Pauline Brown Clinical Nurse Specialist Eczema/Allergies Northland DHB Child Health Centre Debbie Rickard Child Health Nurse Practitioner Candidate Capital coast DHB

This session What is eczema? Who it affects and prevalence Non-allergic triggers Eczema and Atopy (allergy) The skin barrier Gene-environment interactions Reasons for treatments Costs and stresses on families Pathophysiology of skin and eczema Complications of eczema – bacteria, fungus, virus Nurse led clinics Debbie Basic Skin treatments/management concepts Debbie Management infant/pre-school Pauline Management in the school age/adolescent/adult – Debbie

What is eczema Eczema is a chronic, inflammatory skin condition that is characterised by Dryness Deep-seated itch Redness and inflammation Sometimes areas can be weepy or oozing

Incidence The incidence of eczema has increased steadily in westernised countries, over the past 40 years (Cork et al 2006, p3 ISAAC study, lancet, 2006) It is believed that up to 1 in 4 children may be affected and there is no cure. (Gold & Kemp, 2005) It affects around 30% of preschool-age children, 15% of school-age children and 9% of adolescents 60 % of the children will have onset before the age of 1 year (Krakowski, Pediatrics, 2008) Historically it is poorly understood and frequently under treated.

Name Confusion? Eczema has been historically thought of as an allergic disease hence the name Atopic Dermatitis (inflammation of the skin due to allergies) (Cork et al, Exchange, NES 2006) However, more recently it has been suggested that we should be dividing the condition of ‘eczema’ into 2 terms (Darsow etal European Task Force on Atopic Dermatitis, JEADV, 2010, Ricci etal, Am J Clin Derm, 2009, Cork et al, Exchange, NES 2006)

Atopic - having allergic tendencies (extrinsic) Non atopic – not having allergic tendencies (intrinsic)

Eczema - Atopic Atopy, or the tendency to be sensitised or allergic approximately 1/3 rd of all individuals with eczema has either; IgE (immediate hypersensitivity) (example hayfever, asthma, food allergies) or Cell-mediated (delayed type hypersensitivity). (example contact dermatitis to nickel, dyes etc.) Cell mediated allergy does not show on skin prick testing or RAST (Cork et al 2006)

Eczema – Non Atopic 2/3 rds have non allergic eczema Trigger (things that irritate) factors include: Soap based products, body wash chemicals Heat, dry air or heating Stress and anxiety Woolly/rough clothes/fabrics Certain food chemicals or colourings/preservatives (intolerances and not allergy) Some infections/bacterial, viral, fungal teething

However Regardless of the classification, it is thought that the primary problem is the skin barrier

Functions of the skin Skin cells (keratinocytes) divide at the bottom of the epidermis to make a new supply of skin cells The new cells mature as they move up through the skin At the top of the skin, the skin barrier (stratum corneum) is formed The barrier protects the body from the environment and prevents the penetration of irritants and allergens The skin cells in the stratum corneum are locked together by structures call corneodesmosomes and the skin cells are surrounded by lipid bi-layers. (Cork et al, Exchange, NES 2006)

The skin barrier The stratum corneum can be viewed as a brick wall Comparing skin cells to the bricks and lipid lamellae to the cement The wall is stabilised by passing iron rods though the bricks which are compared to the corneodesmosomes The iron rods keeps the skin together In order to maintain a constant thick barrier skin cells shed from the surface of the skin

Malfunctioning skin barrier The skin cells in the stratum corneum are locked together by structures call corneodesmosomes and the skin cells are surrounded by lipid bi- layers. ?Faulty genes break down the skin barrier's binders or iron rods much faster than normal. People with eczema have gaps in their lipids or mortar. This results in cracks all the way through the skin barrier. Irritants such as soap cause more break down and the "brick wall" starts to fall apart. A broken barrier lets allergens enter the skin easily. Germs and more irritants then lead to an eczema flare

Management includes repairing the skin barrier with moisturisers (more discussion later)

Why has the prevalence increased? The genes that predispose us to eczema has not changed, but our environment has One theory - we are exposing our skin to more soaps and surfactants such as bubble baths to wash babies Soap and surfactants shown to decrease the stratum corneum by 40% (Cork et al Dermatol in Practice, 2002)

The rising prevalence of atopic eczema and environmental trauma to the skin. Cork et al. Dermat Pract 2002, 10, 22. UK data Personal use of soap -detergent 76 million £453 million £ Water for personal washing 11 L /day51 L/day Increased skin barrier dysfunctions

Genes associated with strength of skin barrier Chemicals called proteases break down the corneodesmosomes (iron rods) Normal skin has low levels of proteases so skin barrier is thick Non-allergic eczema has a change in the gene which produces higher levels of protease Leads to premature break down of the iron rods. The lipid lamellae (cement) is also incomplete

Normal pH of the skin is 5.5 Exposure to soap and surfactants ↑ 7.5 or higher The protease SCCE is pH sensitive 50% increase in protease activity Equals greater breakdown of the skin barrier Increase penetration of irritants and allergens.

Aqueous Cream Contains surfactants Surfactants break down the skin barrier Aqueous cream was designed as a soap substitute for eczema Widely used as a ‘leave on’ moisturiser Audit of children attending dermatology clinic showed aqueous cream caused irritant reactions in > 50% (Cork et al, Pharmaceutical J, 2003)

Genetic link If a child has one parent with atopic eczema – 20% If both parents have (or had) atopic eczema – 50%

Which leads us to the treatments Our increasing knowledge and understanding of how the skin barrier breaks down, reinforces the importance of skin-barrier maintenance and repair This is the first-line treatment → Complete emollient (moisturiser) regimes

2 nd line of treatment ↓ Identification and avoidance of irritants and allergens

3 rd line of treatment ↓ Treatment of flares The more attention paid to the first two steps, the less often flares will occur

Loss of skin barrier Moisturise Bathe Cleanse Steroids Antibiotics Primary/secondary infection occurs Immune system responds to Bacterial invasion Desire to scratch Excoriation occurs Creates allergic response Produces more Itch and inflammation

Triggers – micro-organisms (staph. Aureus)

Eczema is no small itch

It is far more…… yet it is a disease that is often minimized by health professionals

Consider The Impact Of Eczema Overall it is the commonest specific skin disorder encountered – yet very poorly managed Second commonest skin disorder seen in dermatologist office – yet very poorly managed

Major issues Physical symptoms Pruritus, skin discomfort, sleep disruption Emotional problems Stigma associated with the visibility of the disease Social dysfunction Loss of work, school, social activities

Financial Burden in Australia Approx. A$1142/year/per person for mild eczema Approx. A$6099/yr/person for severe eczema A$157Million/year per mild eczema population A$316.7 Million/year per severe eczema population These figures do not include national expenditure on subsidised medications Annotation/Atopic eczema: Its social and financial costs; AS Kemp, Department of Immunology, Royal Children’s Hospital, Parkville, Victoria, Australia

Major negative impact on the quality of life (QoL) Since 1987 impact measured in a repeatable standardised way; Dermatology Life Quality Index Children’s Dermatology Life Quality Index Skinex the impairment of the QoL and the psychological wellbeing has been well documented Br J Dermatol 2006; 155:

Recent study on monitoring ‘course of life’ (CoL) impact on children with AD CoL refers to fulfilling age specific developmental tasks and milestones Hampered CoL has been found in adults who have had; Childhood cancer End-stage renal failure Anorectal malformations Hirschsprung disease Esophageal atresia...but this is 1 st study on eczema Paediatric Dermatology, Vol. 26 No. 1, , 2009

Study results 117 patients, median age of 23.4 years 508 control patients, median age 24.2 years Need for support was identified 87% needed more information about treatment regimes 85% wanted improvement of personal guidance and advice of the physician during their treatments 52% desired contact with fellow-sufferers 68% felt they needed psychological support

CoL Results Compared mod eczema to severe eczema Less friends in primary and secondary school Spent less leisure time with friends Fewer belonged to a group of friends Less went to school dances Comparing severe eczema with healthy peers Less were members of sports clubs during primary and secondary years 70% felt shame around their peers 49% avoided intimacy 25% reason for missing school 24% did things on their own

Physical aspects 90.7% experienced pain and itch 69% sleeplessness 60% fatique 74% had increase in eczema when stressed

International Study Of Life with ATopic Eczema (ISOLATE) Largest and most comprehensive study conducted into the impact of eczema on patients' lives and relationships Revealed the extent of the emotional suffering caused by eczema. (2004)

Results 55% either always or sometimes worried about the next eczema flare 51% always or sometimes unhappy/depressed 86% avoid at least one type of everyday activity during a flare-up 43% fairly or very concerned about being seen in public during a flare 74% of patients and caregivers state that their physicians have never discussed the emotional impact that eczema has had on their lives

…..yet very poorly managed

Australian Study Indicated that the family stress related to the care of a child with moderate or severe atopic dermatitis is significantly greater than that of care of children with insulin-dependent diabetes mellitus. (Kemp, 1999)

…..yet very poorly managed

Patients and their families experience considerable emotional distress, anxiety, and embarrassment because of people’s response to this illness. In fact, the emotional scarring on both patient and family members may outlast eczema's physical effects.

Never underestimate the emotional cost of eczema Single young mother 1 year old Moderate – severe eczema and receiving multiple and conflicting advice Multiple food allergies – conflicting advice Multiple environmental allergies No family living in same town Mother studying Minimal income Sleepless nights Irritable child during day Difficult finding childcare due to eczema