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Atopic eczema: assessment, treatment and management

Sandra Lawton
RGN OND
Dermatology Liaison Sister
Queen's Medical Centre
University Hospital Nottingham

Atopic eczema is the most common inflammatory skin disease of childhood, affecting 15-20% of children in the UK at any one time, with adults making up about one-third of all community cases. Eczema lesions vary in appearance from collections of fluid in the skin (vesicles) to gross thickening of the skin (lichenification) on the background of poorly demarcated redness. Other features such as crusting, scaling, cracking and swelling can also occur. Atopic eczema is associated with other atopic diseases, such as hay fever and asthma.(1)
Moderate to severe atopic eczema can have a profound effect on quality of life for sufferers and their families.(1) With onset in early years, this inflammatory skin condition is characterised by itching and eczema ­involving the face and skin creases. Although a tendency to dry skin and irritants may be lifelong, around 60-70% of these children will be clear by their mid-teens. Evidence suggests that the prevalence of atopic eczema has increased substantially over the last 30 years for reasons that are unclear, but it is likely that environmental factors associated with urbanisation are important. Atopic eczema is also more common in wealthier families and Afro-Caribbean children. Although there are no recent national prevalence studies of atopic eczema in the UK, data from a national birth cohort study point to ­considerable variation in disease prevalence and region.(2)

Diagnosis
Atopic eczema is usually diagnosed on clinical grounds, basing it on the patient's history, family history and appearance of the skin rash. Diagnostic criteria for atopic eczema have been suggested(3) and are:

  • An itchy skin condition (or scratching or rubbing in a child).

Plus three or more of the following:

  • History of itchiness in skin creases such as folds of the elbows, behind the knees, front of ankles or around neck (or the cheeks in children under four years of age).
  • History of asthma or hay fever (or a history of atopic disease in a first-degree relative in children under four years of age).
  • General dry skin in the past year.
  • Visible flexural eczema (or eczema affecting the cheeks or forehead and outer limbs in children under four years).
  • Onset in the first two years of life (not always ­diagnostic in children under four years).

Clinical patterns of atopic eczema
In babies and infants, atopic eczema tends to be vesicular and weepy, starting on the face with non-specific ­distribution elsewhere, the nappy area often being spared. In older children the eczema becomes lichenified, dry and excoriated, affecting mainly the elbow creases, back of knees, wrists, ankles and ears (flexural). A stubborn "reverse" pattern affecting the extensor aspects of the limbs is also recognised. Children often present with a "discoid" pattern of atopic eczema, which tends to be stubborn to treat, becomes easily infected and requires stronger forms of treatment. 
In adults the pattern is similar to that of children but tends to be more chronic with lichenification and shows more widespread low-grade involvement of the trunk, face and hands. The most common features of atopic eczema are the itching and scratching, often referred to as the "itch-scratch cycle". This is commonly cited as the most distressing aspect of atopic eczema, causing loss of sleep and impacting on the child and family.(4)

Infection
Bacterial infections are also common in patients with atopic eczema because the skin is dry and damaged by scratching. Children with atopic eczema often present with secondary infections and flare-ups because the dry skin and chronic scratching favours colonisation by Staphylococcus aureus.(5)
Viral infections are less common but can occur. Eczema herpeticum is caused by the herpes simplex virus, and the patient may present with herpetic lesions (small vesicles, crusting, weeping or more often grouped "punched-out" erosions). The patient may also be systemically unwell with malaise and pyrexia. 
Molluscum contagiosum is a viral infection commonly found in children with atopic eczema. They present with groups of pearly-pink umbilicated papules caused by a pox virus. Treatment is by cryotherapy or by expressing the contents. Children, however, do not tolerate this very well, and if left alone the papules will resolve (this can take several months).
It is vital to determine whether the infection is ­bacterial or viral. Swabs should be taken for culture and the appropriate antibiotic/antiviral therapy administered. For Staph. aureus flucloxacillin is the antibiotic of choice (erythromycin may also be given if there is known penicillin allergy). For the herpes infection the antiviral treatment is acyclovir. Admission to hospital may be considered in cases of severe infection.

Assessment
Assessment of patients requires time for examination, explanation and treatment. Patients want a description of the nature of eczema and advice on how to use the treatments prescribed.(6) The assessment sheet used by the author was developed following the British Association of Dermatology audit of eczema ­management in secondary care.(7)

Management
Management must be multidisciplinary. The disabling effects and the psychosocial impact of atopic eczema are substantial. Education about the application of ­topical preparations is essential.(8) Skincare plans and ­information leaflets detailing aspects of atopic eczema management can further support this. Leaflets should be clear, factual, non-controversial and available in a variety of languages (for examples, see: www.eczema.org).

First-line treatment

Avoidance of provoking factors
Irritants such as soaps and detergents which remove the natural lipid from the skin surface should be avoided. Soap substitutes should be used to prevent further ­drying. Extremes of temperature, cold winds or a hot environment with low humidity will also exacerbate eczema, as will woollen clothing worn next to the skin - cotton clothing is more comfortable. Keeping nails cut short will prevent damage from scratching.

Bathing and emollients
Bathing and the use of emollients is the mainstay of any skincare regimen. Bathing is useful for cleansing the skin and removing old treatments and scale. It is also an excellent way of hydrating the skin. Overwashing can dry or irritate the skin. There are many emollients available, and patients should be allowed to decide on the most suitable for them. Emollients are most effective when applied after bathing as this is when the water content of the skin is greatest, and should be reapplied regularly throughout the day. The greasier the emollient the ­better, but individual preference is important.

Infection
Systemic antibiotics are important in treating overt ­secondary bacterial infections in patients with atopic eczema.(3) Use of topical antibiotics should be restricted  - they are generally not ideal for treating bacterial ­infections in patients with atopic eczema as patients often have widespread secondary infection. Prophylactic treatment of staphylococcal carrier sites (nose, axillae and perineum) with topical antibiotics may be ­appropriate in patients with recurrent infected eczema.(3) Patients need advice about infection.

Topical corticosteroids
Topical corticosteroids are the mainstay of treatment for atopic eczema but certain precautions must be taken. Use and abuse of topical steroids has caused ­considerable confusion and controversy and has resulted in the undertreatment of many patients. Lack of adherence to treatment may often stem from fear of steroids. It is important to explain the different potencies and the benefits and risks of topical corticosteroids.(4) The basic principle is to use the least potent preparation required to keep the eczema under control, and when possible the corticosteroids should be stopped for short periods.(3) A child will have more side-effects from itching, scratching, sleepless nights, infection and missing school than from using correctly prescribed topical steroids.(9)

Other treatments
Antihistamines are used for their sedative properties. They are useful in the short term in conjunction with topical treatments when there are relapses and severe pruritus. Long-term use is not recommended as ­tachyphylaxis may occur.
 
Patients often benefit from sharing knowledge and experiences. Patient support groups are often ­beneficial. There are also cognitive behavioural techniques available to patients.

Ichthammol and tar
The principal tars used for atopic eczema are ichthammol and coal tar. They have an antipruritic effect and are useful in lichenified eczema. They can be applied using creams, ointments and pastes - added to the bath or applied as paste bandages. They can be messy but have a place in eczema management. They can also be used as an alternative to topical corticosteroids.

Bandaging
Bandages are an occlusive technique used for eczema. Paste bandages are used for many types of eczema, and wet wraps are used more commonly for childhood atopic eczema. Proper training and understanding are essential as wet wraps can be very time-consuming and can have serious side-effects if used incorrectly.(10) Bandage ­techniques are one aspect of the management package and should not be looked at in isolation.

Second-line treatment
There is some evidence that reduction of house dust mite allergen around the home can result in a benefit to atopic eczema sufferers.(1)
The role of foods in initiating or perpetuating atopic eczema has been extensively investigated. Dietary manipulation is generally indicated only when the patient's history strongly suggests a specific food allergy, or when widespread eczema fails to respond to first-line treatment. A dietitian must be involved to ensure an adequate diet for the growing child. No dietary ­measures should be taken on an ad-hoc basis.(4)
Psoralen plus ultraviolet A and to a lesser extent ultraviolet B are helpful for some patients with atopic eczema. There are, however, some concerns about the long-term effects of skin ageing and malignancies.

Third-line treatment
Oral steroids are occasionally required for patients with severe exacerbation of their eczema, but should not be used routinely. Evidence on the therapeutic value of evening primrose oil remains inconclusive.(3) Azathioprine, cyclosporin and interferon are all effective in treating atopic eczema but are used only for severe cases. Homoeopathic and other complementary remedies have little scientific evidence to support their use.

Conclusion
It is paramount that the patient and their family receive advice, support and education to properly manage their eczema, and most patients should be able to achieve good control. For those who fail to respond, referral should be made to a specialist (see Table 1).

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References

  1. Hoare C, Li Wan Po A, Williams H. Systematic review of treatment of atopic eczema. Health Technol Assess 2000;4(37):1-2.
  2. Williams HC. Dermatology. In: Stevens A, Raferty J, editors. Health care needs assessment (series 2). Oxford: Radcliffe Medical Press; 1997.
  3. McHenry PM, Williams HC, Bingham EA. Management of atopic eczema. BMJ 1995;310:843-7.
  4. Lawton S. Eczema In: Hughes E, Van Onselen J, editors. Dermatology nursing: a practical guide. London: Churchill Livingstone; 2001. p. 151-69.
  5. Williams HC. Epidemiology of atopic eczema. Curr Med Lit (Allergy) 1994;2:3-7.
  6. Long CC, Funnell CM, Collard R, Finlay AY. What do members of the National Eczema Society really want? Clin Exp Dermatol 1993;18:516-22.
  7. Shum KW, Lawton S, Williams HC, Docherty G, Jones J. The British Association of Dermatologists' audit of atopic eczema management in secondary care. Phase 2: audit of service process. Br J Dermatol 2000;142:274-8.
  8. Lynn SE, Lawton S, Newham S, Cox M, Williams HC, Emerson R. Managing atopic eczema: the needs of children. Professional Nurse 1997;12(9):622-5.
  9. Watts J. Eczema and the family. Community Nurse 1997;Sept:35-7.
  10. Watts J. Survey of wet wrapping in general practice for the treatment of atopic eczema. Dermatology nurse perspective. Dermatology in Practice 2001;9(1):15-18.
  11. National Institute for Clinical Excellence (NICE). Atopic eczema in children - referral practice. Version under pilot. London: NICE 2001. (www.nice.org.uk)

Resources
Skin Care Campaign
W:www.skincarecampaign.org
National Eczema Society
W:www.eczema.org
British Association of Dermatologists
W:www.bad.org.uk

Further reading
Hughes E, Van Onselen J. Dermatology
nursing: a practical guide. London: Churchill Livingstone; 2001.
Cork MJ. Complete emollient therapy. In: The National Association of Fund holding Practices Official Yearbook. Dunstable: BPC Waterlow; 1998. p. 159-68.
Lynn SE, Lawton S, Newham S, Cox M, Williams HC, Emerson R. Managing atopic eczema: the needs of children. Professional Nurse 1997;12(9):622-5.
Lawton S. The nurse's contribution to the care of dermatology patients. Community Nurse 2000;6(6):35-6.  

Useful details
British Dermatological Nursing Group (BDNG)
Membership £15/year. Quarterly journal and Annual Conference.
E:emmac@bad.org.uk