Eczema = Atopic Dermatitis

Fact Sheets

Overview

  • Chronic, itchy, inflammatory skin disease

Prevalence

  • 5 to 20% of children

  • Most people grow out of it

Risk factors

Family History

  • Family history of atopy (asthma, eczema, allergy, hayfever) is present 70% of the time

  • 1 parent with atopy increase risk 2-3x

  • 2 parents with atopy increase risk 3-5x

Environmental

  • “Hygiene hypothesis” - Less eczema in children exposed to

    • Early daycare

    • Infections e.g. pinworms, tapeworms

    • Higher number of siblings

    • Farm animals

    • Pet dogs in early life

Cause

  • Multiple mechanisms

    • Skin barrier dysfunction - Likely the main problem

    • Genetic factors

    • Altered skin bacteria

    • Environmental triggers of inflammation

Symptoms

Acute Eczema

  • Intense itch

  • Red raised patches

  • Blisters

Chronic Eczema

  • Dry skin

  • Scaly

  • Scratched or abraded

  • Red raised patches

Variants

Atopic hand eczema

  • Backs of hands and wrists

  • Common in those exposed to “wet work” e.g. dishwashing

Pompholyx

  • Small itchy deep blisters on fingers and palms

Eyelid Eczema

  • Eczema on eyelids, and around the eyes

Atopic Cheilitis

  • Drying, peeling, and cracking of the lips

Laboratory Tests

  • 80% of people have high IgE levels, often with high blood eosinophils

Clinical Course

  • Chronic, relapsing course over months to years

  • Mild cases may experience intermittent flares with spontaneous remission

  • Moderate to severe cases rarely clearly without treatment

Associated conditions

  • Allergic rhinitis (hayfever)

  • Asthma

  • Hives, anaphylaxis, and eosinophilic oesophagitis.

  • Ichthyosis vulgaris (dry scaly skin)

  • Eye diseases such as atopic kerato-conjunctivitis

  • Psychiatric disorders have been implicated to be associated with atopic dermatitis

  • Anaemia

  • Psychosocial changes including

    • ADHD

    • Learning disabilities

    • Depression and Anxiety

Treatment

The goals of treatment are to :

  • Reduce symptoms

  • Prevent exacerbations

  • Minimise therapeutic risk

Assessment of Severity

  • Mild

    • Dry skin

    • Infrequent itch

    • With or without redness

    • Little impact on sleep, everyday activities and psychosocial wellbeing)

  • Moderate

    • Dry

    • Frequent Itch

    • Redness (with or without skin thickening)

    • Moderate impact on everyday activities and psychosocial wellbeing

    • Frequently disturbed sleep

  • Severe

    • Widespread dry skin

    • Incessant itch

    • Redness with or without

      • Skin thickening

      • Bleeding

      • Oozing

      • Cracking

      • Pigment changes

    • Severe limitation of everyday activities and psychosocial functioning

    • Nightly loss of sleep

Elimination of exacerbating factors

  • Excessive bathing without subsequent moisturising

  • Low humidity environments

  • Emotional stress

  • Dry skin

  • Overheating of skin

  • Exposure to solvents and detergents

  • Anything that produces an itch stimulus

Adjunctive Measures

  • Treat skin infections such as staph aureus

  • Use antihistamines for sedation and control of itching

  • Manage stress and anxiety

Skin hydration

  • Emollients should be applied at least two times daily and immediately after bathing or hand washing

  • Thick creams (which have a lower water content) or ointments (which have zero water content) are generally preferred as they better protect against dry skin, but some patients complain they are too greasy.

Optimal Everyday Management

Optimal everyday management (clear skin - mild atopic dermatitis flare, no infection)

Children with eczema must bathe daily and have moisturisers applied at least twice per day top-to-toe. This should continue even when the skin is clear.     

Moisturisers

  • A thick, plain, alcohol-free and fragrance-free moisturiser, with high oil and low water content should be used (see appendix below).

  • Avoid contaminating the moisturiser with bacteria from the hands. With tubs use a tool such as a spatula (not hands) to remove it and place it onto clean paper. Moisturiser from the paper can then be applied by hand to the child’s skin.

  • Apply moisturisers generously twice per day and after bathing or hand washing.

  • Avoid moisturisers containing fragrance, plant or food products (eg vegetable, nut or olive oils) as these may disrupt the skin barrier and sensitise the skin leading to food allergies.

Bathing

  • Daily bathing aids to reduce the bacterial skin load and reduce the risk of infection

  • Baths and showers should be kept luke-warm (<31oC) and limited to 5 minutes to avoid skin flares

  • A capful of bath oil should be added to bath water

  • Do not use soap or shampoo. Use soap-free skin cleansers that will not irritate the skin

  • Use fresh towels with every bath to prevent infections

General considerations

  • Keep skin intact: Avoid skin trauma caused by abrasions (eg rough fabrics, sand) and chemicals (eg soaps). Keep fingernails short. Mittens or night-time hand splints may help prevent scratching when asleep.

  • Food allergies: Allergy testing is usually not required. As food allergy is not commonly responsible for eczema flares, parents are encouraged to discuss the initiation of restrictive diets with a Dermatologist or General Paediatrician.

  • Antihistamines may help ameliorate eczema pruritus. Avoid long-term antihistamine use, manage with eczema flare treatment instead

Minimising common eczema flare triggers

Overheating

  • Keep baths (<31oC), the home and car cool (<18oC)

  • Avoid air-blowing heaters & low humidity environments

  • Use light bed coverings & pyjamas (eg cotton pyjamas, avoid woollen underlays, plastic mattress protectors, sleeping bags, hot water bottles)

  • Avoid thick and multiple layers of clothing

Dry skin

  • Avoid (alcohol) nappy wipes. Use a cloth with water & bath oil.

  • Bathe or shower with bath oil immediately after swimming in a pool
    Avoid dummies – drooling can cause irritation

  • Apply barrier cream to the perioral area when the infant is dribbling

Irritants

  • Use a non-perfumed clothes detergent

  • Avoid chemicals such as soaps & talcum powders

  • Remove clothing tags

  • Avoid rough & prickly fabrics

  • Manage anxiety or behaviours that promote scratching

  • Keep nail shorts.

Infection / Inflammation

  • Daily bathing using appropriate cleansers and/or bath oils.

  • Wash hands before applying eczema treatments

  • Seek medical review early if concerns of infection not responding to prescribed treatment

Eczema flares

Steroids:

  • Topical steroids (see appendix below) are required once or twice daily until the skin is completely clear to reduce skin inflammation.

  • Steroids should be applied generously underneath the moisturiser. Steroid dosage can be calculated using the "Fingertip Unit" method

  • Facial eczema should be treated with low potency steroids to avoid chemical skin irritation.

Moisturisers:

  • The frequency of moisturiser must increase – apply at least 4 times per day

  • Apply the moisturiser on top of other topical medicines such as steroids.

Wet dressings:

  • Assist to return moisture to the skin, protect from infection and further trauma, and help to reduce irritation and itch

  • Dressings should be applied with every flare 1-4 times daily for at least 3 days. More frequent dressings and/or longer treatment may be required in severe eczema

  • Parents must be educated on how to correctly make and apply wet dressings

  • Cool compresses (cloth or towel soaked in water and/or bath oil) should be used on the face or to provide immediate relief of itch before wet dressings

Eczematous skin infections

Broken eczematous skin has a high-risk of bacterial and/or viral skin infections.
Bacterial infections:

  • Common causative organisms include Staphylococcus aureus (consider MRSA if no response to first-line antibiotics.)

  • Remove crusted lesions by wiping them gently with a cloth whilst soaking in the bath. Only apply topical steroids and moisturisers after the crusts are removed.

  • Consider courses of oral antibiotics (eg cefalexin or flucloxacillin for 7 to 10 days).

  • Children who are unwell or who have severe infections may require admission and intravenous antibiotics

Viral infections:

  • Common causes include coxsackievirus, molluscum contagiosum, herpes simplex and varicella zoster viruses

  • Herpetic infection can be treated with antivirals within 72 hours of the onset of symptoms. Intravenous antiviral treatment may be required in severe infections

  • Urgent Ophthalmology review is required if the infection extends periorbital (trigeminal) distribution

Recurrent infections:

  • Consider patient & family Staphylococcus aureus decolonisation

  • Antiseptic preparation may reduce skin bacterial load (eg bleach, benzalkonium chloride, chlorhexidine skin wash, paraffin (OilatumTM bath oil)

Bathing:

  • Bleach baths should be used daily with every flare to reduce the bacterial skin load. The addition of salt and oils to the bath also assists in relieving itch and restoring moisture to the skin.

  • The child’s face and head should be wet during the bath

  • Do not rinse after bathing.

Bathing oils & wash

  • QV® bath oil & wash

  • Hamilton’s® bath oil & wash

  • Kenkay® bath oil & wash

  • Cetaphil® Gentle Skin Cleanser

  • Mustela®, AveneÒ, Bioderma®, La Roche Posay® bath oils and washes

  • White King® Bleach (4%)

  • Salt (table or pool)

  • Use once to twice daily

  • Note do NOT use any bath oils with benzalkonium chloride

Moisturisers & Emollients

  • QV® cream

  • Cetaphil® cream

  • Avene® Xera Calm Cream

  • 10% Sorbolene®, 10% liquid paraffin, 10% soft white paraffin

  • Atoderm (Bioderma®) Cream

  • Mustela Stelatopia® creme

  • Dermeze® cream, Dermeze® ointment (for facial barrier when dribbling)

  • Cicalfate®, Cicplast® or zinc and castor oil creams for barrier creams

  • Apply once or twice daily top-to-toe

  • If eczema flares, apply at least four times per day

  • Barrier creams can be used often when the child is dribbling and applied prior to feeding 

Topical steroids

Apply once to twice daily to affected areas 

Ointment is preferred to creams for their emollient effects

Lotions are best used for the scalp

For sensitive areas  (eg face, nappy)

  • Hydrocortisone 1% cream or ointment

  • Pimecrolimus 1% (Elidel® cream)

  • Methylprednisolone aceponate 0.1% (Advantan® lotion) for short term use only

For body

  • Methylprednisolone aceponate 0.1% (Advantan® cream, ointment, fatty ointment, lotion)

  • Mometasone furoate 0.1% (Elocon® cream, ointment).

  • Betamethasone dipropionate 0.05% (Diprosone® /Eleuphrat® )

Fact Sheets

References