Eczema

Dermatology
Written By Maladywise
 

Fact Sheet

Overview

  • Chronic, itchy, inflammatory skin disease

Prevalence

  • 5 to 20% of children, most grow out of it into adulthood

Risk factors

  • Family history of atopy (eczema, asthma, hayfever) is present 70% of the time

  • Children with one atopic parent have a 2 to 3-fold increased risk of atopic dermatitis

  • Having two atopic parents increases this to a 3 to 5-fold risk

Environmental

  • “Hygiene hypothesis” - There is decreased risk of atopic dermatitis in children exposed to

    • Early daycare

    • Helminth infestations e.g. pinworms, tapeworms

    • Number of siblings

    • Farm animal

    • Pet dogs in early life

  • Other environmental factors that influence rates of atopic dermatitis include climate, urban versus rural settings, air pollution, and water hardness.

Cause

  • Skin dysfunction - Likely the key abnormality in atopic dermatitis, hence the importance of moisturisers.

  • Genetic factors

  • Altered skin microbiome

  • Environmental triggers of inflammation

Symptoms

  • Dry skin

  • Severe itch

Acute atopic dermatitis

  • Intense itch

  • Erythematous papules (red raised patches)

  • Vesicles with exudate and crusting (blisters that leak fluid)

Chronic atopic dermatitis

  • Dry

  • Scaly

  • Excoriated (scratched or abraded)

  • Erythematous papules (red raised patches)

Young Children

Atopic dermatitis usually presents with itchy, red, scaly, crusted lesions on extensor surfaces, cheeks and scalp.

Older Children

Less weeping, more lichenified (thickened) plaques in flexural distribution (elbow creases, behind knees, front of wrists and ankles, neck)

Adults

More localised to flexural regions and thickened

Associated features

  • Centrofacial pallor (pale central face)

  • White dermatographism (scratching skin causes white marks along scratch line)

  • Keratosis pilaris (skin bumps, often outside arms)

  • Palmar hyperlinearity (lots of palm lines)

  • Pityriasis alba (pale patches, usually on the face)

  • Periorbital darkening (around the eyes)

Variants

Atopic hand eczema

Backs of hands and wrists, more common in adults, more so in those who are exposed to “wet work” e.g. dishwashing

Eyelid Eczema

Eczema on eyelids, and around the eyes

Atopic Cheilitis

Drying, peeling, and fissuring of the lips

Laboratory Tests

80% of patients have increased immunoglobulin E levels, often with high blood eosinophils

Clinical Course

  • Chronic, relapsing course over months to years

  • Mild cases may experience intermittent flares with spontaneous remission

  • Moderate to severe cases rarely clearly without treatment

  • Most patients are clear of atopic dermatitis by late childhood

    • 20% of childhood cases persisted at 8 years after diagnosis

    • 5% of cases persisted at 20 years after diagnosis

  • Patients with atopic dermatitis are predisposed to secondary skin infections

    • Impetigo / School Sores caused by Staph aureus

    • Eczema herpeticum caused by Herpes Simplex Virus

    • Atypical Hand Foot and Mouth Disease infections can appear in sites of atopic dermatitis

Comorbidities

Atopic dermatitis is linked to

  • Allergic rhinitis

  • Asthma

  • Food allergies including hives, anaphylaxis and eosinophilic eosophagitis.

  • Ichthyosis vulgaris (dry scaly skin)

  • Eye diseases such as atopic kerato-conjunctivitis and vernal kerato-conjunctivitis

  • Psychiatric disorders have been implicated to be associated with atopic dermatitis

  • Anaemia

    • Impaired psychosocial functioning

    • ADHD (possibly due to sleep disturbance due to itch at night, elevated stress or pro-inflammatory chemicals on brain development)

    • Learning disabilities

    • Depression and Anxiety

Diagnosis

Based on history and examination

The American Academy of Dermatology criteria for the diagnosis of atopic dermatitis includes three sets of criteria

Essential features:

  • Pruritus

  • Eczema (acute, subacute, chronic) with typical morphology and age-specific patterns:

    • Facial, neck, and extensor involvement in infants and children

    • Current or previous flexural lesions in any age group

    • Sparing of the groin and axillary regions

  • Chronic or relapsing history

Important features:

  • Early age of onset

  • Personal and/or family history of atopy, IgE reactivity

  • Xerosis (dry skin)

Associated features:

  • Atypical, vascular responses (eg, facial pallor, white dermographism, delayed blanch response)

  • Keratosis pilaris, pityriasis alba, hyperlinear palms, ichthyosis

  • Periocular changes

  • Perioral changes, periauricular lesions

  • Perifollicular accentuation, lichenification, prurigo-like lesions

Differential Diagnosis

  • Allergic or irritant contact dermatitis

  • Seborrheic dermatitis

  • Psoriasis

  • Scabies

  • Less common conditions include drug reactions, immunodeficiencies, nutritional deficiencies

Treatment

The goals of treatment are to

  • Reduce symptoms (itch and dermatitis)

  • Prevent exacerbations

  • Minimise therapeutic risk

Assessment of Severity

  • Mild

    • Dry skin

    • Infrequent itch

    • With or without redness

    • Little impact on sleep, everyday activities and psychosocial wellbeing)

  • Moderate

    • Dry

    • Frequent Itch

    • Redness (with or without skin thickening)

    • Moderate impact on everyday activities and psychosocial wellbeing

    • Frequently disturbed sleep

  • Severe

    • Widespread dry skin

    • Incessant itch

    • Redness with or without

      • Skin thickening

      • Bleeding

      • Oozing

      • Cracking

      • Pigment changes

    • Severe limitation of everyday activities and psychosocial functioning

    • Nightly loss of sleep

Elimination of exacerbating factors

  • Excessive bathing without subsequent moisturising

  • Low humidity environments

  • Emotional stress

  • Dry skin

  • Overheating of skin

  • Exposure to solvents and detergents

  • Anything that produces an itch stimulus

Adjunctive Measures

  • Treat skin infections such as staph aureus

  • Use antihistamines for sedation and control of itching

  • Manage stress and anxiety

Skin hydration

  • Emollients should be applied at least two times daily and immediately after bathing or hand washing

  • Thick creams (which have a lower water content) or ointments (which have zero water content) are generally preferred as they better protect against dry skin, but some patients complain they are too greasy.

Optimal Everyday Management

Optimal everyday management (clear skin - mild atopic dermatitis flare, no infection)

Children with eczema must bathe daily and have moisturisers applied at least twice per day top-to-toe. This should continue even when the skin is clear.     

Moisturisers

  • A thick, plain, alcohol-free and fragrance-free moisturiser, with high oil and low water content should be used (see appendix below).

  • Avoid contaminating the moisturiser with bacteria from the hands. With tubs use a tool such as a spatula (not hands) to remove it and place it onto clean paper. Moisturiser from the paper can then be applied by hand to the child’s skin.

  • Apply moisturisers generously twice per day and after bathing or hand washing.

  • Avoid moisturisers containing fragrance, plant or food products (eg vegetable, nut or olive oils) as these may disrupt the skin barrier and sensitise the skin leading to food allergies.

Bathing

  • Daily bathing aids to reduce the bacterial skin load and reduce the risk of infection

  • Baths and showers should be kept luke-warm (<31oC) and limited to 5 minutes to avoid skin flares

  • A capful of bath oil should be added to bath water

  • Do not use soap or shampoo. Use soap-free skin cleansers that will not irritate the skin

  • Use fresh towels with every bath to prevent infections

General considerations

  • Keep skin intact: Avoid skin trauma caused by abrasions (eg rough fabrics, sand) and chemicals (eg soaps). Keep fingernails short. Mittens or night-time hand splints may help prevent scratching when asleep.

  • Food allergies: Allergy testing is usually not required. As food allergy is not commonly responsible for eczema flares, parents are encouraged to discuss the initiation of restrictive diets with a Dermatologist or General Paediatrician.

  • Antihistamines may help ameliorate eczema pruritus. Avoid long-term antihistamine use, manage with eczema flare treatment instead

Minimising common eczema flare triggers

Overheating

  • Keep baths (<31oC), the home and car cool (<18oC)

  • Avoid air-blowing heaters & low humidity environments

  • Use light bed coverings & pyjamas (eg cotton pyjamas, avoid woollen underlays, plastic mattress protectors, sleeping bags, hot water bottles)

  • Avoid thick and multiple layers of clothing

Dry skin

  • Avoid (alcohol) nappy wipes. Use a cloth with water & bath oil.

  • Bathe or shower with bath oil immediately after swimming in a pool
    Avoid dummies – drooling can cause irritation

  • Apply barrier cream to the perioral area when the infant is dribbling

Irritants

  • Use a non-perfumed clothes detergent

  • Avoid chemicals such as soaps & talcum powders

  • Remove clothing tags

  • Avoid rough & prickly fabrics

  • Manage anxiety or behaviours that promote scratching

  • Keep nail shorts.

Infection / Inflammation

  • Daily bathing using appropriate cleansers and/or bath oils.

  • Wash hands before applying eczema treatments

  • Seek medical review early if concerns of infection not responding to prescribed treatment

Eczema flares

Steroids:

  • Topical steroids (see appendix below) are required once or twice daily until the skin is completely clear to reduce skin inflammation.

  • Steroids should be applied generously underneath the moisturiser. Steroid dosage can be calculated using the "Fingertip Unit" method

  • Facial eczema should be treated with low potency steroids to avoid chemical skin irritation.

Moisturisers:

  • The frequency of moisturiser must increase – apply at least 4 times per day

  • Apply the moisturiser on top of other topical medicines such as steroids.

Wet dressings:

  • Assist to return moisture to the skin, protect from infection and further trauma, and help to reduce irritation and itch

  • Dressings should be applied with every flare 1-4 times daily for at least 3 days. More frequent dressings and/or longer treatment may be required in severe eczema

  • Parents must be educated on how to correctly make and apply wet dressings

  • Cool compresses (cloth or towel soaked in water and/or bath oil) should be used on the face or to provide immediate relief of itch before wet dressings

Eczematous skin infections

Broken eczematous skin has a high-risk of bacterial and/or viral skin infections.
Bacterial infections:

  • Common causative organisms include Staphylococcus aureus (consider MRSA if no response to first-line antibiotics.)

  • Remove crusted lesions by wiping them gently with a cloth whilst soaking in the bath. Only apply topical steroids and moisturisers after the crusts are removed.

  • Consider courses of oral antibiotics (eg cefalexin or flucloxacillin for 7 to 10 days).

  • Children who are unwell or who have severe infections may require admission and intravenous antibiotics

Viral infections:

  • Common causes include coxsackievirus, molluscum contagiosum, herpes simplex and varicella zoster viruses

  • Herpetic infection can be treated with antivirals within 72 hours of the onset of symptoms. Intravenous antiviral treatment may be required in severe infections

  • Urgent Ophthalmology review is required if the infection extends periorbital (trigeminal) distribution

Recurrent infections:

  • Consider patient & family Staphylococcus aureus decolonisation

  • Antiseptic preparation may reduce skin bacterial load (eg bleach, benzalkonium chloride, chlorhexidine skin wash, paraffin (OilatumTM bath oil)

Bathing:

  • Bleach baths should be used daily with every flare to reduce the bacterial skin load. The addition of salt and oils to the bath also assists in relieving itch and restoring moisture to the skin.

  • The child’s face and head should be wet during the bath

  • Do not rinse after bathing.

Bathing oils & wash

  • QV® bath oil & wash

  • Hamilton’s® bath oil & wash

  • Kenkay® bath oil & wash

  • Cetaphil® Gentle Skin Cleanser

  • Mustela®, AveneÒ, Bioderma®, La Roche Posay® bath oils and washes

  • White King® Bleach (4%)

  • Salt (table or pool)

  • Use once to twice daily

  • Note do NOT use any bath oils with benzalkonium chloride

Moisturisers & Emollients

  • QV® cream

  • Cetaphil® cream

  • Avene® Xera Calm Cream

  • 10% Sorbolene®, 10% liquid paraffin, 10% soft white paraffin

  • Atoderm (Bioderma®) Cream

  • Mustela Stelatopia® creme

  • Dermeze® cream, Dermeze® ointment (for facial barrier when dribbling)

  • Cicalfate®, Cicplast® or zinc and castor oil creams for barrier creams

  • Apply once or twice daily top-to-toe

  • If eczema flares, apply at least four times per day

  • Barrier creams can be used often when the child is dribbling and applied prior to feeding 

Topical steroids

Apply once to twice daily to affected areas 

Ointment is preferred to creams for their emollient effects

Lotions are best used for the scalp

For sensitive areas  (eg face, nappy)

  • Hydrocortisone 1% cream or ointment

  • Pimecrolimus 1% (Elidel® cream)

  • Methylprednisolone aceponate 0.1% (Advantan® lotion) for short term use only

For body

  • Methylprednisolone aceponate 0.1% (Advantan® cream, ointment, fatty ointment, lotion)

  • Mometasone furoate 0.1% (Elocon® cream, ointment).

  • Betamethasone dipropionate 0.05% (Diprosone® /Eleuphrat® )

References

 
Maladywise https://www.maladywise.org
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