1. Case study Atopic eczema

2. James is 18m old. He has an itchy rash on his flexural creases of his elbows, knees and wrists His skin is generally dry with red patches and itchiness on cheeks and neck His mother had eczema since being a child. Her hands and wrists show lichenification. She also has mild asthma and his father has hayfever

3. What information supports a diagnosis of atopic eczema?

4. Diagnose atopic eczema when a child up to the age of 12 has an itchy skin condition plus 3 of the following: – Visible flexural dermatitis involving skin creases (elbows, knees) or visible dermatitis on cheeks &/or extensor areas in children ≤18m – Personal history of flexural dermatitis or dermatitis on cheeks &/or extensor areas in children ≤18m – Personal history of dry skin in last 12m – Personal history of asthma or allergic rhinitis (or history of atopy in 1 st degree relative of children < 4 years – Onset of signs or symptoms < 2 years In Asians, black Caribbean or African children the extensor surfaces may be affected and discoid (circular) or follicular (around hair follicles) patterns may be more common

5. What further information do you require?

6. Severity of the eczema Effects on quality of life – sleep, everyday activities, psychosocial wellbeing Personal history of atopy and eczema Family history of atopy and eczema Examination – Extent, location, severity and infective elements

7. What would you advice about avoiding exacerbating factors?

8. Avoid soaps and detergents – Use emollient soap substitute – Use gloves – Reapply emollients after wetting skin Avoid temperature extremes – Humidity Avoid abrasive clothing – Use cotton fabrics

9. Should you investigate for food allergens using an exclusion diet?

10. Diet is a significant trigger in <10% Common triggers include cows’ milk, eggs, soya, wheat, fish and nuts Consider if: – Child has previously reacted to a food with immediate symptoms – Infants and young children with moderate or severe eczema not controlled with optimum management, particularly if gut motility is affected – Symptoms are associated with failure to thrive

11. Should they take measures to avoid dust mites and other airborne allergens?

12. Measures often time consuming, difficult and costly with limited benefits Consider inhalant allergy if : – Seasonal flares – Children with atopic eczema associated with asthma or allergic rhinitis – Children ≥ 3 years with atopic eczema on the face particularly around the eyes

13. What should you discuss about using emollients?

14. Use even when skin is clear Aim is to retain the skin’s barrier function and to prevent painful cracking The drier the skin, the more has to be applied. Greasier products have a better emollient effect Can also use bath products Optimum time to apply is after a bath

15. Should he use topical corticosteroids?

16. Depends of the state of the skin Only use intermittently and for short periods (1-2 weeks) Tailor potency to severity Do not use very potent products in children without specialist advice

17. Would oral antihistamines help?

18. Efforts to reduce dryness and inflammation should be promoted ahead of antihistamines Offer 1 month trial of non-sedating antihistamine to those with severe atopic eczema or those with mild or moderate eczema with severe itching or urticaria Review Rx every 3 months Use 7-14 days of a sedating antihistamine if sleep disturbance is significant

19. James manages for a considerable period of time but when aged 4 he returns with a significant flare. Some patches look moist and inflamed and some have a golden yellow crust. He also has a mild pyrexia

20. What would you recommend?

21. The skin is colonised with S.aureus in 90% of affected areas. If there are clinical signs of widespread infection, oral antibiotics are recommended Topical antibiotics should be reserved for cases of clinical infection in localised areas and use for no more than 2 weeks

22. What signs would make you suspect he had a herpes simplex infection and what would you prescribe?

23. Punched out erosion, vesicles or infected skin lesions failing to respond to oral antibiotics should raise suspicion If a severe infection is suspected start immediate treatment with systemic aciclovir and refer for same day specialist advice

24. Eczema herpeticum