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Principles of care for adults with eczema

There are several different types of eczema that affect adults, but overall the main management principles are the same. Demographic changes in Britain mean that an increasing proportion of people will suffer consequences of skin problems in old age.1

The classifications of eczematous skin disorders use the term 'eczema' synonymously with 'dermatitis', as both terms apply to the inflammatory skin changes provoked by either internal (endogenous) or external (exogenous) factors. These disorders include atopic eczema, pompholyx eczema, discoid eczema, asteatotic eczema, varicose eczema, contact irritant dermatitis and contact allergic dermatitis.

Endogenous (or atopic) eczema is a common inflammatory cutaneous skin disorder with associated genetic and environmental factors. The word 'atopy' covers the classification of related disorders, eg, asthma, eczema and hayfever. Atopic eczema can be a chronic itchy distressing disorder, affecting quality of life and causing severe disruption to family life.

Late onset or reoccurrence of atopic eczema can be very distressing, from acute onset to the development of chronic pattern of episodic exacerbations. Commonly affected sites are the flexural aspects of knees and elbows with involvement of the face and wrists. The pattern of distribution can alter into adulthood and environmental factors play large part.

Pompholyx eczema, or 'blistering' eczema, is localised to palms and soles. It develops rapidly, causes acute discomfort and can become secondarily infected. The cause is unknown and outbreaks can be linked to heat and humidity or a reaction to contact dermatitis or fungal infections.

Discoid eczema is characterised by symmetrical coin-shaped lesions that affect the limbs and can be intensely itchy. There are two types; wet and dry. It is more common in middle-aged and older people and may only last for a few weeks.
Asteatotic eczema mainly affects older people, commonly on the lower legs. It appears to be associated with a deficiency of sebaceous secreting glands, resulting in excessive dryness and scaling of the skin. Central heating, diuretic therapy and over-frequent washing are also implicated as possible causes. The stratum corneum develops a 'crazy paving' appearance due to a network of fine red superficial fissures.

Varicose eczema is chronic patchy eczema of the legs, with or without the presence of a varicose ulcer. The eczema arises due to associated chronic venous stasis. The presence of varicose veins, oedema and pigmentation of the skin, the latter occurring due to haemosiderin from the blood leaking through capillary vessels under elevated venous pressure.2 The area involved may become itchy and hot to touch, and a secondary response to this initial area of eczema may produce associated eczematous areas on other parts of the body.

Exogenous eczema, or irritant contact dermatitis, is very common especially in industrial and work settings. The eczema usually erupts at the maximum point of contact, but presentation varies according to the nature of the irritant contact. The epidermis may be damaged by water or abrasion, and the effect of the irritant, eg, coal dust or cement, is exacerbated by rubbing against clothing. Epidermal necrosis may occur within hours of contact with strong chemicals, while eczema triggered by milder substances, such as detergents, may take longer to evolve. Many patients with atopic eczema appear prone to irritant contact dermatitis and should be advised to avoid work where exposure to irritants could be problematic.

Allergic contact dermatitis is a condition in which the skin develops a specific immunological hypersensitivity. The most common allergic response is to nickel, as found in inexpensive jewellery or body piercings. Continued exposure to the allergen will result in an eczematous response, ranging from mild to severe. Allergy patch testing may identify the allergen which many cases a change of job or avoidance of the allergen may be necessary. The most difficult cases to treat are those in which allergic contact dermatitis is suspected but no definitive triggering factor can be proven.

Agents which moisturise and lubricate the skin are the mainstay of dermatological treatment. They are used in different forms such as soap substitute/bath oils or 'leave-on preparations'. They can be used in skin maintenance programmes and are vital in preparing the skin for the specific therapies such as corticosteroids. The choice of emollient depends on the disorder:
    Dry, hyperkeratotic skin: use oily occlusive ointments.
    Flaky rough excoriated skin: use grease-based preparations.
    Erythematous, inflamed skin: benefits from the cooling effect of water-soluble creams.
Aqueous cream is not recommended as a soap substitute or a leave on moisturiser in the management of atopic eczema or seborrhoeic dermatitis. Sodium lauryl sulphate (SLS) 1% as found in aqueous cream:
    Elevates pH within the stratum corneum.
    Enhances protease activity and decreases the synthesis of the lipid lamellae.
    Should never be used as a leave-on emollient in Atopic eczema.3

Patients may use a combination of emollients for different areas, eg, cream for the face and ointment for the body. Taking time to demonstrate technique of application and trial different moisturisers so the patient is involved in choice4 is key to compliance. The drier the skin, the more frequent the application, but using an oil-based product might be better than a water-based one, especially at night.

How to apply a topical moisturiser
Ask the patient to demonstrate how they apply the moisturiser, and then show the technique that is recommended. Apply the moisturiser with smooth downward strokes in the direction of the hair - this reduces friction/irritation on the skin surface and avoids an increase in skin temperature that triggers itching. Rubbing it in can block hair follicles, leading to localised infection (folliculitis). Humidity and temperature within the home affects the skin.5 If the bath water or bathroom is too hot, the child/patient will loose water through evaporation, causing the skin to become drier. If moisturiser is applied too thickly, it can trap in body heat, leading to itching. To be effective it needs to be reapplied several times through out the day.

If the skin feels immediately dry after applying a moisturiser, then change to use one that has a high oil-to-water ratio. Scratching is a sign of dry skin, and the product needs to be applied often enough to prevent the skin drying. Look at the daily routine, and talk through when the moisturiser should be applied. As the epidermal barrier recovers, frequency can be reduced. Writing instructions about the application on the prescription will reinforce the message and act as a reminder.6

Topical corticosteroids
The risk of significant skin atrophy from brief treatment with a mild or moderately potent topical steroid appears extremely low. Epidermal thinning, however, does occur within 1-3 weeks of treatment with potent or very potent topical steroids on normal skin, but reverses within four weeks of stopping.7 It is the fear of using topical steroids that can lead to failure to optimise treatment and can turn the condition from acute to chronic. A balanced approach must be taken to ensure treatment is optimised.

The topical corticosteroid should be applied approximately 30 minutes8 after the topical emollient, or bathing with a bath oil or soap substitute, to the affected areas only. The topical emollient can then be reapplied a minimum of 60 minutes later. This can be a challenge for community nurses, but the main issue is frequency of skin care. Older patients may live alone and have no help with their skin care, so use of products to help with application may be required if no family/friends are available. Negotiate with carers for assistance with skin care so that it becomes part of their personal care package.

Protecting the skin from potential irritants or allergens is very helpful, eg, the use of vinyl/non-latex gloves when handling food/detergents. Gloves themselves can also cause a problem with sweating that in itself irritates the skin further. Again it essential to use enough emollient therapy to restore the epidermal barrier and protect against wear and tear.

Itch-scratch cycle
Itch is a sensation and scratch is a learnt behaviour. It is easy to scratch without thinking, so through repetition it becomes a habit. The mechanical damage can prolong the inflammatory process and delay healing. Make patients aware of this and ensure that emollient therapy is carried out regularly. If there is inflammation, then topical corticosteroid is necessary - potent at first, then stepped down when the skin has improved by 80%. Corticosteroid should be used at least once a day, so a weekly application will not suffice. Sometimes you may have to prioritise skin over ulcers if the lower leg is involved.

If scratching continues and the patient cannot learn an alternative, non-damaging behaviour, eg, pressing with a nail on the itchy area, then you may have to use impregnated bandages to cover the skin area to protect it. For small areas you can use extra thin granuflex.

Topical corticosteroids should only be used with caution underneath occlusive dressing as it increases the potency, so regular review needs to be carried out to check for atrophy, especially on older skin.

1.     APGS. Report on the enquiry into skin disease in elderly people. London: Associate Parliamentary Group on Skin; 2000.
2.     Gawkrodger DJ. Dermatology: an illustrated colour text, 4th ed. Edinburgh: Churchill Livingstone; 2008.
3.     Lewis-Jones S, et al. A Systematic Review of the Treatment for Atopic Eczema and Guidelines for its management. London: National Institute for Clinical Excellence; 2007.
4.     Peters J, Sterling A, Robertson S. Knowledge and Application of topical emollients: an audit. Dermatological Nursing 2008;7(2):30-5.
5.     Cork MJ, Murphy R, Carr J, Buttle D, Ward S, Båvik, Tazi-Ahnini R. Atopic eczema and environmental trauma to the skin. British Journal of Dermatology Nursing 2002;6(2):14-6.
6.     Peters J. Exploring the use of emollient therapy in dermatological nursing. British Journal of Nursing 2005;14(9)494-502.
7.     O'Donoghue N. Corticosteroids in Dermatology. Dermatological Nursing 2005;4(1):11-13.
8.     Flohr TC, Williams H. Evidence based management of atopic eczema Archives of Disease in Childhood, Education and Practice 2004;89(2):35-9.