Atopic Eczema

Sharon Wong

Suzy Tinker

Classification

• Endogenous vs Exogenous

• Acute vs Chronic

Acute eczema

• Acute: pruritus, erythema, vesiculationAcute: pruritus, erythema, vesiculation

Chronic eczema

• Chronic: pruritus, xerosis, lichenification, Chronic: pruritus, xerosis, lichenification, hyperkeratosis, +/- fissuringhyperkeratosis, +/- fissuring

Chronic eczema

Eczema – clinical subtypes

• Irritant contact dermatitis• Allergic contact dermatitis

• Atopic• Discoid• Seborrhoeic• Venous• Pompholyx• Asteatotic• Follicular/papular

Exogenous

Endogenous

Atopic dermatitisAtopic dermatitis

• Chronic relapsing skin disorder (prevalence Chronic relapsing skin disorder (prevalence 20%)20%)

• Onset <5 years in 80%Onset <5 years in 80%

• 40-60% remain symptomatic as adult40-60% remain symptomatic as adult

• 85% ↑ IgE, 80% associated with asthma/allergy85% ↑ IgE, 80% associated with asthma/allergy

• Family Hx of atopyFamily Hx of atopy

Pathogenesis of ADPathogenesis of AD

• Interaction of skin barrier, genetic, Interaction of skin barrier, genetic, environmental, pharmacologic, and environmental, pharmacologic, and immunologic factorsimmunologic factors

• Release of vasoactive substances from Release of vasoactive substances from mast cells and basophils, that have been mast cells and basophils, that have been sentitized by the interaction of the antigen sentitized by the interaction of the antigen with IgE.with IgE.

Exacerbating factors– Inhalants (dust mites, pollens)Inhalants (dust mites, pollens)

– Infections Infections

– Autoallergens (IgE)Autoallergens (IgE)

– Foods (eggs, milk, peanuts, soy-beans, fish, wheat)Foods (eggs, milk, peanuts, soy-beans, fish, wheat)

– Contact irritants (wools)Contact irritants (wools)

– Season (improves in summer, flares in winter)Season (improves in summer, flares in winter)

– Emotional stressEmotional stress

Clinical features

Atopic eczema

The Itch-Scratch cycle

• Pruritus usually begins and causes itch sensation

• Scratch causes skin trauma and precipitates skin inflammation

• Chronic inflammation leads to lichenification

Clinical variants

Discoid eczema

Seborrhoeic

Seborrhoeic eczema

Lichen simplex

Pompholyx

Follicular

Contact dermatitis (exogenous)

Allergic vs irritant

• Immunological• Type IV

hypersensitivity• Lifelong

• Positive patch test

• Non-immunological• Can affect anyone• More common atopics

Complications of Atopic Dermatitis

Impact of Atopic Dermatitis

• Hinders social interactions

• Disrupts sleep

• Disturbs schooling

• Failure to thrive

• Affects entire family

Treatment

Aim

• To get the eczema under control

• Keep the eczema under control

Basic stuff

• Avoid provoking factors (wool, bubble baths, soaps, perfumes)

• Avoid dryness:Bath oils (Oilatum, Hydromol, Aveeno, Dermol)Soap substitutes (Aqueous cream, Dermol)Emollients (500g in 2 weeks)

• Treat any infection

• Antihistamines

• Reduce inflammation

Reduce inflammation

• Topical steroids

• Topical immunomodulators

• Oral prednisolone

• Oral immunosuppressives

• Phototherapy

Topical steroids

• Ointments better than creams

• Learn 3 topical steroids

I) Hydrocortisone

ii) Eumovate

iii) Betnovate/Elocon

Common topical steroid myths

• Can’t apply to infected or broken skin

• Can’t use topical steroids for more than 1 week non stop

• Hydrocortisone topically can thin the skin

• Cannot use potent topical steroids on the face

To get the eczema under control

• Apply steroid daily until skin is back to normal

• Then stop or wean down

• Continue emollients

To keep the eczema under control

• Apply topical steroid immediately the eczema flares

• Consider maintenance Rx (eg Protopic)

• Eumovate >30g per month- baby- refer

• Betnovate>60g per month –child-refer

Tacrolimus ointment

• Inhibits T cell activation & suppresses cytokine gene transcription

• Inhibits IgE-induced histamine release from mast cells and basophils

• Down-regulates high affinity IgE receptor on Langerhans cells

Important instructions to patients

• Burning/stinging sensation following application which will spontaneously resolve

• Avoid application after a hot bath or shower

• Recommend adequate application of tacrolimus ointment, it is NOT a topical steroid

• Care in sun - long term immunosuppression???

Particular indications for topical tacrolimus ointment

• Peri-ocular involvement

• Flexural involvement

• Facial involvement

• Requirement for maintenance treatment with moderately potent or potent topical steroids

• Presence of topical steroid-induced cutaneous atrophy or striae

• Pigmented skin

Not winning?

• Compliance?• Infected?• Contact dermatitis• Difficult eczema?

Dressings & bandaging

• Dressings

• Wet wraps

• Comfifast, tubifast, dermasilk garments

– Over emollient / weak steroids

Quality Nursing Quality Nursing CareCare

Phototherapy

• UVB/TLO1

• Psoralen + UVA = PUVA– Methoxypsoralen– Topical or systemic

• Whole body or regional

Systemic treatments

• Short courses prednisolone

• Ciclosporin

• Azathioprine

• Methotrexate

• Mycophenolate mofetil

Steroid side effects- local

• Skin atrophy

• Telangiectasiae

• Acne

• Pigmentaion change

ALL MORE MARKED IN FLEXURAL SITES!

Steroid Side EffectsSteroid Side Effects

Atrophy, telangiectasia

Steroid side effects- systemic

• suppression HPA axis• cataracts• growth suppression• loss bone density• diabetes• cushings

Take home messages

• Bath oils, soap substitutes and emollients - all stages/severity of eczema

• Use the most appropriate strength of steroid for the severity and site

• Steroids can be used for longer than a week – arrange follow-up to review and step down when skin improved

• Check compliance – ask how long a tube of steroid/pot of emollient lasts

• Prompt treatment of coexistent infection• Assess severity by asking about sleep/school

disturbance, weight/height gain (red book), mood, family dynamics