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

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Eczema and its Management A Guide for Healthcare Professionals CONTENTS PAGE Contents Introduction 1 Bandaging 31 Antihistamines What is eczema? 1 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.
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