells to the bricks and lipid lamellae to the cement
The wall is stabilised by passing iron rods though the bricks which are compared to the corneodesmosomes
The iron rods keeps the skin together
In order to maintain a constant thick barrier skin cells shed from the surface of the skin
Malfunctioning skin barrier
The skin cells in the stratum corneum are locked together by structures call corneodesmosomes and the skin cells are surrounded by lipid bi-layers.
?Faulty genes break down the skin barrier's binders or iron rods much faster than normal.
People with eczema have gaps in their lipids or mortar.
This results in cracks all the way through the skin barrier.
Irritants such as soap cause more break down and the "brick wall" starts to fall apart.A broken barrier lets allergens enter the skin easily.
Germs and more irritants then lead to an eczema flare
Why has the prevalence increased?The genes that predispose us to eczema has
not changed, but our environment has
One theory - we are exposing our skin to more soaps and surfactants such as bubble baths to wash babies
Soap and surfactants shown to decrease the stratum corneum by 40% (Cork et al Dermatol in Practice, 2002)
The rising prevalence of atopic eczema and environmental trauma to the skin.
Cork et al. Dermat Pract 2002, 10, 22.
UK data 1960 - 1981 1995 - 2001Personal use of soap -
detergent76 million £ 453 million £
Water for personal washing 11 L /day 51 L/day
Increased skin barrier dysfunctions
Genes associated with strength of skin barrier
Chemicals called proteases break down the corneodesmosomes (iron rods)
Normal skin has low levels of proteases so skin barrier is thick
Non-allergic eczema has a change in the gene which produces higher levels of protease
Leads to premature break down of the iron rods.
The lipid lamellae (cement) is also incomplete
Normal pH of the skin is 5.5Exposure to soap and surfactants ↑ 7.5 or
higherThe protease SCCE is pH sensitive50% increase in protease activityEquals greater breakdown of the skin
barrierIncrease penetration of irritants and
allergens.
Aqueous CreamContains surfactantsSurfactants break down the skin barrierAqueous cream was designed as a soap
substitute for eczemaWidely used as a ‘leave on’ moisturiserAudit of children attending dermatology
clinic showed aqueous cream caused irritant reactions in > 50%
(Cork et al, Pharmaceutical J, 2003)
Genetic link
If a child has one parent with atopic eczema – 20%
If both parents have (or had) atopic eczema – 50%
Which leads us to the treatments
Our increasing knowledge and understanding of how the skin barrier breaks down, reinforces
the importance of skin-barrier maintenance and repair
This is the first-line treatment →Complete emollient (moisturiser) regimes
2nd line of treatment
↓
Identification and avoidance of irritants and allergens
3rd line of treatment
↓Treatment of flares
The more attention paid to the first two steps, the less often flares will
occur
Loss of skinbarrier
Moisturise
Bathe
Cleanse
SteroidsAntibiotics
Primary/secondary infection occurs
Immune system responds toBacterial invasion
Desire to scratch
Excoriation occurs
Creates allergic response
Produces moreItch and inflammation
It is far more…… yet it is a disease that is often minimized by health professionals
Consider The Impact Of Eczema
Overall it is the commonest specific skin disorder encountered – yet very poorly managed
Second commonest skin disorder seen in dermatologist office – yet very poorly managed
Major issuesPhysical symptoms
Pruritus, skin discomfort, sleep disruptionEmotional problems
Stigma associated with the visibility of the disease
Social dysfunctionLoss of work, school, social activities
Financial Burden in AustraliaApprox. A$1142/year/per person for mild eczema
Approx. A$6099/yr/person for severe eczema
A$157Million/year per mild eczema population
A$316.7 Million/year per severe eczema population
These figures do not include national expenditure on subsidised medications
Annotation/Atopic eczema: Its social and financial costs; AS Kemp, Department of Immunology, Royal Children’s Hospital, Parkville, Victoria, Australia - 1998
Major negative impact on the quality of life (QoL)Since 1987 impact measured in a repeatable
standardised way;Dermatology Life Quality IndexChildren’s Dermatology Life Quality IndexSkinex
the impairment of the QoL and the psychological wellbeing has been well documented
Br J Dermatol 2006; 155: 145-151
Recent study on monitoring ‘course of life’ (CoL) impact on children with ADCoL refers to fulfilling age specific developmental
tasks and milestonesHampered CoL has been found in adults who
have had; Childhood cancerEnd-stage renal failureAnorectal malformationsHirschsprung diseaseEsophageal atresia...but this is 1st study on eczemaPaediatric Dermatology, Vol. 26 No. 1, 114-22, 2009
Study results117 patients, median age of 23.4 years 508 control patients, median age 24.2 years
Need for support was identified87% needed more information about treatment
regimes85% wanted improvement of personal guidance and
advice of the physician during their treatments52% desired contact with fellow-sufferers68% felt they needed psychological support
CoL ResultsCompared mod eczema to severe eczema
Less friends in primary and secondary school Spent less leisure time with friends Fewer belonged to a group of friends Less went to school dances
Comparing severe eczema with healthy peers Less were members of sports clubs during primary and
secondary years 70% felt shame around their peers 49% avoided intimacy 25% reason for missing school 24% did things on their own
Physical aspects90.7% experienced pain and itch69% sleeplessness60% fatique74% had increase in eczema when stressed
International Study Of Life with ATopic Eczema (ISOLATE)
Largest and most comprehensive study conducted into the impact of eczema on patients' lives and relationships
Revealed the extent of the emotional suffering caused by eczema. (2004)
Results55% either always or sometimes worried
about the next eczema flare51% always or sometimes unhappy/depressed86% avoid at least one type of everyday
activity during a flare-up43% fairly or very concerned about being seen
in public during a flare74% of patients and caregivers state that their
physicians have never discussed the emotional impact that eczema has had on their lives
Australian StudyIndicated that the family stress related to the care of a child with
moderate or severe atopic dermatitis is significantly greater than that of care of children with
insulin-dependent diabetes mellitus. (Kemp, 1999)
Never underestimate the emotional cost of eczema
Single young mother 1 year old Moderate – severe eczema and
receiving multiple and conflicting advice
Multiple food allergies – conflicting advice
Multiple environmental allergies
No family living in same town Mother studying Minimal income Sleepless nights Irritable child during day Difficult finding childcare due
to eczema