Eczema and Its Management a Guide for Healthcare Professionals CONTENTS PAGE Contents

Eczema and its Management A Guide for Healthcare Professionals CONTENTS PAGE Contents

Introduction 1 Bandaging 31 What is eczema? 1 Antihistamines 32 Causes of eczema 1 Complementary treatments 32

Types of eczema 3 Managing the itch 33 Atopic eczema 3 The itch–scratch–damage cycle 33

Seborrhoeic dermatitis 5 Eczema in children 35 Contact dermatitis 6 Skin care 35 Varicose/gravitational/stasis eczema 8 Immunisation 35 Discoid/nummular eczema 9 Dietary treatment 35 Pompholyx/dishydrotic eczema 9 Support in primary care 36 Neurodermatitis (lichen simplex) 10 Nursery and school 36 Eczema craquelé/azteatotic eczema 11 Laundry 37 Quality of life 11 Clothes and bedding 37

Diagnosis and history 12 Additional help 38 Skin examination and clinical Referral and specialist advice 38 presentation of eczema 13 Professional resources Tests and triggers 14 and guidance 38

Eczema and infections 15 Prescribing resources 38 Bacterial infections 15 Further reading 38 Viral infections 16 Further information Fungal and yeast infections 18 and support from the Eczema management 18 National Eczema Society 39 Washing and bathing 18 Healthcare professionals 40 Emollients – leave-on preparations 21 Topical corticosteroids 24 Topical calcineurin inhibitors or immunomodulators (TCIs) 30 Eczema and its Management – a Guide for Healthcare Professionals

an inflammatory response and Introduction causing eczema flares. Nurses, midwives, health visitors, Atopic eczema is the most common school nurses and community nurses and usually the most persistent are in an ideal position to promote form of eczema. In the UK it affects the care of skin and to educate and 1–2% of adults and 15–20% of schoolchildren, accounting for 30% support those with skin disease and of dermatological consultations in their carers. This booklet gives a general practice and 10–20% of all broad overview of current practice referrals to dermatologists. Many and knowledge in the management of children with atopic eczema improve eczema. as they get older, but they are usually left with dry and sensitive skin. Other What is eczema? children continue to have eczema as Eczema is a common inflammatory, an adult, or eczema can return at any dry skin condition which can affect age, particularly after 60 years, due to anyone from early infancy to old physiological changes in ageing skin. age. Another name for eczema is There is no way to predict the natural dermatitis – ‘derma’ means skin, and course of atopic eczema. ‘titis’ means inflammation. Both terms In other types of eczema and are used interchangeably. Dry skin is a dermatitis, the skin barrier becomes key feature of all types of eczema. Dry faulty when the skin is inflamed skin is itchy skin, and scratching sets (for example, in contact dermatitis, off the itch–scratch cycle, triggering irritants will cause this inflammation). Causes of eczema To understand what eczema is and what causes it, it helps to know something about the differences between healthy skin and skin affected by eczema. Skin is made up of a thin, protective outer layer (the stratum corneum), a small layer containing skin cells (the Page 1 epidermis), a middle layer (the dermis), has been found in 56% of people with and a fatty layer at the deepest moderate to severe eczema and in level (the adipose tissue). Each layer 15% of those with mild eczema; third, contains skin cells, water and fats, all some skin cells (corneocytes) have of which help to maintain and protect an irregular shape. Together, these the condition of the skin. structural differences result in gaps opening up between the skin cells and Healthy skin cells are plumped up with an altered skin barrier, which then water, forming a protective barrier offers insufficient protection, allowing against damage and infection. Fats and entry to bacteria, irritants and allergies oils in the skin help to retain moisture, and facilitating increased trans- maintain body temperature and prevent epidermal water loss (see diagram harmful substances or bacteria from opposite). entering our bodies. As we get older, the glands responsible for keeping Some everyday substances contribute our skin soft and supple become less to further breaking down the skin. efficient. Soap, bubble bath and washing-up One way of picturing how the skin liquid, for example, have a high pH works is by thinking of it as a brick and will remove oil from anyone’s wall. The outer skin cells are like bricks, skin. In people with eczema the skin is while fats and oils are like the mortar especially prone to drying out and will that keeps everything together and break down more easily than normal acts as a seal. The skin cells attract and skin. This means it can quickly become keep water inside, and the fats and oils cracked and inflamed on contact with also help to keep the water in. substances that are known to irritate or In many people with eczema there are cause an allergic reaction. genetic reasons for the skin being so If the skin is not moisturised, it can dry. Research has identified genetic become flaky, itchy and sore. This is mutations leading to a number of often most noticeable on exposed parts changes in the structure of the skin: of the body, such as the face, hands first, eczematous skin does not produce as much fat and oil as normal skin and and lower legs. It can be particularly there is a lack of natural moisturising problematic during the winter months factors; second, there is often a as the skin becomes drier due to deficiency of filaggrin, a structural environmental triggers such as central protein which acts to tie skin cells heating, lack of humidity, wind and together in the top layer of skin (the cold, and moving between different stratum corneum) – filaggrin deficiency temperatures.

Page 2 NORMAL SKIN ECZEMA SKIN ALLERGENS IRRITANTS ALLERGENS AND IRRITANTS INCREASED CAN PENETRATE H2O LOSS

LIPID CELL NATURAL BONDING FEWER (OIL FILAGGRIN LIPID CELLS MOLECULE) MOISTURISING FACTOR PROTEIN AND LESS MOISTURISING FACTOR LAYERS OF KERATINOLYTE STRATUM CORNEOCYTE CELLS CORNEUM CELLS (SIX)

other family members affected by Types of eczema atopic eczema, asthma or hay fever. The Atopic eczema genetic component in eczema affects the epidermal barrier and its ability to WHAT IS ATOPIC ECZEMA? bind water within it. Filaggrin deficiency Atopic eczema is the most common occurs in the majority of people with form of eczema, especially in children. atopic eczema. ‘Atopic’ is a term used to describe a tendency to develop eczema, asthma or hay fever. Atopic eczema is multifactorial with a genetic and environmental component. Atopic eczema, asthma and hay fever often occur together. Atopic eczema usually develops first, followed by asthma and then hay fever, although patients do not necessarily have all three and there is no test to predict this. It is also common for people with atopic eczema to have Page 3 Faces are a common site for atopic eczema Flexural atopic eczema on the back of a in babies, with cheeks often the first place to three-year-old’s knees. be affected.

Lichenification (increased skin markings) on In Asian, Black Caribbean and Black African an adult arm, caused by chronic rubbing. patients, atopic eczema can affect the extensor surfaces rather than the flexures.

Hyperpigmentation (dark patches) and Post-inflammatory hyperpigmentation chronic changes in Asian skin following (dark) and hypopigmentation (light). It may inflammation. take 6–12 months or longer for normal skin colour to return.

Page 4 WHAT DOES IT LOOK LIKE? of Malassezia yeasts. The yeasts are part of the normal skin flora but The clinical features of atopic eczema for an unknown reason they trigger often have age-specific patterns: for seborrhoeic dermatitis in certain example, flexural eczema in children individuals. and hand eczema in adults. Eczema symptoms are similar for all ages, with Seborrhoeic dermatitis is not acute and chronic patterns. There will contagious or related to diet, but be periods of flare and remission. Other it may be aggravated by illness, factors will influence the appearance, psychological stress, fatigue, change of such as infection, treatments and season and a general deterioration of ethnic origin. health. Those with immunodeficiency (especially infection with HIV), heavy WHO GETS IT? alcohol intake, and neurological • 1–2% of adults and 20% of infants disorders such as Parkinson’s disease and children and stroke are particularly prone to it. It may or may not be itchy and can HOW IS IT TREATED? vary from day to day. • Emollients WHAT DOES IT LOOK LIKE? • Topical corticosteroids Infantile: Commonly the scalp is • Topical calcineurin inhibitors (TCIs) affected (known as cradle cap) and is • Antibiotics if eczema is infected characterised by yellow, waxy scales, • Phototherapy which are thick and confluent on the • Systemic drugs for severe eczema scalp and hair and are difficult to remove. In addition, it can appear as Seborrhoeic dermatitis non-itchy, salmon-pink, flaky patches on the scalp, eyebrows, forehead, temples, WHAT IS SEBORRHOEIC DERMATITIS? nasolabial folds and behind the ears. The Seborrhoeic dermatitis is a common, nappy area can also be affected. Very harmless, scaly rash affecting the face, rarely, infantile sebhorrhoeic dermatitis scalp and other areas. There are two can become generalised. types: infantile and adult. Sebhorrhoeic dermatitis in infants usually presents as cradle cap or napkin dermatitis and is due to developing sebum glands. Adult sebhorrhoeic dermatitis is believed to be an inflammatory Infantile seborrhoeic dermatitis (known as reaction related to a proliferation cradle cap on the scalp) is a patchy, greasy, of normal skin inhabitants – species scaly and crusty skin rash seen in babies. Page 5 Adult: Seborrhoeic dermatitis appears WHO GETS IT? as faintly red areas of inflamed Infants: Infants aged 3–8 months may skin with a greasy-looking white be affected. or yellowish scale on the surface, especially on more exposed areas. Adults: The condition affects 1–3% On the face it typically affects the of the adult population and is more nasolabial folds and eyebrows, common in males than females. The sometimes the eyelids (blepharitis) adult form of sebhorrhoeic dermatitis and even the cheeks. The ears, chest, can develop from puberty but axillae, groin and upper back can also more usually occurs in adulthood – be affected. prevalence rises sharply over the age of 20, with a peak at 30 years for men and 40 years for women. HOW IS IT TREATED? Infants: • Emollients or mineral oil (for the scalp) • Topical corticosteroids with an antifungal (for the body) Patches of adult seborrhoeic dermatitis, Adults: involving the forehead, eyebrows, eyelids and nasolabial folds. • Antifungal (anti-yeast) shampoo On the scalp it can range from mild • Topical corticosteroids with salicylic flaking (dandruff) to red and scaly acid (for the scalp) areas all over the scalp, which can • Topical antifungals (may sometimes weep. It can sometimes be combined with topical affect flexural areas, where the scale corticosteroids) may be absent and the skin can look glazed. Seborrhoeic dermatitis can be • Oral antifungal treatment (in severe itchy and, if more severe, sore. cases) Contact dermatitis WHAT IS CONTACT DERMATITIS? Contact dermatitis is caused by substances coming into contact with the skin. Many different substances can cause contact dermatitis, including common things in the home or work Seborrhoeic dermatitis on the adult scalp appears environment. Contact dermatitis can be as a patchy, greasy, scaly and crusty rash. divided into two types:

Page 6 causes no immediate problems. Over a period of time, however, the allergen entering the skin sets up an immune response, with further subsequent exposures resulting in an inflammatory eczematous reaction. Common sensitisers (allergens) are nickel, chromate, rubber and fragrances. Allergic contact dermatitis accounts for the majority of occupational skin Irritant hand dermatitis with a glazed disease. surface, redness and scaling. WHAT DOES IT LOOK LIKE? Both irritant contact dermatitis and allergic contact dermatitis can be localised or generalised. Irritant contact dermatitis is a well- demarcated rash with a glazed surface, but there may be redness, itching, swelling, blistering and scaling of the damaged area. Contact dermatitis develops in places where the irritant or allergen (in this case nickel- Allergic contact dermatitis has a containing metal) is touching the skin. variable presentation and shape, including redness (erythema), blistering Irritant contact dermatitis is very (vesicles or bullae), oedema, dryness, common, accounting for over three- scaling, fissuring, lichenification and quarters of cases of contact dermatitis. pigmentary changes. Excoriations, It occurs from exposure to an acute crusting and pustules may also be toxic insult (e.g. exposure to acids) or evident. Generally, eczema is seen in the by cumulative damage from irritants area of exposure to the allergen but it (e.g. water, soaps, detergents, solvents can also be more generalised, depending and diluted acids or alkalis). These on the allergen, or may appear in substances irritate the skin. Examples unexpected areas – for example, on the include excessive hand-washing, dribble neck/face in the case of a nail varnish rashes and nappy rash. Irritant contact allergy (i.e. if varnished nails touch the dermatitis often occurs under rings. Patch neck/face or due to an airborne allergy testing will confirm whether a rash is from drying nail varnish). irritant or caused by allergy (see below). Allergic contact dermatitis is a WHO GETS IT? type IV (cell-mediated or delayed) Contact dermatitis is more common hypersensitivity. This means that in adults but can occur in children the first contact with a substance and young people. It is often related Page 7 to occupation, especially in people who work with chemicals or do wet work (e.g. healthcare professionals, hairdressers, cleaners, chefs, construction and industrial factory workers). Patients with atopic eczema have an increased susceptibility to both irritant and allergic contact dermatitis. Varicose/gravitational/stasis eczema on the HOW IS IT TREATED? leg of an elderly patient. • Avoidance of irritants and allergens • Emollients haemosiderosis (causing brown staining) and ulceration (venous leg ulcers). • Topical corticosteroids • Oral steroids WHO GETS IT? • Alitretinoin (Toctino) as an oral Varicose eczema is most common in treatment for adult severe chronic adults who have varicose veins, or who hand eczema that has not responded have a history of leg ulcers or deep to potent topical corticosteroids vein thrombosis in the legs. However, some people develop increased pressure Varicose/gravitational/ in their leg veins without ever having stasis eczema had varicose veins, leg ulcers or blood clots. Other risk factors include being WHAT IS VARICOSE/GRAVITATIONAL/ overweight or spending a lot of time STASIS ECZEMA? standing up. Varicose eczema is more Varicose eczema (also known as common in women than men because gravitational or statis eczema) is a female hormones and pregnancy both common type of eczema related to increase the risk of developing the increased pressure in the veins of the condition. legs. WHAT TESTS SHOULD BE DONE? WHAT DOES IT LOOK LIKE? • Doppler using the ankle brachial Varicose eczema affects the lower legs. pressure index (ABPI) – a simple The skin becomes thin, fragile, shiny, non-invasive method of identifying inflamed, itchy and flaky. The eczema can arterial insufficiency within a limb arise as discrete patches or affect the leg all the way around, often with exudating • Patch testing if contact allergy is areas around the ankles. This type of suspected eczema is often accompanied by other HOW IS IT TREATED? manifestations of venous hypertension, including dilation or varicosity of • Emollients superficial veins, oedema, purpura, • Topical corticosteroids Page 8 • Graduated compression stockings/ socks • Avoidance of standing for long periods • Regular exercise • Elevation of legs • Weight loss • Surgery for varicose veins Discoid/nummular eczema WHAT IS DISCOID/NUMMULAR Discoid/nummular eczema with round or oval, blistered or dry skin lesions. ECZEMA? Discoid eczema (also known as WHAT TESTS SHOULD BE DONE? nummular eczema) is a common type of eczema in which there are round or In most cases, no investigations are oval, blistered or dry skin lesions. The necessary but the following may be exact cause of discoid eczema is not appropriate: known. • Bacterial swabs for possible infection WHAT DOES IT LOOK LIKE? • Skin scraping for mycology to Several red, round lesions appear, exclude a fungal infection usually on the lower legs, trunk or forearms. At first, these patches are • Patch testing if a contact allergy is suspected slightly raised, but after a few days they may develop raised papules or HOW IS IT TREATED? vesicles which start to ooze. Later on, • Emollients the surface of the discs becomes scaly • Topical corticosteroids with a clear centre. Discoid eczema can be very inflamed, itchy, crusted and • Antibiotics if infected infected. • Phototherapy or systemic immunosuppressive drugs for severe WHO GETS IT? cases or if generalised Discoid eczema affects males and females equally. It can occur at any Pompholyx/dishydrotic/ age, including childhood, but tends vesicular eczema to affect women in early adulthood, WHAT IS POMPHOLYX/DISHYDROTIC/ whereas male onset is more common in older age groups. Discoid eczema is VESICULAR/ECZEMA? more likely in people with atopy and Pompholyx (also known as dishydrotic those with infected eczema and allergic or vesicular) eczema is a common type contact dermatitis. of eczema affecting the hands and feet. Page 9 The exact cause is not known, but it is sometimes aggravated by heat and stress or could be the result of contact with irritants or allergens. WHAT DOES IT LOOK LIKE? Initially, tiny blisters (vesicles) appear deep in the skin of the palms, fingers, instep or toes. They are intensely itchy, In pompholyx eczema, vesicles (tiny blisters) are or the patient may complain of a commonly seen on the fingers and palms or sides burning feeling. The condition has both and soles of the feet, and are intensely itchy. an acute and chronic presentation with some dryness, erythema, peeling, • Potassium permanganate soaks blistering (vesicles and bullae), (under supervision) for exudating fissuring and crusting. The condition hand and foot eczema may be mild with only a little peeling, Neurodermatitis or very severe with large blisters, (lichen simplex) cracks and nail involvement. If only one hand/foot is affected, the problem WHAT IS NEURODERMATITIS may be a fungal infection. (LICHEN SIMPLEX)? WHO GETS IT? Lichen simplex is a localised area of eczema caused by repeated rubbing Pompholyx probably affects about or scratching. The trigger to scratch 1 in 20 people who have eczema on may be an existing skin condition their hands. 50 percent of people with such as atopic eczema or psoriasis, the condition have atopic eczema or or a compressed nerve leading to the a family history of atopic eczema. skin (neuropathic itch or pruritus), or Pompholyx eczema can occur at any scratching may occur at times of stress age but is more common before the and worry. Neurodermatitis tends to be age of 40. very persistent and recurring. WHAT TESTS SHOULD BE DONE? WHAT DOES IT LOOK LIKE? • Skin scraping for mycology to Neurodermatitis presents as a localised exclude a fungal infection demarcated plaque more than 5cm in • Patch testing if a contact allergy is diameter, with scaling, excoriations suspected and lichenification. Common sites are the ankle, calf, elbow, back of the neck, HOW IS IT TREATED? and genitalia (vulva or scrotum). • Emollients WHO GETS IT? • Topical corticosteroids It occurs in 12% of the population • Antibiotics if infected and is more common in mid- to late • Systemic immunosuppressive drugs adulthood, peaking between the ages or light therapy for severe cases of 30 and 50 years. Page 10 cracks that look like crazy-paving or a dried-up river bed. The cracks only affect the very top layers of the skin but can look very red and feel sore or itchy. It is uncommon to see blistering or thickening of the skin in this type of eczema. Neurodermatitis/lichen simplex presents as a WHO GETS IT? very itchy and thickened single patch. Ankles are a common site. Generally the elderly are affected. WHAT TESTS SHOULD BE DONE? WHAT TESTS SHOULD BE DONE? • Pruritus screen (see Box 1, page 14) • Pruritus screen to exclude to exclude the underlying cause of underlying cause of itching itching (see Box 1, page 14) HOW IS IT TREATED? HOW IS IT TREATED? • Emollients • Emollients • Topical corticosteroids • Topical corticosteroids • Paste bandages or occlusive treatments to stop the itch–scratch cycle Eczema craquelé/ asteatotic eczema WHAT IS ECZEMA CRAQUELÉ/ Eczema craquelé/asteatotic eczema has a ASTEATOTIC ECZEMA? distinctive crazy-paving appearance. Eczema craquelé (also known as asteatotic eczema) is a type of eczema associated Quality of life with very dry skin. It occurs most commonly in people over the age of 60 Eczema is often considered to be a years. Elderly people living in dry, heated trivial condition, which can easily be rooms or those exposed to winter weather, treated by creams alone. People with or excessive bathing or showering are all at all types of eczema know that this is risk of developing this type of eczema. not the case! The psychological and emotional effects of eczema should not WHAT DOES IT LOOK LIKE? be underestimated. Sleep loss and itch Asteatotic eczema most often affects the are common themes, which impact on shins, but sometimes involves other areas all aspects of life, including school, work such as the thighs, arms and back. The and social activities. The appearance skin becomes rough and scaly. Affected of the skin can make patients anxious areas may show a criss-cross pattern of about exposing their skin and forming Page 11 relationships. Having an understanding of how eczema impacts on the quality of life for our patients is an important aspect of a holistic patient assessment. Several tools are available to help assess the effects of eczema on quality of life. These are listed in the professional resources section on page 38.

Diagnosis and Contact allergic dermatitis is diagnosed history by patch tests (see Box 3, page 14). If allergy is suspected to food or other It is important that the diagnosis is triggers, specific IgE blood tests will be correct, so that the right treatment taken (see Box 4, page 15). and lifestyle advice can be given and potential wider implications can be The history-taking should include the discussed. following questions and identify any trigger factors: All types of eczema are generally diagnosed by history and clinical • Onset: When did the eczema first examination, observing symptoms. start? If there is diagnostic doubt, further • Duration: How long has the investigation may be necessary: skin condition been present? scraping, for example, may be done to detect fungal infection; skin swabs may • Site: What areas are affected? be taken to diagnose bacterial infection • Pruritus (itch): How great is the (this is not routine, as skin infection degree of pain, itching and soreness is usually diagnosed on clinical associated with the eczema? What appearance); a skin biopsy may be measures are used to cope with required to detect other skin conditions this, and how does it impact on the or to make a firm eczema diagnosis. patient’s life? For older patients If itch is a major symptom in adults, complaining of pruritus, consider and an eczema diagnosis is uncertain, a further screening. pruritic screen can be taken to exclude • Family history: Is there, or has there other causes of underlying itch (see been, anyone else in the family with Box 1, page 14) skin disease, eczema, asthma or hay There are no specific tests for trigger fever? factors (see Box 2, page 14), unless • Occupation: What types of products allergy is suspected. Trigger factors are does the patient use? What kinds of diagnosed on patient history. protection are used at work (e.g.

Page 12 clothing, gloves and barrier creams)? Skin examination and Does the skin improve when the clinical presentation of patient is not at work? eczema • What Hobbies and leisure time: The clinical presentation of eczema types of hobbies does the patient varies depending on the type of eczema, have? Do they have contact with site affected and skin type. In Asian, particular materials and substances, Black Caribbean and Black African animals and plants or exposure to patients, atopic eczema can affect sunlight? the extensor surfaces rather than the • Clothing: What types of clothing flexures, and discoid (circular), papular fabrics are usually worn and which (small bumps) or follicular (around hair fabrics flare/irritate the eczema? follicles) patterns with lesions may be • Jewellery: What types of watches more common. In white skin these are and jewellery are worn? red or brown, but are black or purple in pigmented skin. Redness (erythema) • Impact on quality of life: How are in pigmented skin may be masked school, work, family and relationships completely, and post-inflammatory affected by the patient’s eczema? hypopigmentation (reduced) and • Skin care: What everyday products hyperpigmentation (increased) may (e.g. shampoo, soaps, wipes) are persist after the eczema has settled (see used? What skin-care products have images on page 4). been and are being used? What types When assessing the skin, ensure that all of make-up, perfumes and after- the areas are examined and document shave are used? using a body chart. Clinically, eczema • Medication: What medicines are can be classified as follows: taken regularly? What topical • Acute: The skin is erythematous medicaments are used? (Ask about (red), inflamed, and oedematous with prescribed and over-the-counter dryness and flakiness. There may be products.) vesicles (small fluid-filled blisters), • Allergies: Does the patient have which may coalesce to form large any known allergies to medicines or bullae (blisters) which ooze and crust. products that come into contact or • Sub-acute: The skin shows features are applied to the skin? of acute and chronic eczema but with • Diet: Is there anything in the less inflammation. environment that makes the skin • Chronic: The skin is lichenified worse? Is the patient affected by (thickened) (see page 4) with seasonal changes? In particular for accentuated skin markings from children under 2 years, does the repeated trauma (i.e. scratching, parent think their child is affected picking and rubbing). It is often darker by diet? (See diet section on pages than the surrounding skin, and fissures 35–36.) (splits and cracks) may be present. Page 13 Tests and triggers BOX 1 PRURITUS SCREEN • Detailed history of pruritus; skin lesions, severity • Constitutional symptoms: weight loss, fatigue, fever, malaise • Recent emotional stress • Drug history • Evidence of primary skin condition • General physical examination • If the duration is longer than two weeks and no other cause has been established, laboratory investigations and screens will be required: chest x-ray, full haematological screening and other tests dependent on assessment. To exclude: Metabolic and endocrine conditions, haematological disease, malignant neoplasms, hepatic disease, drug-induced cause, infestations, primary skin disease or psychogenic cause BOX 2 TRIGGER FACTORS

Irritants: soaps, detergents, fabric conditioners, wool, synthetic clothing, chlorine Overheating: after exercise (sweat), direct heat Climate: extremes of temperature, humidity, sunlight and seasonal variations Airborne: house-dust mite, animal dander, tree/grass pollens and mould Contact allergens: preservatives in topical treatments, perfumes, metals, latex Other environmental factors: smoking, traffic pollution Infections: bacterial and viral

BOX 3 PATCH TESTING

Patch testing involves the reproduction of allergic contact dermatitis under the patches in an individual sensitised to a particular antigen or antigens. It involves the application of the antigen to the skin at standard concentrations in an appropriate vehicle and under occlusion for 48 hours before removal, with a final reading at 96 hours. The reading will assess whether the reaction is a true allergic reaction or an irritant reaction. Page 14 BOX 4 SPECIFIC IGE BLOOD TESTS (RADIO ALLERGO SORBANT TESTS – RAST)

These tests look at allergen-specific IgE. However, the results should not be interpreted in isolation. An allergy diagnosis is based on an allergy-focused history, assessment of the eczema and response to treatment. The presence of allergen-specific IgE only indicates that sensitisation has occurred; it does not diagnose the allergy.

eczema), it can be found in over 90% Eczema and of patients. It is one of the commonest causes of secondary skin infection and infections eczema flares. All types of eczema can become infected. Signs of infection, including an acute Infections can be bacterial or viral. flare of the eczema with vesicles, Bacterial infection is often related to pustules, oozing and golden crusting, persistent scratching and damage to the can affect areas of eczema or the skin. Viral infections are due to the person whole body. Other bacterial infections with eczema being infected by a virus include folliculitis, impetigo and (e.g. by herpes simplex, the causative cellulitis. virus for eczema herpeticum). Bacterial inflection with S.aureus is Patients should be made aware of signs diagnosed by clinical signs. If there is of infection. If their skin flares and diagnostic doubt, skin swabs should does not respond to their prescribed be taken to identify the causative treatments, they should contact their organism and sensitivity to antibiotics. nurse or GP for a review. If they feel The decision on whether to treat with febrile or their skin is becoming confluent topical or oral antibiotics depends on or erythematous (widespread redness), several variables: whether the size of they should seek advice immediately. the infected area is greater or less than 5% (the size of 2 palms), whether there The most important factor is to identify are multiple sites of infection, and the cause/type of infection and initiate previous history. the correct treatment. For small, localised areas, topical Bacterial infections antibiotics or antibacterial corticosteroid combinations (e.g. Staphylococcus aureus (S. aureus) is the Fucibet or Synalar C or N) can be used, main bacteria which causes secondary generally for up to 14 days (see Box 9, infections in eczema. S. aureus can be page 28). found on the skin in 5–20% of people without eczema, but usually in low If the infection is not cleared by these amounts. However, in people with topical treatments within a 14-day inflamed eczema (particularly atopic period (one would expect a response Page 15 CREAM study (see further reading, page 38) has shown that even if there are signs of infection, children with milder eczema are unlikely to benefit from topical antibiotics, and their use can promote resistance and allergy or skin sensitization, so should be used with caution. The use of topical corticosteroids or stepping up their An acute flare with inflamed, red, and sometimes potency, in addition to applying blistered and weepy patches indicates a emollients, should therefore be the secondary bacterial infection. main focus in the care of milder clinically infected eczema flares. Bleach baths (using diluted Milton) are an emerging antimicrobial intervention for people with infected eczema. More research is required to understand how this potential adjunctive treatment option can reduce bacterial burden and, potentially, bacterial skin infections. Viral infections ECZEMA HERPETICUM A bacterial infection (staphylococcal) with oozing and crusting on an adult’s lower legs. Cold sores (caused by the cold sore virus, herpes simplex) are very common within 5 days), it will be necessary to in otherwise healthy individuals, switch to oral antibiotics. Systemic especially around the mouth. In people antibiotics should be prescribed for without eczema, cold sores usually 7 days in line with local antibiotic remain localised in a small area of skin guidelines and then reviewed. and clear up by themselves over a week or two. Other interventions include emollients with antimicrobial ingredients (see Box However, if the surrounding skin is 5, page 20, and Box 6, page 22), using inflamed and damaged from eczema creams rather than ointments as they (especially atopic eczema), the cold sore are easier to apply on wet skin, and virus can spread very rapidly, causing an potassium permanganate soaks. infection known as eczema herpeticum. Although rare, it is very important to be Note: Topical antibiotics, often in able to recognise eczema herpeticum as combination products such as topical it can be serious and potentially fatal. corticosteroids, are frequently used Eczema herpeticum needs immediate to treat eczema flares in children treatment with antiviral tablets and with milder eczema. However, the may require hospital admission for Page 16 shiny bumps (papules) (1–6mm) on the skin, which often form little clusters, with a small depression or dent in the middle of the bump (umbilicated). They can occur anywhere on the body including the face and genital area. They typically affect children between the ages of 4–8 years, but anyone – including adults – can get them. Although molluscum is extremely Eczema herpeticum requires immediate common in all school-age children, they antiviral treatment and an appropriate referral (dermatology/ophthalmology), as it is one of the are more common in people who suffer few dermatological emergencies. from atopic eczema. They usually clear spontaneously with time, which can vary IV aciclovir. Eczema herpeticum is a from 6 to 18 months. As they resolve, medical emergency that requires prompt, they may become inflamed, crusted or same-day treatment. scabby. Molluscum often causes eczema In the early stages, vesicles (small in the affected areas, and an itchy rash blisters filled with clear fluid), may sometimes appear on distant sites surrounded by a bright red halo, appear (an immunological reaction or ‘id’ to the on the surface of the skin. These virus). vesicles can leave punched-out erosions Generally, molluscum is not treated (the on the skin surface that can spread very papules will gradually disappear of their quickly, especially across the face. The own accord although this may take area may become very painful, and the several months). However, if a child with patient will feel generally unwell with eczema has molluscum over a large area the skin feeling sore and tender rather and it is affecting them psychologically, than itchy. there are some topical hydrogen peroxide Patients and parents need to ensure treatments available. Cryotherapy is that there is no skin-to-skin contact sometimes used but is painful. between anyone with a cold sore and VIRAL WARTS the patient with eczema. If eczema herpeticum is suspected, the patient Warts are caused by the human should seek same-day advice from papilloma virus (HPV), and there are a dermatologist, ophthalmologist (if many types, affecting a variety of body near eyes), GP or A & E doctor so that sites. Most warts are harmless and treatment can be given promptly. clear up without treatment. The length of time it takes for a wart to disappear MOLLUSCUM CONTAGIOSUM will vary from person to person. They Molluscum contagiosum is a harmless are common in children. virus caused by the pox virus. Molluscum develops as small, skin-coloured or pink, Page 17 Fungal and yeast infections Eczema Fungal and yeast infections management occasionally cause secondary infection It is important to spend time with in people with eczema. patients and their carers to discuss the cause of their condition, the diagnosis Yeast infections such as candida and to provide practical, realistic (thrush) can secondarily infect eczema advice in order for them to manage in warm, moist sites, such as under the their condition. breasts or in the genital area. Signposting patients to disease- and Fungal infections (tinea) can develop, age-specific information is important and discoid eczema is often mis- (see Further information and support diagnosed as ringworm. Tinea pedis from the National Eczema Society on (athlete’s foot) is a common fungal page 39). The consultation should be infection on the feet, and other tinea supported by a practical demonstration infections are named based on their of the treatments, including where site on the body. and when to use them and when to If a fungal infection is suspected, skin seek additional support if infection scrapings, and hair and nail samples is suspected. Ask if you can provide should be taken for mycology to emollient testers in the clinic, for identify the fungi. Treatment will patients to try, prior to prescribing, be based on the site of the body – explaining the differences between treatment for fungal infection is them and their role in treating usually topical but fungal scalp and eczema. This demonstration should nail infections do not respond to be supported with an individualised topical treatments and should be written plan and a follow-up date treated with oral therapies. booked to review progress, adjust the plan and reinforce education. Templates of individual plans for adults and children can be downloaded from www.eczema.org Washing and bathing Cleansing the skin is an integral aspect of eczema care. A daily bath or shower is recommended and it is very important to always use an emollient for washing. Soap, cosmetic washing products, wipes Round or oval red scaly patches, often less and any product containing bubbles red and scaly in the centre, are a common should be avoided as they contain Page 18 presentation of ringworm. detergent and fragrance, and are alkaline - all of these things have the potential to additional benefits if also using leave- dry and irritate the skin. on emollients and emollient as a soap substitute. These products are still SOAP SUBSTITUTES available to buy but they are unlikely Soap substitutes are used instead of to be prescribed. soap bars or liquid soap to cleanse the After bathing or showering, leave-on skin, in the bath or shower and also emollient should be applied. It is very for washing hands. There are various important that adequate quantities of washing products available (see Box 5, leave-on emollient are prescribed and page 20) and the patient may have that patients are encouraged to use it to try several before finding one they additionally as a soap substitute. like. They can use an emollient product Advise the patient not to have the designed specifically for washing, or water too hot (ideally it should be at their usual leave-on emollient as a body temperature (37ºC). Heat makes soap substitute (see Box 6, page 22). the capillaries in the skin dilate as the Soap substitutes can be applied to the skin tries to cool itself, and evaporates entire body, including the face, prior more water from the skin surface, to the bath or shower and rinsed off making the skin drier. in the water; alternatively, they can Hard water can be drying and irritating be used in the bath or shower like a to the skin so, if the patient lives in normal soap bar or liquid. a hard water area, it is even more Cleansing the skin with emollients important to use emollients for washing, removes surface dirt and debris (dried showering and bathing. Water softeners blood and skin scales), which could have been shown not to be of benefit in cause infection, helps to repair the the management of eczema. skin barrier by trapping moisture, reduces itching, removes and prevents Examples of bath and shower products build-up of previous treatments, and are shown in Box 5, page 20. A prepares the skin for the application leave-on emollient can be used as a of further treatments such as topical soap substitute (see Box 6, page 22) corticosteroids. – with the exception of liquid and white soft paraffin 50%/50%. For BATH AND SHOWER optimum benefit, the patient should be A daily bath or shower is recommended, encouraged to soak in the bath for a using emollient to wash with (NB plain maximum of 15–20 minutes. However, water without emollient will dry out the if the skin is cracked and painful, this skin). Bath additives added to the bath may not be possible. Emollient wash water, or applied directly to the skin in products may contain additional the shower, are no longer recommended therapeutic ingredients with anti-itch as there is evidence (the BATHE study and anti-microbial properties. It is – see further reading, page 38) that important that patients are aware of these additives provide minimal or no this as many people tend just to tip Page 19 BOX 5 BATH AND SHOWER PRODUCTS Bath Shower Additional properties Aveeno bath oil® Doublebase emollient Antimicrobial Balneum bath oil® shower gel ® Dermol 200 shower Cetraben emollient bath Oilatum shower emollient® (antibacterial) additive® emollient® Dermol Wash 200ml Diprobath bath oil® Wash products Dermol 600 bath emollient® E45 emollient bath oil® Aquamax Wash 250g Emulsiderm liquid emulsion® Hydromol bath additive® E45 Emollient Wash Oilatum Plus bath additive® Oilatum Junior emollient Cream 250ml bath additive® Eucerin Replenishing Body Anti-itch Wash 450ml Balneum Plus bath oil® QV Gentle Wash 250ml, 500ml

This is a selection of products available. The list is not exhaustive. Please see the National Eczema Society’s factsheet on Emollients. Alternatively, please visit BNF (www.bnf.org), eMC (www.medicines.org.uk) and MIMS (www.mims. co.uk) for prescribing guidance and a full list of available products. Note: The prescribing of some emollient products, especially bath additives, will be discretionary, as the BATHE study concluded that bath additives provided minimal or no additional benefit in the management of eczema. There is, however, a sound evidence-base for the use of emollients as leave-on products and soap substitutes, and these can be prescribed or bought.

them into the water and not measure Hair-washing should be performed them appropriately, which increases separately from bathing or showering the risk of causing an irritant effect to reduce the risk of the suds irritating and making things worse. Patients who the rest of the skin. It may be necessary do not have access to bath or shower to use medicated shampoo. facilities should be encouraged to sluice Some people with eczema find that tar- down using emollient oils, or wash with based shampoos suit them. However, their emollient soap substitute. there is limited evidence for their SHAMPOOS effectiveness and they can be smelly For infants with atopic eczema under 1 and sometimes cause orange/ brown year, shampoos are not recommended staining. For others, a non-tar-based – an emollient wash-product should be shampoo may be preferable – for used instead. If a shampoo is used, it example, E45 Dry Scalp Shampoo, or if should not contain perfume or nut oils the scalp is scaly, Dermax shampoo is and must be suitable for eczema. helpful.

Page 20 Emollients – leave-on glycerol and isopropyl myristate). These emollients have been shown to preparations prevent trans-epidermal water loss for Emollients are first-line eczema considerably longer than simple lotion treatments, used every day to repair and cream formulations. the skin barrier. They act by providing Patients will often need a choice, an occlusive layer to the skin, which reduces water loss, and some contain alternating between a couple of humectants (propylene glycol, lactic emollient creams/ointments – for acid, urea and glycerol), which draw example, a lighter one during the day water into the epidermis from the and in the summer, and a greasier one dermis. Emollients soothe, soften, at night and in the winter. The patient hydrate and protect the skin. They have may have to try several emollients an anti-inflammatory, antipruritic and before finding one that suits their skin. corticosteroid-sparing effect, and help Occasionally, emollient creams may to repair the damaged skin barrier. sting when they are first applied to They come in tubes, tubs and pump very dry skin, but this usually settles dispensers, and are available in several down after a few days. If stinging formulations (see Box 6, page 22). The persists, it may be due to a reaction recommended quantity to prescribe is to an ingredient in the cream, and an at least 500g for adults and 250g for alternative should be tried. children. More may be needed if the Emollients should be applied regularly eczema is very severe or the skin is very throughout the day or whenever the dry. skin feels dry, and also after washing. Creams are less greasy than ointments Emollients should be applied with clean and are easy to spread, are absorbed hands thinly and evenly to the entire easily into the skin and are good for body, and smoothed onto the skin so use during the daytime. Creams can be that the skin just glistens. To minimise used on weeping eczema. Ointments folliculitis, emollients should be applied are most suitable for very dry skin. gently in a soothing downward motion Humectant emollient creams mimic following the direction of the hair or comprise the same molecules as growth. (See Box 7, page 23 for tips on natural moisturising factors (e.g. urea, applying emollients safely.)

Decanting emollient before use to avoid Applying emollient following the direction contaminating the tub. of the hair growth. Page 21 BOX 6 EMOLLIENTS

PRODUCT NAME Lighter Moderate Heavy Humectant Emollient Emollient Emollient Aveeno© cream Aveeno© lotion Balneum© cream Balneum© Plus cream (anti-itch) Cetraben© cream Dermol© cream (anti-microbial) Dermol© 500 lotion (anti-microbial) Diprobase© cream Diprobase© ointment Doublebase© gel Emollin© spray Epaderm ointment© Eucerin© intensive 10% cream Eucerin© intensive 10% lotion E45© cream E45© Itch Relief cream Hydromol© cream Hydromol© ointment Imuderm Liquid & white soft paraffin (50%/50%) BP Oilatum© cream QV© cream Unguentum© M cream White soft paraffin BP

These are examples and the list is not exhaustive. Products are usually specified under local prescribing guidelines. Please see the National Eczema Society’s factsheet on emollients (www.eczema.org). Alternatively, please visit BNF (www.bnf.org), eMC (www.medicines org.uk) and MIMS (www.mims.co.uk) for prescribing guidance and a full list of available products.

Page 22 BOX 7 EMOLLIENT SAFETY

Correct application: Demonstrate Pots versus pumps: If pots or tubs correct use (thinly, gently, frequently, of emollient are used, advise using and in a downward motion following a clean spoon or spatula to decant the direction of the hair from the pot to prevent infections growth to prevent folliculitis). from contaminated pots. Emollients in pumps or tubes reduce this risk. New supplies should be prescribed at the end of treatment for infected atopic eczema.

Slipping: Care should be taken when Fire hazard: Bandages, dressings using emollients in the bath, shower and clothing in contact with or on a tiled floor as there is a risk of paraffin-based products (for slipping. Protect the floor with a example, White Soft Paraffin, White towel or sheet. After bathing or Soft Paraffin plus 50% Liquid showering, the bath/shower should Paraffin) are easily ignited with a be washed with hot water, and naked flame or cigarette. So please washing-up liquid, rinsed well and take care when near naked flames. dried with kitchen towel. This has several benefits: it prevents a build- up of emollient and skin debris, and reduces the risk of infection and slipping. Also, it helps to clear the drains and the build-up of grease.

MHRA alert: Aqueous cream Recent evidence about the use of aqueous cream and the role of sodium lauryl sulphate (SLS), an ingredient, has shown that it causes burning, stinging, itching and redness especially in children with atopic eczema, and has a detrimental effect on the skin barrier. Dermatologists do not recommend its use as a wash or leave-on product; there are better emollient formulations available which have a positive effect on skin barrier function. ------NOTE: Emulsifying ointment also contains sodium lauryl sulphate (SLS).

Page 23 Topical corticosteroids Topical corticosteroids are the most common treatment for inflammation in eczema. They do not cure eczema but act by reducing the inflammation that makes eczematous skin red, itchy and sore, and by reducing the itch sensation. Always leave a gap of 20–30 minutes between Topical corticosteroids are divided into application of emollient and topical corticosteroid. four potency groups in the UK: mild, moderate, potent and very potent be used. It is important to remember (see Boxes 8 and 9, pages 26–9) to that potency increases under occlusion assist in choosing the appropriate (i.e. bandages and dressings), so here a corticosteroid for the severity of lower potency should be used. the inflammation, the extent and On other parts of the body, adults location of the eczema and the age of with moderate to severe eczema will the patient. Potency classification is usually be prescribed moderate to primarily determined by reference to potent corticosteroids, with very potent the amount of vasoconstriction that prescribed by an experienced GP or is produced. However, potency of a dermatology specialist for very severe topical corticosteroid also depends flares. on the formulation, i.e. the salt it contains (diproprianate and butyrate Mild topical corticosteroids are salts are stronger than valerate salts). generally used for babies and In addition, the presence of other children with mild to moderate ingredients (e.g. salicylic acid or urea) eczema. Depending on the part of and occlusion may increase absorption the body being treated, children with and so potency. more severe eczema will usually be prescribed moderate to potent Topical corticosteroids are prescribed corticosteroids for short periods and by taking into account the patient’s age under supervision. (children have a greater body-surface to weight ratio), the severity of their NICE recommends that topical eczema, any other treatments used and corticosteroids are applied once a day the part of the body affected. for children under 12 years. For older children and adults, corticosteroids are Mild or moderate corticosteroids are usually prescribed once or twice a day. usually used for the genital area and the face, where the skin is thinner, Topical corticosteroids are generally whereas in thicker areas of skin (e.g. used for short treatment bursts when the soles of the feet and the palms of the eczema is flaring. Unless the the hands) potent or very potent may eczema is being managed by a mild Page 24 corticosteroid, NICE advocates a Adverse reactions to topical stepped approach to management, corticosteroids do worry patients, with the topical corticosteroid and so it is essential to give balanced treatment tailored to the severity advice to encourage adherence with of the treatment and the age of treatment plans. Patients are often the patient. In practice, this means very concerned about using topical that if the eczema is flaring on the corticosteroids due to skin thinning. body of an older child or adult, a This means that patients are either potent corticosteroid may be used too scared to use them on their own for a week to ‘hit’ the flare, and then or their child’s skin or do not use them stepped down to every other day or as prescribed. Topical corticosteroids to a moderate corticosteroid until the need to be used correctly, with support eczema has settled. NICE recommends and education on the right amounts a similar approach to treating facial to apply so that side effects can be eczema but with weaker potencies of avoided or reduced. In brief: corticosteroids. • Topical corticosteroids are matched Some patients with more persistent flares may use what is termed to the severity of the eczema, the ‘weekend therapy’ (i.e. using age of the patient and the area of corticosteroids on 2 consecutive the body treated. days per week) for more long-term • Topical corticosteroids should be management until the eczema settles stepped up and down to treat down and emollients only can be used. eczema. When stepping up and down with topical corticosteroids, emollients • Sometimes ‘weekend’ therapy (or should be used at all times, even when use on 2 consecutive days per week) the eczema is clear. may be advised by a healthcare professional for maintenance. Written information is essential to support the verbal discussion. It should outline the emollient therapy and topical corticosteroids to be used, stating the potency and site to be treated. See www.eczema.org for individualised plan templates for adults and children. It is important for both the patient and the healthcare professional to have regular reviews to build a therapeutic Appropriate supervision of topical relationship, and to gain knowledge corticosteroids is required. about the effectiveness of the treatments. Page 25 BOX 8 TOPICAL CORTICOSTEROIDS

Trade name Generic name Strength (This is the name chosen (This is the official name of the (Potency) by the manufacturer – it is corticosteroid – it is usually written in big print on the tube) in smaller print on the tube)

Dermacort® Hydrocortisone 0.1% Mild

Dioderm® Hydrocortisone 0.1% Mild

Hc45® Hydrocortisone 1% Mild

Hydrocortisone 0.5% Hydrocortisone 0.5% Mild

Hydrocortisone 1% Hydrocortisone 1% Mild

Lanacort® Hydrocortisone 1% Mild

Mildison Lipocream® Hydrocortisone 1% Mild

Synalar 1 in 10® Fluocinolone acetonide 0.0025% Mild

Betnovate-RD® Betamethasone valerate 0.025% Moderate

Eumovate® Clobetasone butyrate 0.05% Moderate

Haelan® Fludroxycortide 0.0125% Moderate

Modrasone® Alclometasone dipropionate 0.05% Moderate

Page 26 Synalar 1 in 4® Fluocinolone acetonide 0.00625% Moderate

Ultralanum Plain® Fluocortolone hexanoate 0.25% Moderate

Betnovate® Betamethasone valerate 0.1% Potent

Cutivate® Fluticasone propionate 0.005% Potent

Diprosone® Betamethasone dipropionate 0.05% Potent

Elocon® Mometasone furoate 0.1% Potent

Locoid® Hydrocortisone butyrate 0.1% Potent

Metosyn® Fluocinonide 0.05% Potent

Nerisone® Diflucortolone valerate 0.1% Potent

Synalar® Fluocinolone acetonide 0.025% Potent

Dermovate® Clobetasol propionate 0.05% Very potent

Nerisone Forte® Diflucortolone valerate 0.3% Very potent

This is not an exhaustive list. Please also see the National Eczema Society’s factsheet on topical corticosteroids (www.eczema.org). Alternatively, please visit BNF (www.bnf.org), eMC (www.medicines.org.uk) and MIMS (www.mims. co.uk) for prescribing guidance and a full list of available products.

Page 27 BOX 9 TOPICAL CORTICOSTEROIDS WITH ADDED ANTIMICROBIAL EFFECTS

Trade name Generic name (This is the name used by the manufacturer – (This is the official name of the corticosteroid – it is in big print on the tube) it is usually written in smaller print on the tube)

Canesten HC® Hydrocortisone 1% Antifungal Clotrimazole Mild

Daktacort® Hydrocortisone 1% Antifungal Miconazole nitrate Mild

Fucidin H® Hydrocortisone 1% Antibacterial Fusidic acid Mild

Nystaform HC® Hydrocortisone 0.5% Antibacterial Nystatin Chlorhexidine Mild Antifungal

Timodine® Hydrocortisone 0.5% Antibacterial Benzalkonium chloride Mild Antifungal Nystatin

Trimovate® Clobetasone butyrate 0.05% Antibacterial Oxytetracycline Moderate Antifungal Nystatin

Aureocort® Triamcinolone acetonide 0.1% Antibacterial Chlortetracycline hydrochloride Potent

Betnovate-C® Betamethasone valerate 0.1% Antibacterial Clioquinol Potent

FuciBET® Betamethasone valerate 0.1% Antibacterial Fucidic acid Potent

Lotriderm® Betamethasone dipropionate 0.064% Antifungal Clotrimazole Potent

Synalar C® Fluocinolone acetonide 0.025% Antibacterial Clioquinol Potent

Synalar N® Fluocinolone acetonide 0.025% Antifungal Neomycin sulphate Potent

Page 28 Main antimicrobial effect Added antimicrobials Strength (which type of infection (Potency) it is used in)