What to consider in Primary Care before referring:
General Comments
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Atopic eczema is a common disease affecting up to 15% of children.
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Involvement of the face frequently occurs in infants with adoption of a characteristic flexural distribution by the age of 18 months.
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Spontaneous improvement tends to occur throughout childhood with complete clearance by teenage years in 80-90%
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Realistic treatment aims need to be discussed with the patient and parent
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General treatment measures
Soaps and detergents including bubble bath and shower gels should be avoided.
Cotton clothing should be used and avoid wool next to the skin.
Fingernails should be kept short to reduce skin damage from scratching.
Bathing is not harmful but an emollient has to be used.
Treatment in primary care
Emollients
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Emollients should be prescribed in all cases and added to the bath e.g.
Oilatum—non-fragrance preparation
Balneum
Some patients have a preference and you may have to supply several until the patient finds something they like and will therefore use.
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Used directly on the skin during and after bathing
Epaderm ointment
Diprobase
E45
Cetraben
Epaderm
Doublebase
Some combination preparations have extra benefits e.g.
- Calmurid
- Dermol 500 contain antiseptic
- Dermol 600 contain antiseptic
- Oilatum plus contain antiseptic
Topical Corticosteroids
Although potent preparations can cause skin atrophy, mild corticosteroids such as 1% Hydrocortisone do not and are safe to use in the long term.
Hydrocortisone 1% is the strength of choice for the face and flexures. Topical corticosteroids are often underused because of concern about the side effects.
There are four groups of potency. Within each potency group there is no evidence for increased efficacy or safety of any one particular product. Ointment preparations are more effective than creams and contain fewer additives. Creams can be used if the eczema is weeping or on the face.
Mild or moderately potent preparations should control most cases of eczema when prescribed in appropriate amounts. It may be necessary to gain control with a moderately potent preparation and then reduce to a mild strength.
(1–2 weeks) of a potent strength product may be required, particularly for resistant, lichenified lesions in older children. Avoid repeat prescriptions for potent strength corticosteroids.
In dry eczema try steroid/urea ± lactic acid e.g. Calmurid HC/Alphaderm.
Mild
Hydrocortisone
Moderate
Clobetasone butyrate (Eumovate)
Alclometasonedipropionate (Modrasone)
Potent
Betamethasone 17-valerate (Betnovate)
Mometasone (Elocon)
Very Potent
Clobetasol propionate (Dermovate)
Antihistamines
Suitable for short-term use to control itch especially at night.
Infection Control
(The commonest infecting organism is Staphaureus which produces characteristic yellow crusting)
Infection should be suspected whenever eczema worsens. Eczema that weeps or crusts is probably infected with staphylococcus aureus. If in doubt take swabs for microbiology.
- Tacrolimus (Protopic)
- Pimecrolimus (Elidel
Recommended where conventional therapy fails. Long term side effects unknown. Consult BNF for guidance. Cause irritation at first - which soon subsides as eczema improves.
Bandaging
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Initial training techniques may be required which can be given by a suitably trained nurse or nurse specialist
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Zinc paste bandages used alone or over topical corticosteroids can result in rapid improvement of resistant, particularly lichenified eczema.
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Wet wrap dressings may also be helpful, particularly at night in small children.
Wet wrap garments are more cost effective and acceptable to patients.
Allergies and allergy testing
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The house dust mite can aggravate eczema in some children.
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Vacuum mattress and keep dust level down.
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In severe cases try protective coverings to pillows and bedding (INTERVENT)
No tests are available to confirm or refute food allergy as a cause of worsening eczema. RAST tests and skin prick tests are not helpful. Patch testing is used to investigate specific contact allergic eczema
Food allergies, especially to egg, wheat and dairy products only rarely cause worsening of eczema.
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Consider exclusion diets only in difficult cases.
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Seek advice of dietician for young children and abandon if no improvement is apparent after 2 – 4 weeks.
Food intolerance is often a temporary phenomenon. An attempt should therefore be made every few months to re-introduce the food in question. Dietetic advice is required if exclusion diets are used for more than 2 – 4 weeks.
Evening Primrose Oil
Chinese Herbs-oral/topical
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There are no product licenses and currently standardisation is poor.
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They do have a measurable effect in some children, but serious adverse effects have been recorded and they cannot yet be recommended.
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Some contain potent topical steroids
Referral Threshold
Only cases of severe or difficult eczema need to see a Dermatologist:
