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Managing atopic eczema in adults

Skin disease is not a trivial complaint - it is a painful condition that can have a major impact on the lives of patients in the community. Ann Joy and Jane Moran outline the treatment strategies for atopic eczema in adults …

Ann Joy
RGN
Dermatology Nurse
Queen Margaret Hospital
Fife

Jane Moran
RGN RSCN
Dermatology Nurse Practitioner
Aberdeen Royal Infirmary

Atopic eczema in adults is a distressing chronic skin condition causing significant disability, which can have a major impact on the lives of patients and their families. Support and education of patients is the key to successful management. Primary care nurses are well placed to encourage patients to take control of their condition through a good self-care routine. This article aims to assist primary care nurses to achieve this goal by providing practical advice on the management of atopic eczema in adults.

Atopic eczema
Atopic eczema commonly presents in childhood. It affects 2-17% of adults in Europe and North America and its prevalence continues to rise.(1) The reasons for this are unknown but it is thought that environmental factors play a part.
Atopy is a term used to describe individuals who have a genetic predisposition to asthma, hay fever and eczema, separately or in combination. Atopic eczema is a chronic condition causing pruritic inflammation of the dermis and epidermis, giving rise to painful, thickened, dry and cracking skin. Acute exacerbations can occur where erythema, oedema and vesicles are present, producing crusty, scaly skin prone to infection. Itching may be severe, resulting in scratching, further exacerbation, pain and infection.
 
Psychosocial impact
Atopic eczema can impact on every aspect of a person's life. Patients may isolate themselves from others to avoid unwanted comments about their appearance and because of embarrassment. It can prevent them from engaging in sporting and social activities and place a strain on intimate relationships. Treatment can be time-consuming and messy.
Atopic eczema may cause difficulties at work - approximately four million working days are lost in the UK due to skin disease (with 50% of industrial benefit claims for dermatoses).(2) Patients may not be able to perform certain tasks essential to their job and may have to take time off because of exacerbations or medical appointments, leading to financial hardship. The cost of treatment, including prescription charges, can also be a financial burden.(3) These problems may cause anxiety and depression. Some patients may neglect their skin, leading to exacerbations of their eczema.

Management
The key to helping patients manage their atopic eczema is to spend time explaining the condition, discussing the use of topical treatments, identifying and avoiding exacerbating factors and assessing and reviewing the patient.
 
Emollient therapy
In eczematous skin the lipid barrier function is impaired, resulting in a lack of natural oils. This allows water loss and penetration of irritants. The use of soaps and detergents should be avoided as these products contain perfumes and preservatives that could sensitise the skin. Emollient therapy will moisturise dry skin, diminish the desire to scratch and may also have a steroid-sparing effect.(4)

Cleansing and bathing
Bathing daily, as part of total emollient therapy, is recommended to cleanse and hydrate the skin and reduce the risk of infection.(5) Soap substitutes cleanse the skin without stripping natural oils. They can be applied directly to the skin and will form an emulsion that can be rinsed off when mixed with water. A wide variety of soap substitutes are available as lotions, creams, ointments and gels.
Bath emollients are added to running bath water and some may be applied to wet skin and then rinsed off in the shower. Bathing should be limited to 15 minutes as exceeding this can disrupt the skin's barrier function.6 Bath emollients leave a film of oil on the skin, which will seal in moisture. Following bathing or showering the skin should be patted dry gently, as vigorous rubbing will disrupt the skin barrier function and lead to increased irritation.(6)
Some bath additives have antimicrobial/antiseptic and/or antipruritic properties that can reduce bacterial load and the intense itching associated with atopic eczema. Antimicrobial/antiseptic bath products should not be used regularly unless infection is widespread or recurrent to minimise the risk of resistance.(7)
Care should be taken as soap substitutes and bath additives can make surfaces very slippery.

Moisturising
Leave-on emollients are available in ointment, cream, lotion, gel and spray formulations and should be generously applied all over the body, not just to affected areas. Tips on the use of leave-on emollients are given in Box 1.
Large quantities of emollient should be prescribed. The Primary Care Dermatology Society (PCDS) and the British Association of Dermatologists (BAD) recommend 600 g a week for an adult with generalised eczema.(7)

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Topical steroids
Topical steroids are an effective means of reducing inflammation and relieving itch. They are available in cream, ointment, gel, lotion and mousse form and in four strengths: mild, moderate, potent and very potent. They should always be used in conjunction with a good moisturising regimen to ensure better absorption, efficacy and ease of application. Topical steroids should be applied 20-30 minutes after application of a moisturiser. Application at the same time may cause dilution of the steroid effect. They should be applied to areas of active eczema only, and used once or twice a day.(8) The weakest strength of steroid that controls the eczema should be used, which may involve a step-up or step-down approach.(7)
 Sufficient corticosteroid should be applied to make the skin glisten. The amount is measured in fingertip units (the distance from the tip of the adult index finger to the first crease). One fingertip unit is the equivalent to 0.5 g and is adequate to treat the surface area of both adult palms.(9)
Use of the steroid ladder enables identification of strength of steroid and aids a stepped approach to treatment, dependent on severity of symptoms.(10) Steroid use, potency and quantity should be reviewed regularly for local and systemic side-effects.(7) Topical steroids should be used for a few days a week for acute eczema and for four to six weeks to gain control for chronic eczema. Patients should be reassured about the value of topical steroids in providing symptomatic relief for eczema.(7)

Topical immunomodulators
Immunomodulatory agents (tacrolimus and
pimecrolimus) are an alternative to topical steroids. They inhibit inflammatory cytokine synthesis and reduce inflammation. They should be considered if conventional topical steroid therapy has failed or the patient cannot tolerate steroid treatment. Treatment should be initiated by experienced physicians.(7)

Managing infected eczema
Atopic eczema is prone to infection with Staphylococcus aureus, which can worsen the condition, and patients are also susceptible to the herpes simplex virus. Patients should be advised on how to recognise infection and when to seek medical advice.
Signs and symptoms include skin weeping, pustules, golden crusts, excoriations and erythema, rapidly worsening atopic eczema, and eczema not responding to therapy. Preventive measures against infection can include the use of antimicrobial/antiseptic emollients (as bath additives or moisturisers).
Early use of either topical or systemic antibiotics may prevent a major skin flare. If widespread infection occurs a seven-day course of the oral antibiotic
flucloxacillin is the recommended firstline treatment.(7)

Avoiding environmental irritants
Possible exacerbating factors should be discussed with the patient. Anything that is known to irritate the skin, such as extremes in temperature and clothes containing wool or synthetic fibres, should be avoided. Keeping nails cut short to prevent damage from scratching and using cotton bedding and clothing is recommended. Furry and feathered animals may exacerbate eczema. Stress may also aggravate the condition.(3)

Other treatment strategies
Medicated bandages impregnated with ichthammol or zinc oxide are effective for softening lichenified skin and for soothing and cooling excoriated, inflamed eczema. They can relieve itching and act as a physical barrier to prevent damage from scratching. However, application can be messy and time consuming.(11)
A short course of sedating antihistamines may be useful during exacerbations and help reduce itch and scratch. Nonsedating antihistamines have little benefit.(6) Behaviour modification techniques may help to prevent scratching and can be used to complement conventional therapies.(12)

Referral to secondary care
Atopic eczema accounts for around 30% of all general practice dermatological appointments with a minority referred on to secondary care.(13) Reasons for referral include uncertainty of diagnosis, eczema herpeticum, failure of eczema to respond to treatment or when infected eczema fails to respond to topical steroids and oral antibiotics.

Conclusion
Eczema is a complex and frustrating condition that cannot be cured but, with good education and correct application of topical treatments, may be well controlled. Primary care nurses play a key role in the long-term management of eczema by helping patients to achieve concordance with treatment. Taking time to explain the condition and teaching product application techniques will empower patients to take control of their condition.

Case study
Jenny is a 38-year-old mother with two young children. She works part time as a care assistant in a nursing home.
She suffers from the triad of atopic conditions - she has moderately severe asthma, chronic eczema and seasonal rhinitis. In the past six months her marriage ended and her eczema became acute, and she now has areas of inflammation on her limbs and trunk. Jenny also has hand dermatitis - her hands are inflamed with painful fissures. She is finding this difficult to cope with at work, as she needs to wash her hands frequently.
The practice nurse arranges a double appointment with Jenny. She assesses her skin and enquires about her daily skin routine, past and present treatments and their effectiveness. This allows her to assess which topical treatments suit Jenny and which she is happy to use.
The nurse discusses Jenny's emollient routine. The nurse recommends a leave-on emollient cream for her body, after using her usual soap substitute and bath emollient.
An ointment-based emollient and active topical steroid is recommended for Jenny's dry, fissured hands. Initially a potent steroid ointment is prescribed to control the eczema, to be stepped down to a moderately potent steroid ointment once the skin improves.
As Jenny works, time constraints in the morning make applying active treatments such as steroids difficult so using them once a day at bedtime is recommended. The nurse explains that the emollient ointment should be applied as often as possible to keep her hands soft, supple and moisturised.
After two weeks, Jenny returns for a further appointment. Her eczema is now controlled and the skin on her hands is improving. The nurse recommends stepping down to a moderately potent steroid ointment.
Jenny is prescribed moderate and potent topical steroids to keep in the medicine cupboard so that she can start treatment should symptoms recur. She is advised to continue her daily emollient routine on a long-term ongoing basis.

This article is supported by an unrestricted educational grant from Stiefel Laboratories.

The National Eczema Society
The National Eczema Society is the only UK charity that provides support and information to eczema patients, their carers and healthcare professionals.
Eczema can be a frustrating and difficult condition to manage, from emollients suiting one patient but not another, to managing the sheer despair felt by an eczema patient at the lack of answers or the absence of a cure, meaning that sometimes the most frustrated person of all is the nurse on the receiving end.
The NES has resources to support nurses and their patients, such as factsheets, information and practical advice. The NES also enables patients to share experiences with each other through their website, support groups and quarterly magazine, Exchange.
The National Eczema Society helpline is free. Call 0800 0891122 or log onto www.eczema.org for more information

References

  1. Harrop J, Chinn S, Verlato G, et al. Eczema, atopy and allergen exposure in adults: a population-based study. Clin Exp Allergy 2007;37:526-35.
  2. Sorrell J. Skin disease and work. Br J Dermatol Nurs 1999;3:4.
  3. All Party Parliamentary Group on Skin. Report on the enquiry into the impact of skin diseases on people's lives. London: APPGS; 2003.
  4. Holden C, English J, Hoare C, et al. Advised best practice for the use of emollients in eczema and other dry skin conditions. J Dermatolog Treat 2002;13:103-6.
  5. Cork M. The importance of skin barrier function. J Dermatolog Treat 1997;8:S7-13.
  6. Ersser S, Maguire S, Nicol N, et al. Best practice in emollient therapy. A statement for healthcare professionals. Dermatol Nurs 2007;6:S2-19.
  7. Primary Care Dermatology Society and British Association of Dermatologists. Guidance for the management of atopic eczema. 2006. Available from:  http://www.eGuidelines.co.uk
  8. NICE. Frequency of application of topical corticosteroids for atopic eczema. Technology Appraisal 81. London: NICE; 2004. Available from: http://www.nice.org.uk
  9. Long C, Finlay A. The fingertip unit: a new practical measure. Clin Exp Dermatol 1991;16:444-7.
  10. Page B, Robertson S. Hands on … topical corticosteroids identified. Dermatol Nurs 2004;3(2):16-7.
  11. Lawton S. Eczema. In: Hughes E, Van Onselen J, editors. Dermatology nursing. A practical guide. Edinburgh: Churchill Livingstone; 2001.
  12. Bridgett C, Noren P, Staughton R. Atopic skin disease: a manual for practitioners. Petersfield: Wrightson Biomedical Publishing Ltd; 1996.
  13. McHenry P, Williams H, Bingham E. Management of atopic eczema.  BMJ 1995;310:843-7.

Resources
National Eczema Society
W: www.eczema.org
Provides information, advice and has a helpline dedicated to the needs of people with eczema, dermatitis and sensitive skin

The British Association of Dermatologists
W: www.bad.org.uk 
A source for members of the public searching for reliable information about the skin and skin diseases

Dermatology
W: www.dermatology.co.uk
An independent educational online resource for skin conditions and their treatment to patients, the public and healthcare professionals. Useful practical information on all aspects of eczema therapy and management

Further reading
Nasir A, Burgess P. Eczema-free for life. New York: Harper Collins; 2005.
Armstrong-Brown S. The eczema solution. London: Vermillion; 2002.
Charman C, Lawton S. Eczema: what really works. London: Constable & Robinson Publishing; 2006.
Mitchell T, Hepplewhite A, Clarke G. Eczema. London: Class Publishing; 2005.
National Institute for Health and Clinical Excellence. Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years. Full reference guide. London: NICE, 2007. Available from: http://www.nice.org.uk