The Treatment And Management of Eczema Sharon Hulley Clinical Nurse Specialist in Dermatology University Hospital Of Wales, Cardiff

What Is Eczema ? “Eczema is derived from the Greek ‘ekzein’ meaning ‘to boil over’ and is characterised by dry, itching and inflamed skin” (The Skin Care Campaign 1999)

Types Of Eczema

Atopic Eczema

Atopic Eczema Increasing incidence Affects approximately 1:10 children Familial tendency Associated with asthma and hay fever

Diagnostic Criteria For Atopic Eczema Inflammatory condition of the superficial skin, characterised by 3 or more basic features: pruritus lichenification chronic relapsing course Personal or family history of atopy (asthma, allergic rhinitis, atopic eczema Plus 3 or more minor features: e.g. xerosis, elevated serum IgE, early age of onset, itch when sweating Hanifin & Rajka (1980)

UK Working Party’s Diagnostic Criteria Presence of itchy skin condition, plus 3 or more of the following: history of flexural dermatitis onset <2 years (if child is >4 years) personal or family history of asthma or hayfever visible flexural dermatitis Williams HC et al (1994)

Diagnostic Criteria for atopic eczema (3) Must have an itchy skin condition (or reported scratching or rubbing in a child) plus 3 or more of the following : History of itchiness in skin creases such as folds of the elbows, behind knees, fronts of ankles or around the neck (or cheeks in children under 4 years) History of asthma or hay fever (or a history of atopic disease in a first degree relative in children under 4 years) General dry skin in the past year Visible flexural eczema (or eczema affecting the cheeks or forehead and outer limbs in children under 4 years) Onset in the first 2 years of life (not always diagnostic in children under 4 years) (McHenry et al 1995)

Discoid

Discoid Eczema Presents as well demarcated round oval or annular red scaly plaques. Can be vesicular and crusty or dry and scaly. Usually affects older people. Patients may also have a background of atopic eczema.

Pompholyx (palmar/plantar)

Irritant Contact

Allergic Contact

Erythrodermic

Varicose / Venous

Craquele / Craquelatum

Aim Of Eczema Treatment To treat and control the symptoms of itching, pain and discomfort Reduce inflammation Replace lost moisture Inhibit scratching and thus infection Improve the quality of life for the patient and their family

How Do We Treat Eczema? Moisturisers / Emollients (soap substitute, bath oil, topical) Ointment - dry skin Cream or lotion - wet skin Appropriate quantities

Effects of an emollient Prior to emollient application 20 minutes after an emollient application

Appropriate strengths of steroid How Do We Treat Eczema? Appropriate strengths of steroid

Which Strength Of Topical Steroid ? 1% Hydrocortisone Clobetasone butyrate Betamethasone 0.025% Betamethasone / Mometasone Furoate 0.1% Clobetasol Proprionate Mild Eczema Mild - Moderate Moderate Moderate - Severe Severe

How Do We Treat The Condition? Appropriate quantities of steroid

1 finger tip unit (ftu) = 0.5g The Finger Tip Unit 1 finger tip unit (ftu) = 0.5g

Topical Steroid Quantities (child) Twice daily application of steroid all over: 6 month old = 9.5g daily = 66.5g weekly 4 year old = 19.25g daily = 134.75g weekly 7 year old = 24.5g daily = 171.5g weekly

Topical Steroid Quantities (adult) Face & Neck 2 ftu = 1g Back & Front 7 ftu = 3.5g Arm 3 ftu x2 = 3g Hand (both sides) 1 ftu x2 = 1g Leg (not incl. foot) 6 ftu x2 = 6g Foot 2 ftu x2 = 2g total per once daily application = 16.5g Per week = 115.5g

How Do We Treat The Condition? (cont’d) Bandages Antibiotics (topical / oral) Treatment regime Avoid provoking factors if possible

What If That Doesn’t Work?

Topical immunomodulators Review treatment steroid not strong enough not enough emollient infection not addressed consider bandaging Topical immunomodulators

NICE Recommendations For Use Of Topical Immunomodulators Treatment with both Protopic & Elidel must be initiated by physicians (including G.P’s) with a special interest and experience in dermatology. Prior to commencing - careful discussion with patients and/or parents of potential risks and benefits of all seconds-line treatment options.

Mode Of Action Calcineurin inhibitors. Suppression of T-lymphocyte responses.

Availability Of Protopic & Elidel Protopic (Tacrolimus) 0.03% & 0.1% Ointment 30g (0.03% & 0.1%) 60g (0.03% & 0.1%) Elidel (Pimecrolimus 1%) Cream 30g 60g 100g

Licensed Indications For Protopic (Tacrolimus) 0.03% & 0.1% Ointment Children 2-16 years 0.03% Adults & adolescents over 16 years 0.1%. Treatment of moderate to severe atopic eczema unresponsive to conventional therapy.

NICE Indications For Protopic (Tacrolimus) 0.03% & 0.1% Ointment Not recommended for the treatment of mild atopic eczema or as a first-line treatment. Treatment of moderate to severe atopic eczema in adults & children over 2 years of age. Failed response to topical corticosteroids. At risk of adverse effects from further use of topical corticosteroids e.g. skin atrophy.

Application Of Protopic (Tacrolimus) 0.1% & 0.03% Ointment Prior to use, clinical infections at treatment sites should be cleared. Emollients should not be applied to the same area within 2 hours of applying tacrolimus. Body, limbs, face, neck and flexures. Twice daily for up to 3 weeks then reduce to once daily until clear. Restart as/when necessary.

Side Effects More Common Less Common Burning or tingling sensation Pruritus Erythema Less Common Folliculitis Herpes simplex infection Acne Increased sensitivity to hot and cold Alcohol intolerance Lymphadenopathy has also been reported

Licensed Indications For Elidel (Pimecrolimus) Cream Children over 2 years & adults. Acute treatment of mild to moderate atopic eczema (including flares).

NICE Indications For Elidel (Pimecrolimus) Cream Not recommended for the treatment of mild atopic eczema or as a first-line treatment. Treatment of moderate atopic eczema on face & neck in children aged 2-16 years of age. Failed to respond to topical corticosteroids. At risk of adverse effects from further use of topical corticosteroids e.g. skin atrophy.

Application Of Elidel (Pimecrolimus 1%) Cream Prior to use clinical infections at treatment sites should be cleared. Not to be applied to areas affected by acute cutaneous viral infections. Twice daily until symptoms resolve. Re-start as/when necessary.

Side Effects More Common Less Common Burning sensation Pruritus Erythema Less Common Skin infections (including folliculitis and rarely impetigo, herpes simplex and zoster and molluscum contagiosum) Papilloma (rarely) Local reactions such as pain, paraesthesia, peeling, dryness, oedema and worsening of eczema

Any questions?