Childhood

ECZEMA
NICE
Guidelines 2007

Dr Ellie Day (ST5 Paediatrics)

July 16th 2010
Royal Surrey County Hospital
 Definition
• General term for skin inflammation
• Chronic inflammatory itchy skin condition characterised
by:
– pruritus
– dry, scaly skin
– erythema
– swelling, cracking, weeping, crusting
– lichenification
– superadded infections
•Relapsing & Remitting course
•Flare ups
 Pathophysiology
• Normal skin has a high water content and is flexible and
elastic
– epidermis provides barrier function
– stratum corneum contains layers of lipid
• In Eczema, skin barrier function is disturbed
– water is more readily able to evaporate
– stratum corneum cells dry out & shrink
– cracks appear and act as portal of entry
• Evidence suggests genetic component resulting in skin
barrier breakdown
– 8/10 children where both parents have eczema
• Pathophysiology still poorly understood
– likely multifactoral
 Statistics
• Usually occurs before the age of 5
– Adult onset possible but uncommon
• 1 in 6 UK school age children have eczema
– 2 out of 3 children will outgrow it by teenage years
– 1 in 20 adults have it
• Affects all races
• Ratio 1:1.4 (male to female)
• Has significant morbidity
• Incidence and prevalence on the rise
• climate change
• pollution
• allergies
• diet
 Atopic Eczema
• May occur with other atopic diseases;
 asthma
 allergic rhinitis
 acute allergic reactions to food
 urticaria
 Differential Diagnoses
• Seborrheic dermatitis / eczema
– yellow, oily, scaly patches
– Face, scalp, ears
– “cradle cap”, dandruff
• Contact dermatitis / eczema
– localised reaction (erythema, itching, burning)
– contact with irritant
• Allergic Contact dermatitis / eczema
– red, itchy, weepy
– contact with allergen
• Scabies
• Ringworm
• Psoriatic plaque
 Presentation
• Age & duration
influences
distribution and
appearance
• Infancy;
face,scalp,exten
sor
surfaces,nappy
area spared.
• Children;
longstanding
flare ups
localised to the
flexures
 Morbidity/Mortality
• Significant cause of morbidity
• Incessant itch and loss of work days in adults
• In children,enormous psychological burden to families
and loss of school days
• Mortality is extremely RARE !
 Diagnostic criteria
An itchy skin condition (or parental report of scratching) in
last 12 months plus any 3 of the following:

★ History of involvement of the skin creases

★ History of flexural dermatitis

(or dematitis of cheeks +/or extensor areas in child<18m)

★ History of asthma or hayfever

(or atopy in a 1st degree relative if <4yrs old)

★ History of dry skin

 Assessment
• Detailed history
– time of onset / pattern / severity
– response to past / current Rx
– possible triggers
– dietary history
– growth & development
– impact on child & family
– history of atopy (personal / family)
• Tools
– POEM / CDLQI / Visual analogue scales

1
0
 Management:
General Measures
1. Adopt an holistic approach
– severity
– quality of life
– impact on activities / sleep
2. Identify and manage trigger factors
– irritants
– skin infections
– food / inhalent allergens
3. General measures
– keep fingernails short
– Avoid perfumed / lathering products
– ? Role for antihistamines
 Management -
a stepped approach
1. EMOLLIENTS
• moisturising, washing, bathing
• combination of products or one for all
2.TOPICAL STEROIDS
• Tailor potency to severity & body site
• Short term use
3. INFECTIVE EXACERBATIONS
• Recognition
1. How to access appropriate treatment
• Special reference to recognition of eczema herpeticum
•EDUCATION
1. Patient & Parents
• Verbal & Written
• Practical demonstrations
 Other Forms of Rx
• Antihistamines
– Not for routine use
– trial of non sedating if severe itching
– consider 1-2 week trial of sedating if significant sleep
disturbance
• Bandages & Dressing
– localised medicated or dry dressings
– NOT for infected areas
• Topical calcineurin inhibitors
– tacrolimus and pimecrolimus
– NOT for mild eczema or as 1st line
– Children aged >2 yrs
• Phototherapy & Systemic treatments
 Management -
Dermatological Referral

• Diagnosis is / has become uncertain

• Failure to control
– No of flare ups despite treatment
– adverse reaction to treatment
• Contact allergic dermatitis is suspected
– persistent atopic eczema
– facial, eyelid, hand eczema
• Significant social / psychological problems
• Severe and recurrent infections
• Perceived benefit from specialist advice
 Emollients 1
• In eczema, normal skin barrier function is disturbed
• Use of regular moisturisers will help to rehydrate &
restore barrier
– reduce itching & scratching
– prevent skin penetration
– reduce inflammatory / infective triggers
• Regular use helps prevent flare-ups & need for steroids
• LOTIONS are light & non greasy
– mildly affected large areas or hairy areas
• CREAMS are also non-greasy but thicker
– for moist or weeping lesions
• OINTMENTS are thick, occlusive and greasy
– dry, lichenified or scaly lesions 1
5
 Emollients 2
• Mode of action:
– Occlusive
– Humectant (contain urea, lactic acid...)
– Keratolytics (contain urea, lactic acid, glycolic acid
• For everyday moisturising, washing & bathing
– used more often and in larger amounts than other treatments
– used in conjunction with other treatments
– used instead of soaps, detergent based products, shampoos
• Used on the whole body even when clear
• Advise liberal use & prescribe accordingly (250 - 500g
weekly)
• Review repeat prescriptions at least annually
• Examples:
– Dibrobase, Doublebase, Epaderm, Cetraban, Aveeno,
Oilatum
 Topical Steroids 1
• Suppress inflammation & control / relieve the symptoms
– indirectly reduce risk of infection
– Rebound may occur on discontinuation
• Divided into 4 strengths: (depends on steroid & formulation)
✴ MILD
- Hydrocortisone 0.1-2.5% [Dioderm]
✴ MODERATE
- Betamethasone valerate 0.025% [Betnovate-RD]
- Clobetasone butyrate 0.05% [Eumovate]
✴ POTENT
- Mometasone furoate 0.1% [Elocon]
- Betamethasone valerate 0.1% [Betnovate]
✴ VERY POTENT
1
- Clobetasol propionate [Dermovate] 7
 Topical Steroids 2
• Benefits outweigh the risks WHEN applied correctly
– only on active areas
• Prescribe a strength of topical steroids to match severity
of the eczema & its anatomical location
– Avoid potent steroids on face or neck of children under 1 yr
– Avoid using for > 2 weeks at a time
– Avoid prescribing very potent steroids without specialist advice
• Do not use potent topical steroids for more than 2 wks in
children under 1 year
• For maintenance step down a potency class from what
was used for controlling the flare
• Exclude secondary infection if no result within 2 weeks
• Consider “weekend” treatment in children with >2 flares
per months
– usual steroid 2days/week on weekly basis
 Topical Steroids 2
• Choice of steroid combined with other agents also
available
– Antimicrobial Fucidin H, Canesten HC, Trimovate, Fucibet
– Crotamiton (anti itch) Eurax-Hydrocortisone
– Urea (humectant moisturiser) Calmurid HC
– Salicyclic Acid (keratolytic) Diprosalic

1
9
 Infected Eczema
• Lesions can become infected
– staphylococcus +/or streptococcus (usually)
• Characterised by:
– weeping,
– crusts, pustules,
– failure to respond to treatment,
– fever,malaise and possibly sepsis
• Start treatment as soon as possible and continue for 48
hrs after symptoms subside
• Topical antibiotics for localised infection
• Systemic antibiotics if widespread or not responding
– Flucloxacillin (Erythromycin / Clarithromycin)
• If coexisting with a flare,consider topical steroid or
steroid/abx combinations (eg fucibet)
 Eczema Herpeticum
• Consider HSV infection
– areas of rapidly worsening, painful eczema
– fever, lethargy, distress
– clustered cold sore - like blisters
– punched out erosions which may coalesce & crust
– not responding to usual treatment
• Treat with systemic aciclovir immediately
– +/- antibiotics
• Consider opthalmological / dermatological advice

2
1
NICE Guidelines 2007

2
2
NICE Guidelines 2007

2
3
 ALLERGY
• Consider food allergy
– immediate reaction to a food
– moderate / severe uncontrolled atopic eczema
– above + history of gut dysmotility or failure to thrive
• Consider inhalent allergy
– seasonal flares
– associated asthma, rhinitis
– >3 yrs with facial eczema
• consider allergic contact dermatitis
– previously controlled
– reaction to topical treatments
2
4
 ALLERGY 2
• Offer 6-8 week trial of extensively hydrolysed or amino
acid formula in bottle fed infants < 6 months with
uncontrolled > moderate eczema
• Avoid partially hydrolysed, soya protein or other species
milk if suspect CMPI
• It is not known if altering a breastfeeding mother’s diet is
effective in reducing the severity of symptoms but can
consider a trial if strongly suspect

2
5
• NICE Guidelines 2007

2
6
 Acknowledgements
• NICE Guideline- CG57

• emedicine.org

• Cks.nhs.uk