Atopic Eczema in Children and Adults
GENERAL ADVICE FOR ALL:
- Advise short baths/showers and avoid having the water hot.
- Eczema written action plan – (can edit, save to desktop and text to patient or incorporate as macro into practice IT) -http://www.bristol.ac.uk/primaryhealthcare/researchthemes/apache/ewap/
- Ointments are better as less likely to cause allergic contact dermatitis and don’t contain preservatives. However, they are less well tolerated than creams/gels.
- It is more important to find an emollient a patient will use and tolerate though and those with frequent eczema should be given a selection of emollients to try.
- Warn patients they make sting for a couple of days
- FIRE RISK! - Please advise ALL patients of fire risk with topical emollients: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/904956/Emollients_A5_leaflet_290720.pdf
- Useful link showing ‘greasiness’ scale of emollients: https://www.stgeorges.nhs.uk/wp-content/uploads/2018/11/Management-of-Adult-Eczema.pdf
WET WRAPS IN CHILDREN:
- Use for ANY stage eczema
- Wear instead of pyjamas - most useful in winter (wrap clothing can be too hot in summer)
- Allows children not to scratch at night
Prescribe: Comfifast leggings x2 -same size as child
- Comfifast vest x2 – order one size above
- You can also prescribe mittens etc if needed
- Patient leaflet
Consider sedating antihistamines in moderate/severe eczema and disturbing sleep:
- Children – chlorphenamine (Piriton)
- Adults – Hydroxyzine 25mg nocte (Atarax)
- Advise patients to apply emollients FIRST and allow to dry for 15-20minutes before applying steroid cream.
- Strength of steroid to be determined by the age of patient, site and severity:
(see BAD steroid potencies)
- Child face: mild potency eg 1% hydrocortisone
- Child trunk and limbs: moderate potency eg Eumovate ® (clobetasone butyrate 0.05%) or Betnovate-RD ® (betamethasone valerate 0.025%)
- Adult face: mild or moderate potency eg Eumovate ®
- Adult trunk and limbs: potent eg Betnovate ® (betamethasone valerate 0.1%), Elocon ® (mometasone)
- Adult palms and soles: potent or very potent eg Dermovate ® (clobetasol propionate 0.05%
- If having allergic contact reaction try to use ointments rather than creams
- Advise re: calculating fingertip units (FTUs): https://patient.info/treatment-medication/steroids/fingertip-units-for-topical-steroids
- Topical steroids leaflet (including FTUs in children) - https://eczema.org/wp-content/uploads/Topical-steroids-Sep-19-1.pdf
- Children – see notes on “wet wraps”
- If getting frequent flares then advise “weekending” = apply steroid creams/ointments on two consecutive days a week long term
- If recurrent infections use antimicrobial emollient e.g. Dermol Bath/Shower
CALCINEURIN INHIBITORS (2yrs+ only) – Consider for moderate/severe eczema with FREQUENT need for topical steroids AND risk of skin atrophy. Protopic (0.03% for 2-15 yrs, 0.1% 16+yrs) or Elidel. (Dermatology happy to answer questions via A&G if needed).
- PROTOPIC OINTMENT (0.03% for 2-15 yrs, 0.1% 16+yrs) – Tends to work quickly but sometimes stings a little
- ELIDEL – (2yrs+) – Cream, no stinging,
- BAD leaflet: https://www.bad.org.uk/shared/get-file.ashx?id=155&itemtype=document
- Typical regime: Use protopic/Elidel Mon-Fri then steroid cream at weekend, review after 3/12 and if improving drop Elidel to twice weekly and steroid cream at weekend, then stop Elidel etc
IMPORTANT PRESCRIBING POINTS:
- Do not use continuously for more than 6/52. Have 2/52 application-free period between
- Avoid in immunocompromised patients
- Avoid in patients with neoplasia
- Avoid in those with skin disorders liable to lead to increased systemic absorption e.g. ichthyosis
- Patients should also be encouraged to use a broad-spectrum sunscreen daily on all sunlight-exposed skin4.
- We also advise night time use only during summer months and on sunny days
- Avoid in patients with recurrent skin infections including viral e.g. HSV, molluscum, also bacterially infected eczema – can make it worse
- <18 months – emollient bath oil
- Itchy and erythematous – Coal tar shampoo (e.g. Capasal) or Betacap OD/BD until itch settles then PRN
- Synalar gel – use if other preparations sting
- Sebco – use if thick scale
- <6 months mod/severe eczema – if not controlled with emollients/mild topical steroids consider trial of extensive hydrolysed/amino acid formula. Refer to allergy clinicif no response.
- Consider referral to allergy clinic for allinfants and children with significant atopic eczema where IgE mediated food allergies are suspected via the history (some are referred by the Dermatology team internally).
- Consider INHALANT ALLERGY if: seasonal flares or associated with asthma/allergic rhinitis or over 3yrs old and eczema of face (especially around eyes)
WHEN TO CONSIDER REFERRAL:
Only cases of severe or difficult eczema usually need to see a Dermatologist.
- For consideration of second line treatment such as photochemotherapy, cytoxic drugs and topical immunomodulators.
- Eczema herpeticum – contact the on-call team.
- If contact allergic dermatitis is suspected for patch testing.
- Children – In addition to above please also refer:
- Consider early referral for severe disease in children so as to minimise any psychological impact of the disease.
- Children with complex medical needs and significant eczema
- Vulnerable children at risk of neglect/poor social situation
Please include the type and duration of all treatments in the referral letter.
PATIENT LEAFLET/VIDEO LINKS:
- http://www.itchysneezywheezy.co.uk/EczemaVideos.html- useful videos on common eczema questions, how to apply emollients etc
- Videos on how to use topical steroids and emollients: https://www.guysandstthomas.nhs.uk/our-services/dermatology/dermatology-videos.aspx
Review date March 2022
Next review due March 2023
Reviewing GP Dr Madeleine Attridge
Contributors Dr Vandana Jones