Eczema

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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties

Scope:

• assessment, diagnosis and management of atopic dermatitis/eczema in primary care

Out of scope:

• assessment and management of:
  • contact dermatitis/eczema − includes irritant and allergic contact dermatitis
  • seborrhoeic eczema
  • venous eczema
  • photosensitive dermatitis
  • pompholyx eczema
• management of eczema in pregnancy

Atopic eczema affects;

• 15 - 20% school children
• 2 - 10% adults

 National Eczema society

http://www.pcds.org.uk/clinical-guidance/psoriasis-scalp-psoriasis

The British Association of Dermatologists -leaflets

http://www.bad.org.uk/shared/get-file.ashx?id=69&itemtype=document

http://www.bad.org.uk/shared/get-file.ashx?id=183&itemtype=document

Patients can get free phone advice from specialist nurses by registering with the following website

https://www.allergyuk.org/information-and-advice/conditions-and-symptoms/35-eczema-dermatitis

• 'Atopic eczema' (PDF) from Patient UK
• 'Discoid eczema' (PDF) from Patient UK
• 'Eczema − triggers and irritants' (PDF) from Patient UK
• 'Emollients (moisturisers) for eczema' (PDF) from Patient UK
• 'Fingertip units for topical steroids' (PDF) from Patient UK
• 'Topical steroids for eczema' (PDF) from Patient UK

 NSCCG Sign off form

Date of publication: 31-Oct-2011

Interim update:

Three information points now appear at the top of each care map page. These provide:

• easy access to scope and background information on each page of the care map whilst reducing repetition between care points
• easy access to patient resources/leaflets
• information on care map updates

Date of publication: 31-Jan-2011

The care map has been updated in line with the following guidelines:

• [2] National Institute for Clinical Excellence (NICE). Frequency of application of topical corticosteroids for atopic eczema. Technology appraisal 81. London: NICE; 2004.
• [3] National Institute for Clinical Excellence (NICE). Tacrolimus and pimecrolimus for atopic eczema. Technology appraisal 82. London: NICE; 2004.
• [4] Clinical Knowledge Summaries (CKS). Eczema - atopic. Version 1.4. Newcastle upon Tyne: CKS; 2008.
• [5] National Collaborating Centre for Women's and Children's Health. Management of atopic eczema in children from birth up to the age of 12 years. London: Royal College of Obstetricians and Gynaecologists (RCOG); 2007.
• [6] Primary Care Dermatology Society and British Association of Dermatology (BAD). Guidelines for the management of atopic eczema. London: BAD; 2009.
• [8] Royal College of Nursing (RCN). Caring for children and young people with atopic eczema: guidance for nurses. London: RCN; 2008.
• [12] National Institute for Health and Clinical Excellence (NICE). Alitretinoin for the treatment of severe chronic hand eczema. Technology appraisal guidance 177. London: NICE; 2009.
• [13] National Institute for Health and Clinical Excellence (NICE). Grenz rays therapy for inflammatory skin conditions. Interventional procedure guidance 236. London: NICE; 2007.
• [14] Scottish Intercollegiate Guidelines Network (SIGN). Management of atopic eczema in primary care. A national clinical guideline. SIGN publication no. 125. Edinburgh: SIGN; 2011.

 Presentation of eczema [2,3]:

• intense itching
• dry skin
• redness
• inflammation
• exudation

Eczema can affect any part of the body, although it tends to settle in the skin creases [1].

Commonly affected areas include:

• face and neck [2], including the eyes and ears [1]
• flexor surfaces of the elbows and knees [2]
• front of wrists and tops of ankles [1]
• under the buttocks [1]

 History:

• enquire about:
  • itchy rash [4,5]
  • distribution of disease and onset [6]
  • family or personal history of atopy, including allergic rhinitis or asthma [4,5], or eczema
  • trigger factors, including:
    • irritants, eg soaps and detergents [4,5]
    • skin infections [5]
    • contact allergens [4,5]
    • food allergens [4,5]
    • inhalant allergens [5]
    • secondary bacterial infection [1]
    • clothing [7]
    • dust [7]
    • pets [6,7]
    • sweating [7]
    • occupational causes
  • episodic flares in infancy [4,5]
  • previous treatments [6]
  • dietary restrictions [6]
  • other medications, eg steroids for asthma [6]

Examination:

• examine the rash − patient's age and duration will influence appearance and distribution [4]:
  • infancy − primarily involves the face, scalp, extensor surfaces of the limbs [4]
  • adults:
    • flexure involvement [4]
    • generalised dryness and itching [4]
    • primary manifestation may be on the hands [4] and face [2]
  • acute eczema − varies in appearance, ie [4]:
    • poorly demarcated redness [4]
    • fluid in the skin (vesicles) [4], oedema [1]
    • oozing [1]
    • scaling [4]
    • crusting of the skin [4]
  • chronic eczema − skin becomes thickened [4] (lichenification [1])
• consider concurrent bacterial infection if the following are present [4]:
  • eczema is:
    • weeping [4,5,8]
    • crusted [4,8]
    • rapidly worsening or has not responded to treatment [4,5]
  • pustules are present [4,5]
  • fever or malaise [4,5]
  • extreme redness [4,8]

Eczema diagnostic criteria:

• itchy skin condition [2,4,5] in the last 12 months [2,4], plus :
  • history of skin crease involvement
  • history of generally dry skin in the last year
  • visible flexural eczema
• expert opinion recommends a diagnosis of eczema if the above criteria are met after 3 months of an itchy skin condition [1]
• if it does not itch, it is unlikely to be eczema [1,6]
• investigations are not required to establish a diagnosis of eczema [1]

Grade severity of new episode or flare-up:

• mild eczema [5]:
  • areas of dry skin
  • infrequent itching
  • with or without small areas of redness
  • little impact on everyday activities, sleep and psychosocial wellbeing.
• moderate eczema [5]:
  • areas of dry skin
  • frequent itching
  • redness, with or without:
    • excoriation
    • localised skin thickening
  • moderate impact on everyday activities, psychosocial wellbeing and frequently disturbed sleep.
• severe eczema [5]:
  • widespread areas of dry skin
  • incessant itching
  • redness, with or without:
    • excoriation
    • localised skin thickening
    • bleeding
    • oozing
    • cracking
    • alterations of pigmentation
  • severe limitation of everyday activities and psychosocial functioning
  • nightly loss of sleep.

Holistic assessment :

• enquire about the effect of eczema on quality of life (QoL), eg activities of daily living, sleep, and mood [1,4,5]:
  • mild impact [4,5]:
    • little effect on everyday activities, sleep, and psychosocial wellbeing
  • moderate impact [4,5]:
    • moderate effect on everyday activities and psychosocial wellbeing
    • frequently disturbed sleep
  • severe impact [4,5]:
    • severe limitations of everyday activities and psychosocial functioning
    • nightly loss of sleep
• enquire about effect on:
  • schoolwork, career, or social life
  • the patient or family

Consider using the following additional tools to measure the severity of eczema, QoL, and response to treatment [5], eg:

• visual analogue scales (0-10) [5]
• validated tools [5]
• Patient-Oriented Eczema Measure (POEM) scale − the only validated patient-derived outcome measure that can be used practically for monitoring patient outcomes [1]

NB: There is not necessarily a direct relationship between the severity of eczema and the impact on the patient's QoL [5].

 Refer immediately to dermatologist (arranged via telephone) for further investigation if disseminated herpes simplex infection (eczema herpeticum) is suspected [14] − signs are [4,5]:

• rapidly worsening, painful eczema
• clustered blisters resembling early stage cold sores
• uniform, punched-out erosion
• fever, lethargy, or distress

Consider commencing treatment of eczema herpeticum with systemic aciclovir, but do not delay referral [5].

If eczema herpeticum involves skin around the eyes, immediately (same day [1]) refer for ophthalmological and dermatological advice [5].

 Differential diagnoses include [4]:

• psoriasis − see 'Psoriasis NS MOM' care map [4]
• contact dermatitis − allergic and irritant [1]
• seborrhoeic dermatitis [4]
• fungal infection [4]
• scabies and other infestations [4] 
• varicella (chicken pox) [4]
• molluscum contagiosum [4]
• verrucae vulgaris (viral warts) [4]; however, expert opinion suggests that viral warts would not be confused with eczema [1]
• keratosis pilaris [1]

Consider referral to a dermatologist if there is uncertainty concerning the diagnosis [14].

 Provide self-care advice to patient including:

• recognising flares early
• avoiding triggers
• managing itch, eg short nails
• not to alter diet unless evidence of exacerbation by certain foods
• keeping skin hydrated, eg using emollients and soap substitues

Ensure emollients are applied often enough; up to 4-5 times daily during eczema exacerbations https://bnf.nice.org.uk/treatment-summary/skin-conditions-management.html 

Try different types of emollients if one does not suit patient or if there is a lack of response to one type. Different types of emollients can also be used at different times eg. a cream for easy application in work and an ointment for use at home. https://www.bnssgformulary.nhs.uk/131-Dry-and-scaling-skin-disorders/

Providing clear information on eczema and use of treatments supported by patient information leaflets
 
PCDS site 
http://www.pcds.org.uk/clinical-guidance/atopic-eczema#management

Enquire about the patient's or family's expectations from treatment and their understanding of medication use [6].

Management should:

• be according to severity and location [5]
• involve management of flares as well as maintenance therapy [1]
• be stepped up or down according to physical severity [5]

aims to:

• rehydrate skin [8]
• reduce inflammation [8]
• improve quality of life (QoL) [8]
• prevent complications, eg infections [2]

should aim to [6]:

• keep the patient informed about their condition and treatment
• educate the patient on the use of topical treatments
• demonstrate how to use medications
  provide written information and practical advice

 Consider concurrent bacterial infection if eczema presents with the following:

• Weeping
• Crusted
• Rapidly worsening or has not responded to treatment
• Pustules are present
• Fever or malaise
• Extreme redness

BNSSG Antimicrobial prescribing guidelines (use the same guidelines as impetigo on page 10)

Treating infected atopic eczema

For concurrent infection, ensure there is adequate control of underlying inflammation with topical steroids.

National Institute for Health and Clinical Excellence (NICE) recommend taking swabs if [5]:

• the suspected causative organism is not Staphylococcus aureus (S.aureus); or
• antibiotic resistance is relevant

Consider antibiotics:

• Prescribe topical antibiotics for localised infections for no longer than 2 weeks. Can be combined with corticosteriod.
• Only prescribe oral antibiotics for infected atopic eczema.

When prescribing antibiotics consider:

• first-line flucloxacillin
• clarithromycin − if allergy or resistance to flucloxacillin

If infection does not respond to antibiotics:

• seek specialist advice
• suspect infection with herpes simplex virus
• ​consider commencing treatment with systemic aciclovir, but do not delay referral
• consider results of swabs

 Treatment of Sereve flares include:

• potent topical corticosteroid:
  • e.g. betamethasone valerate 0.1% https://www.bnssgformulary.nhs.uk/133-Inflammatory-skin-conditions/
  • once daily to a maximum of twice daily
  • only to areas of active eczema
  • continue for 48 hours after flare controlled (typically 1-2 weeks).
  • for flares in vulnerable sites, eg axillae and groin, use for short periods only (7−14 days)
  • use mild potency for the face and neck, except for short-term (3−5 days) use of moderate potency for severe flares
• antihistamines:
  • not routinely used
  • offer 1 month trial of non-sedating antihistamine for severe itching/urticaria and continue if successful for a maximum of 2 weeks
• liberal use of emollients https://www.bnssgformulary.nhs.uk/131-Dry-and-scaling-skin-disorders/
• Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are a second-line option. However, they should only be prescribed by a specialist (including GPs with a specialist interest in dermatology). https://www.bnssgformulary.nhs.uk/133-Inflammatory-skin-conditions/
• Oral corticosteroids (prednisolone) should be reserved for use in the treatment of severe flares, often while waiting for referral to secondary care where the condition can be fully assessed and other treatment options can be tried. There is no evidence from controlled trials to support the effectiveness of oral corticosteroids, but clinical experience suggests that there is a large and rapid treatment effect. Prolonged or frequent treatment should be avoided as there is a cumulative risk of serious adverse effects.
• bandages - ​may increase steroid potency − recent studies have found little evidence to recommend their use [1]
• wet wraps  no good evidence to support the use of these 

Step down strength of topical corticosteroids when condition allows

Provide information on the amount of treatment to use (i.e.FTU - finger tip units)

• 'Fingertip units for topical steroids' (PDF) from Patient UK

 Treatment of moderate flares include:

• moderate potency topical corticosteroid:
  • e.g. betamethasone valerate 0.025%, clobetasone butyrate 0.05%. http://www.bnssgformulary.nhs.uk/134-Topical-corticosteroids/
  • once daily to a maximum of twice daily
  • only to areas of active eczema
  • continue for 48 hours after flare controlled (typically 1-2 weeks).
  • for flares in vulnerable sites, eg axillae and groin, use for short periods only (7−14 days)
  • use mild potency for the face and neck, except for short-term (3−5 days) use of moderate potency for severe flares
• antihistamines: 
  • not routinely used
  • offer 1 month trial of non-sedating antihistamine for severe itching/urticaria and continue if successful for a maximum of 2 weeks
• liberal use of emollients http://www.bnssgformulary.nhs.uk/132-Emollient-and-barrier-preparations/
• bandages - ​may increase steroid potency − recent studies have found little evidence to recommend their use [1]
• wet wraps no good evidence to support the use of these 

Step down strength of topical corticosteroids when condition allows

Provide information on the amount of treatment to use (i.e. FTU - finger tip units)

• 'Fingertip units for topical steroids' (PDF) from Patient UK

 Treatment of mild flares includes:

• emollients http://www.bnssgformulary.nhs.uk/132-Emollient-and-barrier-preparations/
• intermittent mild potency topical corticosteroids :  
  • e.g. hydrocortisone cream or ointment 1%. http://www.bnssgformulary.nhs.uk/134-Topical-corticosteroids/
  • apply once daily up to a maximum of twice daily
  • apply only to areas of active eczema 
  • continue treatment for 48 hours after the flare has been controlled (typically 1-2 weeks)
  • ensure emollient therapy is continued

Provide information on the amount of treatment to use (i.e. finger units)

 Maintenance management (non-infected eczema) 

Advise patients on:

• avoiding trigger factors
• using emollients liberally (up to 4-5 times daily during eczema exacerbations)
• recognising early signs and symptoms of a flare
• using a stepped-care plan
• using potent steroids to treat severe flares, and to use emollients after acute phase skin dry and scaly

Consider topical corticosteroids:

• usually not required for mild eczema.
• for moderate eczema, prescribe the lowest potency steroid to achieve control:
  • consider twice weekly therapy in patients experiencing frequent flares, or weekend therapy for specific patches of frequently flaring eczema

Maintenance management (infected eczema) 

Preventing re-infection:

• use triclosan or chlorhexidine (eg. hibiscrub) as adjunct therapy for those with recurrent infection [5]
• inform patient/carer that they should obtain new supplies of medication after infection due to possible contamination with infectious agent [5]
• consider re-infection with S.aureus from family members [2]:
  • consider the need for carrier site swabs and local topical mupirocin or naseptin ointment if swab is positive

 Follow-up:

• mild eczema [4]:
  • rarely requires active follow-up
  • consider annual review of emollient use
• moderate and severe eczema:
  • depends on [4]:
  • severity of illness
  • treatment the patient is receiving
  • health
  • age
  • annual review of emollient use [4]
  • regularly review topical corticosteroid use if used heavily [4] − expert opinion recommends reviewing topical corticosteroid use to ensure patients are not under-using them (or occasional over-use of potent steroids [rare]) [1]
• severe and extensive flaring [4]:
  • if treatment required oral corticosteroids/oral antibiotics, review after treatment course has finished
  • low threshold for referral

 Continue self management and review as necessary

• Consider stepping up the treatment to the next level of severity
• Consider differential diagnosis
• Consider appropriate referral

 Refer:

immediately to dermatologist if eczema herpeticum is suspected [4] − arrange referral via telephone [14]

urgently to a dermatologist if infected eczema has not responded to treatment [4] within 72 hours [1]; however, expert opinion states that the patient should be seen within 1 week [1]

routinely to a dermatologist if:

• diagnosis is uncertain [4,14]
• eczema is poorly controlled or does not respond to appropriate topical treatment
• eczema is associated with severe and recurrent infections [14], especially deep abscesses or pneumonia [4]
• eczema is impairing quality of life (QoL) despite maximum treatment in primary care [1], eg psychological upset or problems sleeping
• patients has mild eczema and would benefit from education and expertise provided in the eczema clinic [1]

 The standard RSS referral form is available as an EMIS template

 Refer to adult dietitian if considering dietary exclusion [1].

A recent systematic review indicated that there is very little good quality evidence to support exclusion diets in atopic eczema [9].

 Refer to WGH using the standard RSS referral form which is available as an EMIS template
Refer to NSCP Dietitians via Managed referrals