ECZEMA

• Introduction

• Case Scenarios

• Conclusions

Introduction

Eczema = Dermatitis

Effect on Quality of Life(Burden of Disability)

• 10-15% children suffer from atopic dermatitis

• Asteototic dermatitis is becoming more and more common in the elderly

• Hand dermatitis is a major cause of absence from work

• Basic assessment and treatment

Case 1

• 6 months old child• Onset of problems at

age 2 months• Formula fed child-

several changes in milk tried

• “None of the ointments work”

• Sleeping poorly• Allergy tests?

Basic Management of Atopic Dermatitis

• Explanation – expectations of treatment

• Emollients

• Topical Corticosteroids

Explanation

• Incredibly common

• Cause unknown – NOT allergy

• Self-limiting in most cases (eventually)

• Waxing and waning natural history

Emollients

• Bath

• General

• No limit to their use

Topical Corticosteroids

• Mainstay of treatment

• Not dangerous if properly used

• Most “steroid phobias” allayed by explanation

• Awareness of different strengths

Package of Care

• Time

• Explain

• Prescribe a package of emollient(s) and topical steroid(s)

• Empower the parents to alter strengths of corticosteroids depending on clinical severity

Role of Nursing Colleagues

• Ideal disease for follow-up by practice nurses and health visitors

• Offer support through chronic disease

• Easy access for flares of disease

• Support from specialist dermatology nurses in secondary care

What about Infection?

• Staphylococcus aureus on 100% of skin lesions

• But antibiotics don’t cure atopic dermatitis

• But some cases improve when either topical or systemic antibiotics added

Eczema Herpeticum

• Unwell patient• Severe pain• Typical umbilicated,

coalescing papules• Herpes simplex virus

(usually type 1)• Urgent hospital

admission

What to Try if Adequate control NOT Achieved

• Concordance (social issues)

• Infection

• “Pulse” of stronger topical corticosteroid

• Bandaging

• Referral

Case 2

• 75 year old man

• Retirement apartment

• Likes to keep clean

• Diuretics

• Itching started on legs and spread to arms and trunk

Pathogenesis

• Dryness and suppleness = state of hydration of Stratum corneum

• State of hydration of stratum corneum dependant on rate of migration of water through stratum corneum and rate of evaporation from its surface

• Natural level of skin lipids decreases as age increases

Management

• Is the patient clinically or sub-clinically dehydrated?

• Is the environment too dry?

• Is the skin being degreased too frequently or too harshly?

• Emollient

• Topical corticosteroid – dip in and out after initial pulse

Case 3

• 40 year old man

• “Fed-up” with years of dandruff

• Recent onset of itchy, red scaling of eyebrows, naso-labial folds

Seborrheic Eczema

Pathogenesis

• Tentative

• Increased numbers of Pityrosporum ovale coupled with ? Genetic tendency

Treatment

• Targeted against both P.ovale and inflammation

• Chronic condition therefore need for repeated periods of treatment

• Anti-Pityrosporum shampoo eg Selsun, Head & Shoulders, Nizoral (contact time)

• Combination anti-Pityrosporum and anti-inflammatory cream eg Cannesten HC, Daktacort, Nizoral

Case 4

• 35 year old car mechanic

• “Eczema” as a toddler but clear for years

• Recent onset dry, itchy, red rash both hands

• Some improvement when goes on holiday

Hand dermatitis

• Multifactorial

• Endogenous

• Irritant

• Allergic

• Infection – Bacterial and Fungal

Management

• Package of treatment

• Address any precipitating cause

• Scrapings for mycology and swab for bacterial contamination/infection if indicated

• General hand care

• Emollients

• Topical Corticosteroid

Conclusions

• Diagnosis

• Precipitating causes

• Time for explanation – natural history

• Empower the patient to treat their disease

• Package of treatment

• Point of follow-up

What to Try if Adequate control NOT Achieved

• Concordance (social issues)

• Infection

• “Pulse” of stronger topical corticosteroid

• Bandaging

• Referral

Any eczema questions?