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Management of Eczema

Management of Eczema. Practical approach. Heulwen Wyatt R.G.N. R.S.C.N. Dip. Prof. Prac. (Derm) MSc Clinical Nurse Specialist in Paediatric Dermatology. Atopic Eczema. Increasing incidence Affects approximately 1:5 children Familial tendency Associated with asthma and hayfever

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Management of Eczema

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  1. Management of Eczema Practical approach Heulwen Wyatt R.G.N. R.S.C.N. Dip. Prof. Prac. (Derm) MSc Clinical Nurse Specialist in Paediatric Dermatology

  2. Atopic Eczema • Increasing incidence • Affects approximately 1:5 children • Familial tendency • Associated with asthma and hayfever • Most outgrow by the age of 7yrs

  3. Normal Barrier Function

  4. Increased trans-epithelial water loss

  5. Role of steroids

  6. Role of Emollients

  7. Moisturisers • Emollients tend to increase the efficiency of the epidermis • Barrier function Enhance the effects of emollients with occlusion - bandages, wet wraps

  8. Bath Oils or Soap Substitutes • Bath additives – use daily • Oily preparations • Float on water or emulsion • Increasingly soap substitutes preferred

  9. Steroids • Available in 4 strengths • mild - e.g. hydrocortisone • moderate - e.g. eumovate • potent - e.g. cutivate, betnovate • very potent - e.g. dermovate

  10. 9 month baby • Seen 2 months ago and given 500g Aqueous cream, 60g Hydrocortisone 1% cream. • Never clear, awake every night. • What would you prescribe?

  11. Treatment • Swabs, Flucloxacillin • Eumovate ointment 200g for 4 week peroid • 1kg emollient • Soap substitute or bath oil • TIP - split base of earlobe first sign eczema in many babies - avoid soaps

  12. Aqueous Cream • Not suitable as a moisturiser • Only prescribe as a soap substitute

  13. Facial Eczema in Children • Calm down skin with steroids • Immunomodulators • Reduce stinging by using both steroids and immunomodulators for five days • Remember – Tomato sauces and baby wipes!!

  14. How would you approach management? • 2 year old with extensive low grade eczema • Skin very dry • Mum states he’s allergic to all moisturisers as skin goes red and he screams • Refuses to go in bath

  15. Top Tips • Explain that very dry skin takes pale scaly apearance • Any water based emollients may sting dry skin • Ointment soap substitute before bath

  16. Don’t Don’t alter diet Don’t use soaps Don’t bother with housedust mite measures Don’t advise allergy tests

  17. Olive Oil • Contraindicated on the skin • Damages the barrier function of stratum corneum • Use mineral oil or sunflower oil

  18. 7yr old with eczema since aged 1 • Used Eumovate ointment daily for 2 weeks • Scratching at night • Has ointment emollient but won’t use it as makes skin feel sticky.

  19. Treatment • Viscopaste bandages • Coban or actifast • Offer variety of emollients - cream form • Antibiotics?

  20. Occlusive bandages • Hands before treatment and one week after treatment with occlusive bandages, eumovate and flucloxacillin

  21. Hands • Viscopaste to individual fingers or wet mitts over emollients

  22. Generalised severe eczema • If good compliance and appropriate treatment, consider wet wraps • TIP - check for scabies!

  23. Wet Wraps • Steroids and emollients under damp bandages • Ready made garments

  24. Prognosis • Poor: • Severe disease in childhood, family history, asthma, rhinitis, late onset (after 2 yrs), atypical pattern, hand involvement, xerosis

  25. STEROIDS - cream or ointment? • Ointment (oil based) - steroid of choice. Less additives. Helps re-hydrate the skin. • Cream (water based) - use on weeping eczema or when cosmetic acceptability is an issue.

  26. Steroid Quantities • 1 finger tip unit (f.t.u.) = 1/2g = 2 adult hand’s worth of eczema

  27. Steroid quantities • Twice daily application of steroid all over • 6 month old = 9.5g daily = 66.5g weekly • 4 year old = 19.25g daily = 134.75g weekly • 7 year old = 24.5g daily = 171.5g weekly

  28. Typical Daily Routine • 07.20 Wash (soap substitute) • 07.30 Steroid to all patches • 08.00 Moisturiser all over • 12.00 Moisturiser all over • 15.30 Moisturiser all over • 18.30 Bath with oil / soap substitute • 18.45 Steroid to all patches • 19.15 Moisturiser all over

  29. Typical Month’s Prescription • Example - extensive flare of moderate eczema in a 3 year old • Moisturiser - 1.5kg • Soap substitute - 500g • Bath oil - 500mls • Steroid - 300g • +/- antibiotics, bandages etc

  30. What would you do? • Known eczema patient. • Flare last three days. Treated with cutivate. Generally unwell.

  31. Eczema Herpeticum • Dermatology emergency • Stop steroids • Acyclovir - oral or iv • Opthalmic opinion • Admit if unwell

  32. Happy customers

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