Transcript Atopic eczema - Audley Mills

Atopic eczema
Tahera Chaudry
February 2009
Atopic eczema
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Atopic eczema (atopic dermatitis) is a chronic
inflammatory itchy skin condition that develops in early
childhood in the majority of cases
Relapsing/remitting
atopic eczema often has a genetic component that leads
to the breakdown of the skin barrier
Often environmental triggers
many cases of atopic eczema clear or improve during
childhood, whereas others persist into adulthood
some children who have atopic eczema will go on to
develop asthma and/or allergic rhinitis; this sequence of
events is sometimes referred to as the 'atopic march‘
The serum levels of IgE may be raised.
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Approximately 30% of the UK are atopic but the incidence
of atopic dermatitis is about 3 - 10%.
It is less common but more severe and persistent in
certain ethnic groups such as the Chinese than than in
caucasians.
About 50% of patients develop the condition within the
first year of life. By 5 years, 87% have developed their
condition. Less than 2% develop after the age of 20 years.
The condition improves with age - about 50% resolve by
the age of 13 years. Few cases persist beyond 30 years.
Diagnosis
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Atopic eczema should be diagnosed when a child has an itchy skin
condition plus three or more of the following:
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visible flexural dermatitis involving the skin creases, such as the bends
of the elbows or behind the knees (or visible dermatitis on the cheeks
and/or extensor areas in children aged 18 months or under)
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personal history of flexural dermatitis (or dermatitis on the cheeks
and/or extensor areas in children aged 18 months or under)
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personal history of dry skin in the last 12 months
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personal history of asthma or allergic rhinitis (or history of atopic
disease in a first-degree relative of children aged under 4 years)
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onset of signs and symptoms under the age of 2 years (this criterion
should not be used in children aged under 4 years)
Diagnosis (2)
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From time to time, most people have acute flares with
inflamed, red, sometimes blistered and weepy patches. In
between flares, the skin may appear normal or suffer from
chronic eczema with dry, thickened and itchy areas.
NB in Asian, black Caribbean and black African children,
atopic eczema can affect the extensor surfaces rather
than the flexures, and discoid (circular) or follicular
(around hair follicles) patterns may be more common
Infantile
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Infants less than one year old often have widely distributed eczema. The
skin is often dry, scaly and red with small scratch marks made by sharp
baby nails.
The cheeks of infants are often the first place to be affected by eczema.
The napkin area is frequently spared due to the moisture retention of
nappies. Just like other babies, they can develop irritant napkin dermatitis
if wet or soiled nappies are left on too long.
Toddlers and pre-school age
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As children begin to move around, the eczema becomes more
localised and thickened. Toddlers scratch vigorously and the
eczema may look very raw and uncomfortable.
Eczema in this age group often affects the extensor aspects of
joints, particularly the wrists, elbows, ankles and knees. It may
also affect the genitals.
As the child becomes older the pattern frequently changes to
involve the flexor surfaces of the same joints (the creases) with
less extensor involvement. The affected skin often becomes
lichenified i.e. dry and thickened from constant scratching and
rubbing,
In some children the extensor pattern of eczema persists into
later childhood.
Toddler and pre-school
School age
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Older children tend to have the flexural pattern of eczema and it
most often affects the elbow and knee creases. Other susceptible
areas include the eyelids, earlobes, neck and scalp.
They can develop recurrent acute itchy blisters on the palms,
fingers and sometimes on the feet, known as pompholyx or
vesicular hand / foot dermatitis.
Many children develop a 'nummular' pattern of atopic dermatitis.
This refers to small coin-like areas of eczema scattered over the
body. These round patches of eczema are dry, red and itchy and
may be mistaken for ringworm (a fungal infection).
Mostly the eczema improves during school years and it may
completely clear up by the teens, although the barrier function of
the skin is never entirely normal.
School age
Adults
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Adults who have atopic dermatitis may present in various different
ways.
They may continue to have a diffuse pattern of eczema but the skin is
often more dry and lichenified than in children.
Commonly adults have persistent localised eczema, possibly
confined to the hands, eyelids, flexures, nipples or all of these areas.
Recurrent staphylococcal infections may be prominent.
Atopic dermatitis is a major contributing factor to occupational irritant
contact dermatitis. This most often affects hands that are frequently
exposed to water, detergents and /or solvents.
Hand dermatitis in adult atopics tends to be dry and thickened but
may also be blistered.
Adults
Assessment
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Detailed history
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Time of onset, pattern, severity
Response to previous and current treatments
Poss trigger factors
Impact on child and parents
Dietary history
Growth and development
Personal and family history of atopic disease
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Consider using tools to assess QoL and family impact
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Provide verbal and written advice/education, and
practical demos
Management
In children, NICE suggest a treatment schema based on severity:
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mild atopic eczema
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emollients
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mild potency topical corticosteroids
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moderate atopic eczema
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emollients
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moderate potency topical corticosteroids
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topical calcineurin inhibitors e.g. pimecrolimus
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bandages
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severe atopic eczema
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emollients
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potent topical corticosteroids
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topical calcineurin inhibitors
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bandages
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phototherapy
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systemic therapy
Referral criteria
Most children with atopic eczema can be managed in primary
care. They should, however, be referred to a specialist service
if
 ****severe infection with herpes simplex (eczema
herpeticum) is suspected
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*** the disease is severe and has not responded to
appropriate therapy in primary care
*** the rash becomes infected with bacteria (manifest as
weeping, crusting, or the development of pustules), and
treatment with an oral antibiotic plus a topical corticosteroid
has failed
** the rash is giving rise to severe social or psychological
problems; prompts to referral should include sleeplessness
and school absenteeism
** treatment requires the use of excessive amounts of potent
topical corticosteroids
Referral criteria (2)
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* management in primary care has not controlled the rash satisfactorily.
Ultimately, failure to improve is probably best based upon a subjective
assessment by the child or parentfor example, the child is having 1-2
weeks of flares per month or is reacting adversely to many emollients
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* the patient or family might benefit from additional advice on application
of treatments (bandaging techniques)
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* contact dermatitis is suspected and confirmation requires patch-testing
(this is rarely needed)
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* dietary factors are suspected and dietary control a possibility + the
diagnosis is, or has become, uncertain
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Times will be discretionary and depend on clinical circumstances within a
day. maximum waiting time of 2 weeks is appropriate for the urgent
category.
Complications
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Cutaneous infection occurs secondary to reduced immunity and
reduced barrier function of skin:
 viral infections - herpes simplex causing eczema herpeticum;
warts; molluscum contagiosum;
 bacterial infection - colonisation of epidermis by
staphylococcal aureus; frank staphylococcal infection such as
impetigo
atopic cataract - often bilateral, peak incidence between 15 and
25 years; also, increased risk of developing corticosteroid induced
cataracts
growth retardation - affects about 10% of children; not thought
to be due to steroid therapy
Prognosis
Good Prognostic indicators:
 early onset and typical involvement - flexural surfaces
 90% resolution by early teens
 may be recurrence of the disorder in adulthood if there
are circumstances where there is undue stress of the skin
eg the hands of a hairdresser
Poor Prognostic indicators:
 a more guarded prognosis should be given to those where
the condition has a later onset and/or a atypical pattern of
involvement (ie extensor surfaces).
References
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http://www.nice.org.uk/Guidance/C
G57/QuickRefGuide/pdf/English
NICE guidance on atopic eczema in
children 2007
http://www.dermnetnz.org/dermatit
is/atopic.html