Makindo Medical Notes.com

Related Subjects: |Nikolsky's sign |Koebner phenomenon |Erythema Multiforme |Pyoderma gangrenosum |Erythema Nodosum |Dermatitis Herpetiformis |Lichen Planus |Acanthosis Nigricans |Acne Rosacea |Acne Vulgaris |Alopecia |Vitiligo |Urticaria |Basal Cell Carcinoma |Malignant Melanoma |Squamous Cell Carcinoma |Mycosis Fungoides (Sezary Syndrome) |Xeroderma pigmentosum |Bullous Pemphigoid |Pemphigus Vulgaris |Seborrheic Dermatitis |Pityriasis/Tinea versicolor infections |Pityriasis rosea |Scabies |Dermatomyositis |Toxic Epidermal Necrolysis |Stevens-Johnson Syndrome |Atopic Eczema/Atopic Dermatitis |Psoriasis

Widespread herpes simplex (eczema herpeticum) should be considered in any patient with rapidly deteriorating atopic eczema with immediate referral to a dermatologist or paediatrician

About

• A chronic inflammatory skin disease that is characterized by
• intense pruritus and eczematous lesions in typical anatomical sites
• Infants have involvement of the face, scalp, and extensors, whereas late-childhood AD and adulthood AD classically present with flexural eczema

Aetiology

• Genetic and environmental factors are likely to contribute
• Defects in epithelial barrier function arising from abnormalities in structural proteins such as filaggrin making the skin both excessively permeable
• Damage from environmental irritants and allergens

Epidemiology

• 15-20% of school-aged children
• 2-10% of adults will be affected by the condition at some stage.

Clinical

• Dry, itchy, red skin condition with papules an vesicles on erythematous base
• More seen in flexor surfaces (extensor is psoriasis) e.g. elbows
• Skin may show oedema and crusting, flaking
• Severe cases there is blistering, cracking, oozing and bleeding

Skin/physical severity

• Clear: Normal skin, no evidence of active atopic eczema
• Mild: Areas of dry skin, infrequent itching (+/- small areas of redness)
• Moderate: Areas of dry skin, frequent itching, redness (+/- excoriation and localised skin thickening)
• Severe: Widespread areas of dry skin, incessant itching, redness ( +/-excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of skin pigmentation)

Clinical Forms

• Atopic eczema/dermatitis - onset in children, flexural surfaces. Often incredibly itchy and ends up with itch/scratch cycle
• Contact dermatitis typically causes the skin to develop a pink or red rash, which usually itches. May be the reaction to a local substance
• Seborrhoeic Dermatitis: Dermatitis is a red, itchy, flaky (inflamed) skin complaint; seborrhoeic means that the rash affects greasy (sebaceous) skin zones such as the face, scalp and centre of the chest. Often seen in older men, involves the face - side of nose and forehead and eyebrows.
• Seborrhoeic dermatitis: In children causes 'cradle cap'. See below
• Xerotic eczema - dry skins in dry weather and with excessive washing with soap. May be seen in older nursing home residents.

Management

• Emollients (moisturisers)
  • Patients with atopic eczema should have ongoing treatment with emollients. To optimise adherence to emollient therapy, creams, lotions, ointments, or a combination can be used, depending on patient choice. Prescriptions should be reviewed regularly. Creams soak into the skin faster than ointments.
  • Use Emollient soap substitutes These products contain emollient ingredients with very mild emulsifiers. They are used instead of soap and other detergents
  • Patients should be advised to apply emollients liberally and frequently (at least 2-4 times a day). It is particularly important to use emollients during or after bathing
• Topical corticosteroids
  • Patients should be advised to continue with emollient therapy during treatment with topical corticosteroids.
  • Patients with atopic eczema should be advised to apply topical corticosteroids once daily.
  • A Twice weekly maintenance therapy with a topical corticosteroid should be considered in patients with moderate to severe atopic eczema experiencing frequent relapses.
  • Side effects include skin thinning, bruising, perioral dermatitis, folliculitis, pruritus, allergic contact dermatitis and the spread of fungal infection. Topical corticosteroids should be used with caution in the periocular region
• Topical calcineurin inhibitors and dressings
  • Topical tacrolimus should be considered, in patients aged two years and older, for short term, intermittent treatment of moderate to severe atopic eczema that has not been controlled by topical corticosteroids or where there is a serious risk of important adverse effects from further topical corticosteroid use, particularly skin atrophy.
• Anti-infective treatments (such as antibiotics and antiseptics): Oral antibiotics are not recommended in the routine treatment of non-infected atopic eczema
• Antihistamines, complementary therapies and the roles of diet and environmental factors. Short term bedtime use of sedating antihistamines should be considered in patients with atopic eczema where there is debilitating sleep disturbance.
• Phototherapy and systemic immunosuppressant drugs
• Pets: A systematic review concluded that there is no evidence to ascertain whether exposure to a cat or dog in the home contributes to disease flares in atopic eczema
• Diet
  • Dietary exclusion is not recommended for the management of atopic eczema in patients without confirmed food allergy.
  • The exclusion of foods during pregnancy and breastfeeding to prevent the development of atopic eczema in infants is not recommended.
  • Parents should be advised that exclusive breastfeeding for three months or more may help prevent the development of infant eczema where there is a family history of atopy

References

• SIGN guidelines on Eczema