Most patients with mild to moderate eczema can be managed in general practice.

When Can We Help?

1. If the diagnosis is uncertain.

2. If you suspect contact allergic dermatitis.

3. To teach wet wraps for children with very dry eczema.

4. Inpatient treatment.

5. Severe eczema: for consideration of UVB phototherapy, PUVA, Azathioprine, Prednisolone or Cyclosporin.

6. Protopic ointment (after steroid failure).

Which Patients With Eczema Should Be Selected for Patch Testing?

1. Face or eyelid eczema unless obviously part of a widespread atopic or seborrhoeic eczema.

2. Otitis externa.

3. Hand or foot eczema unless obviously part of a widespread constitutional eczema.

4. Pruritus ani with eczema.

5. Pruritus vulvae with eczema.

6. Some cases of lower leg eczema associated with venous hypertension – but refer to “Step Forward for Healthy Legs” for low allergen regime.

7. Asymmetrical eczema – but exclude tinea first.

8. Patients with eczema who seem to get worse with treatment. We occasionally see contact dermatitis to topical steroids as well as other medicaments.

Patch testing should only be done in the Dermatology Department – it is a specialised investigation.

Prick testing is rarely required in children with eczema, even though it may be relevant for their associated asthma. The Dermatology department do not do prick testing which is a test for type I sensitivity.

Management of Eczema in General Practice

Management of Eczema in Children

Usually atopic eczema.

Routine Treatment

KEEP IT SIMPLE-FOLLOW ABC

A. Avoid soap and use bath or shower moisturisers

B. Bland moisturisers directly to the skin

C. Control inflammation with corticosteroid ointments or creams.

Emphasise importance of moisturisers. Keep topical steroids to the weakest possible – usually hydrocortisone in children. Do not use the most potent steroids in children (eg Betnovate, Elocon, Fucibet, Dermovate) unless for short periods of time (one week) and under supervision.

Prescribe steroid ointments rather than creams. Creams can be used for weeping eczema or on the face.

If Infected

Eczema that weeps is probably infected with Staphyloccus aureus. DO SWABS.

1. Use antiseptic/moisturiser combinations, eg: either Oilatum Plus in the bath or Dermol 500 directly onto the skin.

2. If infection suspected, prescribe oral antibiotics and continue topical steroids.

3. If severe, give flucloxacillin for 10 days (penicillin allergic, give Erythro/clarithromycin)

4. If recurrent infections occur, take nasal swabs from family members and, if positive, use Naseptin or Bactroban nasal (tds for one week each month for 6 months).

5. If a child exhibits nasal carriage of Staph. aureus, remember that it may not clear with flucloxacillin and so give Naseptin or Bactroban nasal.

6. The sudden development of vesicopustules, usually in one area, and often with fever (the child will be ill) may represent eczema herpeticum:

a. take viral swabs (special medium required)

b. treat with Acyclovir tablets (dose is weight dependent)

c. refer urgently if in doubt.

Zipzoc and Steripaste Bandages

These are both very soothing for persistent eczema on the limbs, usually with Hydrocortisone Ointment 1% underneath.

Antihistamines

Ucerax (hydroxyzine), Vallergan or Phenergan given to a child at night can reduce scratching and improve sleep (for the parents as well!)

Protopic ointment (tacrolimus)

This is an immunomodulator which is indicated for moderate to severe eczema in patients who have failed to respond to conventional topical steroid therapy or for facial disease. It is not licensed for children under 2 years of age or pregnant/breast feeding women.

Side effects include early, transitory, local irritation.

Elidel cream (pimecrolimus)

This also an immunomodulator similar to, but slightly weaker than Protopic ontment. It is indicated for mild to moderate eczema and otherwise has the same indications and side effect profile as Protopic. It is not as greasy as Protopic and thus may be more acceptable on the face and flexures.

Epogam

There is no consistent evidence that it helps and it is expensive. It is not available on NHS prescription now.

Chinese Herbs

There is no product licence and there is poor standardisation. It does have a measurable effect in some children, but can’t yet be recommended.

Central Heating

Keep the house, and especially the bedroom, cool.

Dust Control

There is some evidence that the house dust mite can aggravate atopic eczema in children. Keep dust down and, in severe cases, try protective coverings to pillows and bedding, damp dusting, removal of carpets and drapes/curtains (replace with blinds). Expensive!

House Dust Mite Prevention

Bedding: “Ventiflex” Coverplus
Hyde
Chester

It is suggested that the parents get details of dust prevention from the National Eczema Society.

Diet

Dietary allergens are not the cause of atopic eczema in children, but rarely egg and cow’s milk may aggravate it. If diets are attempted, a dietician must be involved. Most children grow out of their “food allergies”.

Prognosis

Fifty percent of eczema has gone by the age of eleven and sixty-five percent of eczema has gone by the age of sixteen. In some patients, whose eczema has disappeared in their teens, it may recur in adult life.

Careers

Children with atopic eczema, even if it remits by their teens, are more likely to develop primary irritant dermatitis in certain occupations. The following careers may be inadvisable:

Hairdressing
Catering
Nursing
Mechanical Engineering (cutting and soluble oils)
Car mechanic
Labouring

Advice to a Pregnant Mother

If the mother herself has had atopy or has another child with atopic eczema, it is advised that she herself should avoid peanuts while pregnant. Breast feeding a baby for at least six months is advised but this is also now debatable on current evidence.

National Eczema Society

Hill House,
Highgate Hill,
London
N19 5NA Telephone: 0207 281 3553 / 0870 241 3604

Management of Eczema in Adults

Adult Atopic Eczema
Discoid Eczema
Venous Eczema
Seborrhoeic Dermatitis

Much of the advice already given is applicable but, in general, more potent topical corticosteroids will be required and therefore closer supervision will also be required.

Always prescribe moisturisers for the bath, shower and direct to the skin and usually prescribe topical corticosteroid OINTMENTS rather than creams.

Elocon (Ointment, cream and lotion), Cutivate (Ointment or cream) are potent steroids and are long acting and only require daily application.

They are rapidly metabolised and so the risk of suppression of pituitary adrenal axis is reduced. They are, however, as potent as Betnovate and patients should be monitored closely for atrophy. There is some evidence that they are less likely to produce atrophy of the skin, but this is by no means certain.

We suggest that you do not prescribe any topical corticosteroid in the potent or very potent groups on a repeat prescription basis. This advice could be used as a quality control within your Practice. Also, Betnovate RD, which is in the moderately potent group, can induce skin atrophy, particularly in the flexures and on the inner upper thighs.

Moisturisers and Emollients

Some patients have an emollient preference and so we usually suggest you supply several in order to find something that the patient likes and will, therefore, use.

1. As a soap substitute: -

Aqueous Cream 500 gm
Diprobase Cream 500 gm
Oilatum Shower Emollient 125 gm
E45 wash 250 ml
If infected – Dermol 200 or 500

OR

2. In The Bath: -

Oilatum Emollient 500 ml
Dermalo 500ml
E45 bath 500 ml
Balneum 500 ml
Emulsiderm 300ml/1L
Alpha-Keri Bath Oil 240ml/480ml
Diprobath 400 ml
Aveeno Bath Oil 250 ml
Hydromol 350 ml/1L
If infected – Oilatum Plus 500 ml, Dermol 500/600 500 ml

Oilatum Plus is only a bath product and must not be applied directly to the skin as it would be irritant in an undiluted form.

3. Moisturisers/emollients- used after washing/bathing and at least three times daily:

Lightest first: -

E45 cream 500 gm
Hydromol cream 500 gm
Diprobase cream 500 gm
Doublebase 500 gm
Neutrogena Dermatological cream 100 gm
Unguentum Merck 500 gm
Hydrous ointment (oily cream) 500 gm
Epaderm (greasy but very effective) 500 gm
White Soft Paraffin/Liquid Paraffin 50:50 (greasy but very effective) 500 gm
If infected – Dermol 500

Topical Corticosteroids

Mild: -

Hydrocortisone 1%
Synalar 1:10

Moderately Potent: -

Hydrocortisone 2.5%
Eumovate
Haelan
Betnovate RD

Potent: -

Propaderm
Betnovate
Synalar
Metosyn
Locoid
Elocon
Cutivate
Diprosalic

Very Potent: -

Dermovate

Amounts of Steroid to Prescribe

Depending on extent and severity – two to four weeks in an adult:

• Face 30 gm
• Hands 60 gm
• Scalp 60 gm
• Arms and Legs 200 gm
• Body 200 gm
• Groin and perineum 30gm

Or prescribe by fingertip unit (a fingertip unit is the amount required to cover the terminal phalanx of the index finger)

• Face and Neck 2.5 ftu
• Trunk: front 7 ftu
• Trunk: back 7 ftu
• One arm 3 ftu
• One hand 1 ftu
• One leg 6 ftu
• One foot 2 ftu

Potassium Permanganate Soaks

Potassium Permanganate soaks are very useful for weeping hand and/or foot eczema.
Use Permitabs. One tablet dissolved in four litres of water gives: 1:10,000 solution.
Soak once/twice a day for ten minutes- longer will stain the nails.
Warn patients about staining of the skin, nails, towels and the bowl.
Stop soaks as soon as the rash has dried up – usually a few days.

Seborrheic Dermatitis

Typical asymptomatic scaling is seen on the chest, nasolabial folds of the face, ears, scalp and eyebrows.

There is now good evidence that this is due to infection of the skin with the yeast Pityrosporum. It usually responds well to Nizoral Cream and/or Nizoral Shampoo. Sometimes a mild corticosteroid such as Hydrocortisone is required as well, or combination therapy such as topical Daktacort. All medicated shampoos may help (eg Selsun shampoo, T gel, Capasal).

Seborrhoeic dermatitis is incurable and will recur after treatment cessation, particularly during “stressful” periods. Maintenance treatment is often necessary.