docAtopic eczema Dermatitis
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Atopic eczema Dermatitis
Atopic eczema Dermatitis Steve Goldthorp July 2012 PCDS http://www.pcds.org.uk/image-atlas/a-z-ofdiagnosis/50-image-atlas-detailed-articles/150-eczemasyn-dermatitis#ae2 Dermnet http://www.dermnet.com SIGN 125 on Management of Atopic Eczema in Primary Care http://www.sign.ac.uk/guidelines/fulltext/125/index.html DermNet NZ http://www.dermnetnz.org Dermatology Patient Pathway: Eczema http://www.pathways.scot.nhs.uk/Dermatology/P P_Ecz_ET2004.pdf chronic, itchy skin condition that is very common in children but may occur at any age clinical features may include itching, redness, scaling and clustered papulovesicles wide range of external and internal factors acting singly or in combination An inflammatory skin reaction characterized histologically by spongiosis with varying degrees of acanthosis, and a superficial perivascular lymphohistiocytic infiltrate. SCALY PAPULOVESICLES ERYTHEMA Hyperlinks to articles at dermnetnz.org Atopic eczema (including bandaging, food allergy, eczema herpeticum) Atopic scalp eczema Seborrhoeic eczema Discoid (nummular) eczema Gravitational eczema Asteatotic eczema Hand dermatitis Contact allergic dermatitis (including latex and rubber allergy) Napkin dermatitis Links to DermNet pages about eczematous and allergic skin diseases. Allergic contact cheilitis Allergic contact dermatitis Angioedema Atopic dermatitis (eczema) Atopic dermatitis: causes Atopic dermatitis: complications Atopic dermatitis: treatment Autoeczematisation Chronic actinic dermatitis Contact allergens Contact allergy Contact dermatitis Contact stomatitis Cradle cap Dermatitis Dermatitis herpetiformis Dermographism Discoid eczema Dry skin Dust mite Dyshidrosis Eczema Eczema craquele Eczematous cheilitis Exfoliative keratolysis Fixed drug eruption Gravitational eczema Hand care in healthcare workers Hand dermatitis Intertrigo Irritant contact dermatitis Juvenile plantar dermatosis Lichen simplex Lichen striatus Napkin dermatitis Nummular dermatitis Occupational dermatoses Otitis externa Papular urticaria Patch tests Perioral dermatitis Photocontact dermatitis Photosensitivity Photosensitivity dermatitis Phototesting Pityriasis alba Plant dermatitis Polymorphic light eruption Polymorphous eruption of pregnancy Pompholyx Pressure urticaria Prurigo Prurigo nodularis Pruritus ani Pruritus vulvae SCORAD – SCORing Atopic Dermatitis Seborrhoeic dermatitis Sensitive skin Skin problems in hairdressers and barbers Urticaria Venous eczema Winter itch Incidence 1:5 children, 65% resolved by 7 yrs, 74% by 16 If more severe less likely to grow out of it 33% new presentations in adults Aetiology Both genetic and environmental factors 'atopic tendency‘ ie three closely linked conditions; atopic dermatitis, asthma and hay fever, often in families Mutations in the filaggrin gene Thought to underlie almost half the cases of atopic eczema Filaggrin is critical to the conversion of keratinocytes to the protein/lipid squames that compose the stratum corneum, the outermost barrier layer of the skin, so A primary defect in the skin barrier function Immunological changes are probably secondary to enhanced antigen penetration through a deficient epidermal barrier, hence EMOLLIENTS! Triggers Flares ofton result of triggers, which aren’t the same for everyone Soap and detergents Overheating / rough clothing Skin infection Animal dander (fur, hair) and saliva - if resulting from a pet symptoms often improve when patients spend time in a different environment for a few days Aeroallergens (pollens) - reactions to airborne allergens may cause a worsening of symptoms (often facial) over spring / summer in those sensitised. This is most commonly seen in older children and adults Food – primarily in infants and young children (see later under management) House-dust mites and their droppings - sensitised patients may notice a worsening of facial eczema when they wake up Stress Diagnostic features Personal or family history of atopy Itch Many patients have more troublesome symptoms in winter as a result of central heating drying the skin out Distribution: Morphology: Face in infants Flexures Can become widespread Erythematous patches that are often poorly defined Lichenification Other affected sites: Scalp may be generally erythematous with fine scale Address inflammation Acute exacerbation Address barrier defect Long term management Stratum corneum in non eczematous skin differs from eczematous skin and this is probably lifelong, So emphasizes the need for very long term emollients Time to discuss the condition, advise on how best to use emollients and to provide an individual management plan Provide patient information leaflets and/or direct to appropriate websites At each step it is essential to ensure patient compliance and to make sure that copious amounts of emollients are being used Presenting with a flare of eczema More effective to hit hard with a short duration of more potent steroid Wet skin swab Betamethsone/mometasone + antibiotic for 7 days Localised -> fucibet Sleep disturbance -> sedating antihistamine Emollients Review 2-3 weeks Longer term management Emollients - should be the mainstay of therapy. Good evidence shows that the more emollients are used, the less topical steroids are needed. Emollients, Emollients, Emollients, Emollients Moisturisers May need to try several to suit Don’t use aq cream as a ‘leave on’ emollient Most prefer creams/gels > ointments Ointments less likely to cause allergic dermatitis as fewer preservatives Generous amounts, e.g. 500 g. of moisturisers to use regularly (often QDS) Gently rub until not grossly visible Apply in direction of hairs to reduce risk of folliculitis Moisturisers May sting for several days…..then soothe Ointments come in tubs and so can easily become cross infected with bacteria from the skin – patients must not place hands into tubs but instead use a utensil to scoop out the ointment Bath / shower gels Frequent flares may benefit from emollients with an anti-septic property e.g. Dermol ® 600 Bath Emollient or 200 Shower Emollient, Emulsiderm ® Liquid Emulsion or Oilatum ® Plus Bath Additive Very itchy skin may benefit from an emollient with an anti-pruritic property such as Balneum-plus ® Bath Oil Pat dry after bathing But poor mobility & falls due to the increased risk of slipping in the bath or shower Soap substitutes Soaps make a lather, but they damage the skin barrier and so should be avoided specific soap substitutes can be prescribed it is probably more cost effective to use one of the prescribed moisturisers as a wash lowest appropriate potency and only apply thinly to inflamed skin Allow to emollient to dry into skin for 15 - 20 minutes before applying steroid Avoid using combined steroid/antibiotic preparations on a regular basis (resistance) Prescribe adequate amounts! One fingertip unit = 0.5 g of cream or ointment = two hand (palm) surfaces Brand name Name of corticosteroid Potency Alphaderm cream Hydrocortisone 1% Moderate Other active ingredients Aureocort ointment Triamcinolone acetonide 0.1% Potent Urea (humectant moisturiser) Betacap scalp application Betamethasone valerate 0.1% Potent Chlortetracycline (antibiotic) Betnovate cream/ointment/lotion Betamethasone valerate 0.1% Potent Betnovate-C cream/ointment Betamethasone valerate 0.1% Potent Clioquinol (antiseptic) Betnovate-N cream/ointment Betamethasone valerate 0.1% Potent Neomycin (antibiotic) Betnovate RD cream/ointment Betamethasone valerate 0.025% Moderate Bettamousse Betamethasone valerate 0.12% Potent Calmurid HC cream Hydrocortisone 1% Moderate Urea, lactic acid (humectant moisturisers) Canesten HC cream Hydrocortisone 1% Mild Clotrimazole (antifungal) Clarelux foam Clobetasol propionate 0.05% Very potent Cutivate cream/ointment Fluticasone propionate Potent Daktacort cream/ointment Hydrocortisone 1% Mild Dermacort cream Hydrocortisone 0.1% Mild Dermovate cream/ointment Clobetasol propionate 0.05% Very potent Dermovate scalp application Clobetasol propionate 0.05% Very potent Dermovate-NN cream/ointment Clobetasol propionate 0.05% Very potent Neomycin, nystatin (antibiotic + antifungal) Dioderm cream Hydrocortisone 0.1% Mild Neomycin, nystatin (antibiotic + antifungal) Diprosalic ointment Betamethasone dipropionate 0.05% Potent Salicylic acid (keratolytic) Diprosalic scalp application Betamethasone dipropionate 0.05% Potent Salicylic acid (keratolytic) Diprosone cream/ointment Betamethasone dipropionate 0.05% Potent Diprosone lotion Mometasone furoate 0.1% Potent Elocon cream/ointment Mometasone furoate 0.1% Potent Etrivex shampoo Clobetasol propionate 0.05% Very potent Eumovate cream/ointment Clobetasone butyrate 0.05% Moderate Eumovate eczema and dermatitis cream Clobetasone butyrate 0.05% Moderate Eurax hydrocortisone cream Hydrocortisone 0.25% Mild Crotamiton (anti-itch) Fucibet cream Betamethasone valerate 0.1% Potent Fusidic acid (antibiotic) Fucidin H cream/ointment Hydrocortisone acetate 1% Mild Fusidic acid (antibiotic) Haelan cream/ointment/tape Fludroxycortide Moderate Locoid cream/ointment/crelo/ lipocream/scalp lotion Hydrocortisone 17-butyrate 0.1% Potent Lotriderm cream Betamethasone dipropionate 0.064% Potent Metosyn cream/ointment Fluocinonide 0.05% Potent Mildison lipocream Fluocinonide 0.05% Mild Modrasone cream/ointment Alclometasone dipropionate 0.05% Mild Nerisone cream/oily cream/ointment Diflucortolone valerate 0.1% Potent Nerisone forte oily cream/ointment Diflucortolone valerate 0.3% Very potent Nystaform HC cream/ointment Hydrocortisone 0.5%, 1% Mild Synalar cream/ointment/gel Fluocinolone acetonide 0.025% Potent Synalar 1 in 4 cream/ointment Fluocinolone acetonide 0.00625% Moderate Synalar 1 in 10 cream Fluocinolone acetonide 0.0025% Mild Synalar C cream/ointment Fluocinolone acetonide 0.025% Potent Synalar N cream/ointment Fluocinolone acetonide 0.025% Potent Neomycin (antibiotic) Timodine cream Hydrocortisone 0.5% Mild Dimeticone, nystatin, benzalkonium chloride (barrier +antifungal +antiseptic) Trimovate cream Clobetasone butyrate 0.05% Moderate Oxytetracycline, nystatin (antibiotic + antifungal) Ultralanum plain cream/ointment Fluocortolone Moderate Vioform-hydrocortisone cream/ointment Hydrocortisone 1% Mild Brand name Name of corticosteroid Potency Other active ingredients Alphaderm Hydrocortisone 1% cream Moderate Aureocort Triamcinolone ointment acetonide 0.1% Potent Urea (humectant moisturiser) Betacap Betamethasone scalp valerate 0.1% application Potent Chlortetracycline (antibiotic) Betnovate cream/oint Betamethasone ment/lotio valerate 0.1% n Potent BetnovateC Betamethasone cream/oint valerate 0.1% ment Potent Miconazole (antifungal) Clotrimazole (antifungal) Nystatin, chlorhexidine (antifungal + antiseptic) Clioquinol (antiseptic) 27 in this list http://www.netdoctor.co.uk /skin_hair/eczema_corticost eroids_003762.htm Clioquinol (antiseptic) Strength of steroid to be determined by the age of patient, site and severity: Child face: mild potency e.g. 1% Hydrocortisone Child trunk and limbs: moderate potency e.g. Eumovate ® (Clobetasone butyrate 0.05%) or Betnovate-RD ® (Betamethosone valerate 0.025%) Adult face: mild or moderate potency e.g. Eumovate Adult trunk and limbs: potent e.g. Betnovate ® (Betamethasone valerate 0.1%), Elocon ® (Mometasone) Palms and soles: potent or very potent e.g. Dermovate ® (Clobetasol propionate 0.05%) Side effects If used appropriately it is uncommon to develop steroid atrophy, however extra care needs to be taken in the following sites: Around the eyes: unless used very infrequently topical steroid preparations should be avoided due to the risks of glaucoma The face - the regular use of topical steroids should be avoided Lower legs in older patients / others at risk of leg ulcers - as above Flares 4 – 8 weeks - as per earlier slide More frequent Check compliance Swab the skin - for frequent infections it is useful to take nasal swabs and if positive for S.Aureus treat with nasal Bactroban ® cream BD for one week Elocon ‘weekend regime’ for both children and adults OD for two weeks and then alternate days for a further two weeks use Elocon on two consecutive days (e.g. Sat Sun) of each week to the areas that tend to flare. The treatment must be applied even if the skin in not inflamed – the aim is to reduce the frequency of flares Protopic ® ointment (an immunomodulator) - as above the eczema first needs to be brought under control by more frequent use of the proptopic and then reduce down to twice a week eg at weekends. A so called ‘weekend regime’. Patients not responding to the above - consider the possibility of a contact allergic dermatitis In this area referral to a dermatologist appropriate Eczema tends to be persistent, most people will have to use topical steroids on and off for many years Used continuously topical steroids may lose their effectiveness after a few weeks Avoid by reducing the strength and frequency of the topical steroid as the eczema comes under control. Mild eczema responds well to topical steroids and maintained with emollients alone Moderate and severe eczema are more difficult to manage. The eczema may not have completely cleared with a potent topical steroid after three to four weeks. Manage by Changing to an equipotent steroid prep Treat infection Gradually reducing the number of days the stronger topical steroid is used, for example using a potent topical steroid at weekends and an emollient on weekdays Hence the ‘weekend regimes’.
10 yrs
Fluticasone propionate 0.005%
