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Practice nursing basics - eczema

Julie Smith
SRN ONC
Specialist Nurse
General Practice Nursing
Chaddlewood Surgery
Devon

Eczema describes an itchy, inflamed skin rash. In the UK, up to one-fifth of school-age children have eczema, and about one in 12 of the adult population.(1) It is the most common inflammatory disease of the skin, affecting many millions of adults and children worldwide.
The exact cause of eczema is not known, but genetic, environmental and stress factors are thought to play a role. The cause greatly depends on the type of eczema.
 
Atopy
The word "atopic" means that a person is extrasensitive to substances, usually invisible proteins, called allergens in their environment. In atopy there is an excessive reaction by the immune system, producing, in the case of eczema, inflamed, irritated and sore skin. Associated atopic conditions include asthma and hay fever.
Eczema can be caused by irritants such as chemicals and detergents, allergens such as nickel and yeast growths, and in later years circulatory problems in the legs.
These different types of eczema seem to present in a similar way, but they have very different causes and treatments. It is therefore extremely important to obtain a correct diagnosis so that adequate care can be provided. It would seem logical to obtain a GP's opinion, who may make a referral to a specialist dermatologist for further diagnosis and treatment.

[[NIP08_fig1_25]]

Atopic eczema

Presentation
Itchiness (or pruritus), which can be almost unbearable. Constant scratching can also cause the skin to split, leaving it prone to infection. In infected eczema the skin may crack and weep ("wet" eczema).

Treatments
Emollients to maintain skin hydration, and steroids to reduce inflammation.

Allergic contact dermatitis

Presentation
Rash caused by the body's immune system reaction against a substance in contact with the skin (eg, nickel, often found in belt buckles, jeans buttons and earrings).

Treatment
Avoid repeated contact with irritants.

Irritant contact dermatitis

Presentation
Irritated skin caused by everyday substances, such as detergents and chemicals. Usually seen on adult hands.

Treatment
Avoid irritants and use moisturiser.

Infantile seborrhoeic eczema

Presentation
Usually starts on the scalp or the nappy area of babies under one year. It is often described as "cradle cap" and looks unpleasant. However, it is not sore or itchy and does not cause the baby to feel uncomfortable or unwell.

Treatment
Usually clears up in a few months, but moisturising creams and bath oils can expedite the process.

Adult seborrhoeic eczema

Presentation
Affects adults between the ages of 20 and 40 years. It is seen on the scalp as mild dandruff, but can spread to the face, ears and chest. The skin becomes red, inflamed and starts to flake. The condition is believed to be caused by a yeast growth.

Treatment
If infection ensues, treatment with an antifungal cream may be necessary.

Varicose eczema

Presentation
The lower legs of those in their middle to late years with poor circulation are inflicted with this problem. Commonly the skin around the ankles is affected, becoming speckled, itchy and inflamed (see Figure 2).

[[NIP08_fig2_26]]

Treatment
Emollients and steroid creams. If left untreated the skin will macerate and cause an ulcer.

Discoid eczema

Presentation
Usually found in adults, appearing as a few coin-shaped areas of red skin, normally on the trunk or lower legs (see Figure 2). This is itchy and can weep.

Treatment
Emollients and sometimes steroid creams.

Management and treatment of eczema
An effective skin care routine, including correct use of emollients and steroid cream, is paramount for successful eczema management. Dermatologists may prescribe oral steroids when topical steroids have been found to be ineffective. These may cause side-effects, and the patient should be closely monitored.
Other treatments include antihistamines to reduce inflammation, and wet wrap bandaging to soothe dry itchy skin. Ultraviolet light treatment and stronger medication may be considered for very severe eczema.
Many patients use complementary therapies as well, and it is important to explain to them that there has been only limited scientific evaluation of these to date. However, in New Zealand, Active Manuka honey treatment has been researched with encouraging results at the University of Waikato's Honey Research Unit.

Is there a cure?
Currently there is no cure for eczema or any guarantees that a child will grow out of it. However, research has shown that 60-70% of children are virtually clear of the condition by the time they reach their mid-teens.

Clinical governance
As nurses we are entering exciting times. Clinical governance is a framework that helps all clinicians, including nurses, to continuously improve quality and safeguard standards of care.(2,3) In simple terms, it means putting nurses and doctors in charge of the way things are done - and making both clinicians and managers accountable for the quality of patient care. It's also about helping the NHS to make decisions based on clinical judgment ­- and not just on how much things cost.
The NICE (National Institute for Clinical Excellence) guidelines on eczema are being awaited at this time (pilot texts are available on the NICE website - see Resources). However, to implement these guidelines the NHS needs to address certain problems that the British Association of Dermatologists (see Resources) has highlighted, which are:

  • The shortage of dermatology nurses in both ­primary and secondary care.
  • That there are currently only 350 consultant ­dermatologists in the UK. This is the lowest per head of population in Western Europe.
  • That there are currently insufficient specialist ­registrar posts in dermatology, which will in turn cause problems in expanding the number of ­consultants.
  • GP training typically lasts less than six days of an entire degree.
  • The reported extremely long waiting times (by patients). Waits of between 36 and 42 weeks are not uncommon.

If clinical governance is to work for eczema, all of these issues will need to be addressed.

References

  1. Charman C. Atopic eczema. In: Clinical evidence. London:?BMJ Publishing; 1999. p. 640-9.
  2. RCN. Clinical governance - how nurses can get involved. London: RCN; 2001.
  3. RCN. Guidance for nurses on clinical governance. London: RCN; 2001.

Resources
British Association of Dermatologists
W:www.bad.org.uk
The National Eczema Society
Hill House,
Highgate Hill
London N19 5NA
T:020 7281 3553
F:020 7281 6395
Helpline:
0870 241 3604
W:www.eczema.org
Eczema
website describing the different types of eczema
W:www.eczema-uk.co.uk
National Institute for Clinical Excellence (NICE)
"Atopic eczema in children" - online 5 Oct 2002
"Atopic eczema in children - referral practice" - online 6 Oct 2002
W:www.nice.org.uk

Further reading
McHenry PM, Williams HC, Bingham EA. Management of atopic eczema. BMJ 1995;310:843-7