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• Most outgrow by the

age of 7yrs

Normal Barrier Function

Increased trans-epithelial water loss

Role of steroids

Role of Emollients

Moisturisers

• Emollients tend to increase the efficiency of the epidermis

• Barrier function

Enhance the effects of emollients with occlusion - bandages, wet wraps

Bath Oils or Soap Substitutes

• Bath additives – use daily

• Oily preparations• Float on water or

emulsion• Increasingly soap

substitutes preferred

Steroids

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

• 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?

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

Aqueous Cream

• Not suitable as a moisturiser• Only prescribe as a soap substitute

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!!

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

Top Tips

• Explain that very dry skin takes pale scaly apearance

• Any water based emollients may sting dry skin

• Ointment soap substitute before bath

Don’t

• Don’t alter diet• Don’t use soaps• Don’t bother with

housedust mite measures

• Don’t advise allergy tests

Olive Oil

• Contraindicated on the skin

• Damages the barrier function of stratum corneum

• Use mineral oil or sunflower oil

• 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.

Treatment

• Viscopaste bandages

• Coban or actifast

• Offer variety of emollients - cream form

• Antibiotics?

Occlusive bandages

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

Hands

• Viscopaste to individual fingers or wet mitts over emollients

Generalised severe eczema

• If good compliance and appropriate treatment, consider wet wraps

• TIP - check for scabies!

Wet Wraps

• Steroids and emollients under damp bandages

• Ready made garments

Prognosis

• Poor:• Severe disease in

childhood, family history, asthma, rhinitis, late onset (after 2 yrs), atypical pattern, hand involvement, xerosis

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.

Steroid Quantities

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

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

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

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

What would you do?

• Known eczema patient.

• Flare last three days. Treated with cutivate. Generally unwell.

Eczema Herpeticum

• Dermatology emergency

• Stop steroids

• Acyclovir - oral or iv

• Opthalmic opinion

• Admit if unwell

Happy customers