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Management of infected eczema in primary care.

Siobhan Hicks
RGN BSc
Nurse Practitioner in Primary Health Care
Tower Hamlets PCT
London
E:Siobhan.hicks@nhs.net

Eczema is a chronic relapsing inflammatory condition. It can take many forms and has varying causes (although the precise causes are unknown), which may affect treatment. There is an immunological component - 80% of children with eczema demonstrate a raised immunoglobulin E (IgE) level.(1) Moderate-to-severe eczema can have a profound effect on the quality of life for both sufferers and their families. As well as itching, skin damage, soreness, sleep loss and the social stigma of a visible skin disease, other factors such as frequent visits to doctors, special clothing and the need to constantly apply topical applications all add to the burden of the disease.(2)
The main types of eczema are allergic, contact, atopic, venous and discoid, although different types may coexist.(3) Lichenification due to scratching and rubbing may complicate any chronic eczema. Atopic eczema is the most common type and usually involves dry skin as well as infection and lichenification (see Table 1).(4)

[[NIP20_table1_26]]

Diagnosis
Making a diagnosis is a process of elimination through history taking and examination. Before examining the patient it is vital to obtain a thorough and systematic history - the use of open questions encourages the patient to tell their story. Some useful ones to start with include:(6)

  • What is your main problem?
  • How and when did it start?
  • What did it look like at first compared with now?
  • How long has the lesion been present on the skin?
  • Has the rash spread?
  • Did anything trigger it off?
  • Do you have any history of allergy?

The use of analogue scales helps to determine the severity of the patients' symptoms (see Table 2). These questions may reveal dry, itchy, scaly skin; they may reveal that the skin texture has changed, that it is lumpy under the surface; they may reveal disturbed nights from itch, with blood on the sheets; that exudate has been seen; and that the patient feels unwell, cannot stop scratching, feels embarrassed to socialise or has stopped playing sports.

[[NIP20_table2_26]]

Physical assessment follows. Skin conditions can be uncomfortable and painful, so use your senses when examining the skin: look, touch and smell.(6) Examine all of the skin in as good a light as possible; the use of a body map may be helpful to record the location and distribution of lesions. Decide whether the patient looks ill and assess the skin texture - any fever, exudate or cellulitis? In atopic eczema the skin is dry and red, with plaques commonly on the face, antecubital and popliteal fossae with fine scales, vesicles and scratch marks.(8)

Remember to think about the differential diagnosis, such as eczema herpeticum (infected with herpes virus), contact dermatitis or pompholyx. Investigations may sometimes be carried out in primary care, the most common being bacterial swab for culture and sensitivity or virology, full blood count and erythropoietin sedimentation rate (ESR). Other investigations usually carried out in specialist clinics include IgE, RAST and patch testing (see Glossary).

Education
Before medication, patient and carer education is vital if the treatment regimen is to be complied with. A general introduction to the disease and advice on exacerbations and remissions is helpful - there are many websites today with excellent patient advice leaflets (see Resources). Discuss trigger factors and any occupational or domestic irritants; consider the itch/scratch cycle and the use of cotton clothing for the skin; have a chat about environmental factors, such as house dust mites, central heating, air conditioning and changes in the weather; explain the role of medication and give practical advice about the pros and cons of treatment. Also, consider involving other members of the healthcare team, such as the health visitor and school nurse in the case of children.

Treatment and management
The prevention of infected eczema starts with basic skin care. The frequency of bathing can make a big difference to the dryness of the skin. Ideally, the patient should spend 10 minutes maximum in the bath; otherwise the epidermis becomes waterlogged, permeability increases and the skin becomes dryer.(9) Baby wipes, soaps, shower gels and bubble bath should be avoided, as these can dry the skin further. The water should be lukewarm to reduce vasodilation. A soap substitute such as aqueous cream may be used and can be applied to the skin before bathing - but a note of caution: remind the patient that the bath may become slippery when oils/creams are added to the bathwater. It is easy to get confused with too many products, so consider whether a patient needs both bath oil and a soap substitute, or whether a soap substitute is sufficient. The skin should be gently patted dry to prevent epidermal damage and then moisturised. Antiseptics (eg, Oilatum, Balneum Plus) may also be used in bath oil to prevent infection.
Moisturisers and emollients soothe and hydrate the skin, preventing further water loss, and are indicated for all dry and scaling disorders. Their effects are short-lived, and they should be applied frequently, even after improvements occur. Light emollients such as aqueous cream are suitable for many patients with dry skin, but a wide range of more greasy preparations, including white soft paraffin, emulsifying ointment, and liquid and white soft paraffin ointment, are available.(4) Patient preference often guides the patient's choice of product. The emollient should be applied in the direction of hair growth to prevent the risk of folliculitis. Some ingredients may cause sensitisation, and for this reason it is recommended that simple emollients be used initially.(10) Emollients should be used five to six times daily to prevent loss of water through evaporation - their use could mean that the patient potentially uses much less steroid over a lifetime.(11)
Topical steroids come in different strengths of potency, which should be chosen according to the severity of the condition (see Table 3). Corticosteroids suppress the inflammatory reaction while in use, but they are not curative and symptoms may rebound when treatment is discontinued. They are indicated for relief of symptoms when potentially less harmful measures are ineffective.(4) Side-effects of topical steroids from the very potent and potent group are rare but can include:

  • Adrenal suppression and Cushing's syndrome.
  • Spreading/worsening of untreated infection.
  • Thinning of the skin.
  • Irreversible striae.
  • Perioral dermatitis.
  • Mild depigmentation.

[[NIP20_table3_28]]

Creams are suitable for moist or weeping lesions, whereas ointments are generally chosen for lichenified or scaly lesions.(4)
Topical steroids should be applied sparingly once or twice daily. As a general rule, one fingertip is sufficient to cover an area that is twice that of the flat of an adult hand. They should be applied 30 minutes after bathing.
Other remedies that may reduce the discomfort of eczema are:

  • Antihistamines, which help reduce the itch/scratch cycle and have a sedating effect, but there is little evidence that all itches are caused by histamine.(12)
  • Wet wrap bandages containing icthamol paste - may give relief from pruritis if applied over a ­corticosteroid.
  • Shampoos containing ketoconazole and coal tar are usually effective against seborrhoeic eczema, which is associated with yeasts and affects the scalp and face.
  • Combination topical antibiotics and steroids in a cream preparation can be used on localised areas, but for generalised infections systemic antibiotics should be prescribed. In some situations topical antiseptics (eg, Crystacide) may be used as an alternative to ­antibiotics.(13)
  • Topical antibacterials such as fusidic acid and mupirocin can be effective for short-term use, but to avoid the development of resistance these should not be used for more than 10 days.
  • Secondary infection commonly occurs in flexural areas such as under the breast or in the groin. This is often fungal, and combined steroid and ­antifungal creams are usually effective against this.
  • Potassium permanganate soak 1 in 10,000 (Permitabs) is ­effective for weeping infected skin but should be stopped on resolution of symptoms.
  • Widespread herpes simplex infection may ­complicate eczema, and treatment with a systemic antiviral drug is indicated.(4)

Bacterial infection (commonly Staphylococcus aureus and occasionally Streptococcus pyogenes) can exacerbate eczema. Before prescribing systemic antibiotics, consider the following:

  • Drug allergy.
  • Renal and hepatic function.
  • Age/sex.
  • Antibiotic resistance.
  • Is the patient pregnant, breastfeeding or on the pill?

Become familiar with your local policies, which often limit the use of antibacterials to achieve reasonable economy consistent with adequate cover and to reduce development of resistant organisms.

[[NIP20_table4_26]]

Occasionally patients will need to be referred to a specialist. Indications for referral are listed in Table 5.

[[NIP20_table5_26]]

Conclusion
Consistent basic skin care and hygiene can do much to prevent the use of topical steroids and antibiotics. Most of these products are included in the extended nurse prescriber's formulary for independent prescribers; supplementary prescribers could consider clinical management plans including topical antibacterials and systemic antibiotics for chronic/well-known patients. Thorough history taking, physical examination, robust communication and referral pathways, together with up-to-date, evidence-based knowledge are the key to providing an effective service for patients with eczema.

References

  1. Higgins E, du Vivier A. Skin diseases in childhood and adolescence. Oxford: Blackwell Science; 1996.
  2. Hoare C, Li Wan Po A, Williams H. A thorough systematic review of ­treatments for atopic eczema.Arch Dermatol 2001;137;1635-6.
  3. Dains J, Bauman L, Scheibel P. Advanced health assessment and clinical diagnosis in primary care. St Louis: Mosby; 1998.
  4. BMA and RPSGB. Emis drug explorer. London: BMA; 2004.
  5. Cross S, Rimmer M, editors. Nurse practitioner manual of clinical skills. London: Baillière Tindall; 2002.
  6. Peters J. Assessment of patients with skin conditions. Practice Nurse 1998;15:525-30.
  7. Bickley S, Szilagyi P, editors. Bates guide to physical examination and history taking. Philadelphia: Lippincott Williams and Wilkins; 2002.
  8. Cox C. Physical assessment for nurses. Oxford: Blackwell Publishing; 2004.
  9. Peters J. Caring for dry and damaged skin in the community. Br J Community Nurs 2001;6:645-51.
  10. Medical Research Council. The use of emollients in dry skin conditions. MeReC Bull 1998;9(12):45-8.
  11. Peters J. Eczema. Nurs Standard 1999;13(16):49-55.
  12. Beltrani V. Managing atopic eczema. Dermatol Nurs 1999;11:171-85.
  13. Shah M, Mohanraj M.Br J Dermatol 2003;148:1018-20.

Resources
British National Formulary
W:www.bnf.org

National Eczema Society
W:www.eczema.org

Patient UK
W:www.patient.co.uk