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

2. 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)

3. Types Of Eczema

4. Atopic Eczema

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

6. 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)

7. 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)

8. 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)

9. Discoid

10. 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.

12. Pompholyx (palmar/plantar)

14. Irritant Contact

17. Allergic Contact

19. Erythrodermic

20. Varicose / Venous

22. Craquele / Craquelatum

24. 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

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

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

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

28. 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

29. How Do We Treat The Condition?
Appropriate quantities of steroid

30. 1 finger tip unit (ftu) = 0.5g
The Finger Tip Unit
1 finger tip unit (ftu) = 0.5g

31. 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 = g weekly
7 year old = 24.5g daily = 171.5g weekly

32. 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

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

34. What If That Doesn’t Work?

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

36. 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.

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

38. 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

39. 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.

40. 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.

41. 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.

42. 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

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

44. 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.

45. 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.

46. 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

47. Any questions?