1. Atopic Eczema

2. Clinical Features and DiagnosisWilliams HC. N Engl J Med 2005;352:2314-24Clinical Knowledge Summary (PRODIGY) 2004NICE. Clinical Guideline 57, Dec 2007 • Reduced skin lipid layer increases transdermal water loss and lowers resistance to irritant substances. • Associated with other atopic disease. • asthma in 30% & allergic rhinitis in 35% of children with eczema. • Prevalence 15-20% children and 2-10% adults. • Approx 80% start before age of 5 years; 75% get it by age 6 months. • Present in 80% of children where both parents affected and 60% where only one parent affected. • Typically episodic – relapse & remission. • Often has genetic component. • Does occur in de novo in later life – 10% of eczema seen in hospital settings. • Clears in 60% of children by their early adolescence, although relapses may occur in later life.

3. 1. Overview of management in primary careClinical Knowledge Summary (PRODIGY) 2004 General • Management in primary care is based upon: • Identifying and avoiding the provoking factors. • Using emollients regularly. • Using topical corticosteroids and oral antibiotics intermittently for flare-ups. • Referring selected people to a specialist. • Information about the condition, the factors that may provoke it, the role of different treatments, and their effective and safe use, is required to manage eczema effectively. • Treatment should be planned to balance the individual's goals of disease control against the safety and acceptability of treatment. Without this approach, compliance is likely to be poor and management less than optimal. • It is important to demonstrate how to use topical treatments, particularly topical corticosteroids, and to emphasise the correct quantities to use.

4. Overview of management inchildren ≤12 yearsNICE. Clinical Guideline 57, Dec 2007 • Seek to identify potential trigger factors. • Stepped approach to management – tailored to severity. Step up or down. • Emollients should always be used, even if eczema clear. • Potency of corticosteroids should be tailored to severity, which may vary according to body site. • Topical tacrolimus and pimecrolimus not recommended for treatment of mild eczema or as first-line treatments for eczema of any severity. • Offer information on how to recognise staphylococcal and/or streptococcal infection and eczema herpeticum. • Advise what to do if infection possible or if eczema worsens rapidly or doesn’t respond to treatment. • Healthcare professionals should spend time educating children and their parents or carers about atopic eczema and treatment. • Referral recommendations – see guidance. Eczema herpeticum– image reproduced with permission from Danderm www.danderm-pdv.is.kkh.dk/atlas/index.htm

5. 2: Managing dry skinClinical Knowledge Summary (PRODIGY) 2004 • The aim of management of eczema between flare-ups is to control skin dryness and itching and reduce the frequency of flare-ups. • Establish a daily skin-care regime with emollients. The type of emollient, its frequency, and the quantity to apply should be tailored to the individual's skin requirements and lifestyle. • Avoid irritation to the skin by prescribing an emollient soap substitute, and advising the person to: • Use gloves when unable to avoid handling irritants such as detergents. • Avoid extremes of temperature and humidity. • Use non-abrasive clothing fabrics, such as cotton. • Reapply emollients after wetting the skin.

6. 3: Managing flare-upsClinical Knowledge Summary (PRODIGY) 2004NICE Clinical Guideline 57, Dec 2007 • Offer information on how to recognise flares. • Give instructions on how to manage flares according to the stepped-care plan (see earlier). • Settle inflammation with topical corticosteroids. • Treat clinically apparent bacterial infection with oral antibiotics. • Treatment for flares should be started as soon as signs and symptoms appear. Continue for approximately 48 hours after symptoms subside. • Urgently refer or admit someone with severe unresponsive disease, and admit someone if you suspect eczema herpeticum.

7. 4: Managing frequent flare-ups  1Clinical Knowledge Summary (PRODIGY) 2004 • Settle acute flare-up as before. • Review and emphasise the use of emollients to improve the skin's barrier function. Increase the intensity of emollient treatment, if acceptable to the individual, by all or any of the following: • Change the emollient to one with a higher lipid content. • Advise the person to apply the emollient more often. • Recommend applying more emollient each time. • Review the factors that might be provoking flare-ups: • Are there environmental irritants or stresses that can be avoided? • Allergen avoidance is burdensome, but may be considered when other measures fail.

8. 4: Managing frequent flare-ups  2Clinical Knowledge Summary (PRODIGY) 2004NICE Clinical Guideline 57, Dec 2007 • Refer to a specialist if there is a risk of either systemic adverse effects or localised adverse effects due to topical corticosteroid use. • Refer to a dietitian when you are considering dietary intervention. • In children with 2 or 3 flares/month consider topical corticosteroid for 2 consecutive days/week once the eczema has been controlled. • Review within 3 to 6 months to assess effectiveness.

9. 5: Management in adultsClinical Knowledge Summary (PRODIGY) 2004 • Settle chronic lesions with a potent corticosteroid. • Review and consider: • The use of emollients. • The avoidance of environmental irritants and stress. • Antigen avoidance, if appropriate. • Settle further flare-ups with intermittent use of a topical corticosteroid of an appropriate potency and duration of use. • Refer to a specialist if there is a risk of either systemic adverse effects or localised adverse effects due to topical corticosteroid use.

10. 6: Managing severe widespread eczemaClinical Knowledge Summary (PRODIGY) 2004 • Seek specialist help if a flare-up is widespread, severe, and distressing to the individual. • Consider oral prednisolone and antibiotics if there is a delay before specialist review. • There is a risk of rebound flare-up when oral corticosteroids are stopped. The individual should stay on the oral corticosteroid until other measures are instituted. It is, therefore, important that the specialist sees the individual within 7 days, in order to avoid prolonged oral corticosteroid use.

11. Summary • Eczema is common. • Assessment should be based on both severity and quality of life. • The mainstay of management is emollients, even when the eczema is clear. • A stepwise approach, tailored to severity is recommended. • Topical steroids should be used as short-term treatment of flares. • Treat widespread infectious exacerbations with oral therapy rather than topical antibiotics. Tell patients how to recognise infection. • Refer patients with severe and/or unresponsive disease, and urgently refer or admit someone if you suspect eczema herpeticum. • Education is an important part of treatment.