What to consider in Primary Care before referring:
Clinical features
A) Endogenous Eczema (eg. atopic)
B) Exogenous Eczema
(i) Irritant Contact Eczema ICD
Due to substances coming into contact with the skin, usually repeatedly, causing damage and irritation. Substances such as:
- Water
- Detergents
- Shampoos
- Household cleaning products
(ii) Allergic Contact Dermatitis (ACD)
Due to type IV allergic reaction to a substance the skin is in contact with.
All types of endogenous and exogenous eczema can present with either ‘wet’ (blistering and weeping) or ‘dry’ (hyperkeratotic and fissured) eczema.
General Comments
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Other skin conditions can mimic eczema and should be kept in mind.
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It is usually worth examining the patient’s skin all over as this can provide clues to other diagnoses e.g. plaques in extensor distribution in psoriasis, scabetic nodules in scabies.
- If an eczematous looking rash is present on only one hand, a fungal infection needs to be excluded by taking skin scrapings for mycology.
- If contact dermatitis is suspected a careful occupational and social history should be taken and the patient may require Patch Testing
- Patch Testing is only of value in patients with eczema - it is of no use with type 1 reactions (e.g. food allergies causing anaphylaxis or urticaria).
- In practice the cause of eczema is often multi-factorial with external factors precipitating eczema in a constitutionally predisposed individual, in which case PT’s usually unhelpful. Resistant hand eczema does however, merit consideration of these to exclude type 4 reactions.
Treatment in Primary Care
Avoidance of irritants
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Soap substitutes such as Epaderm should be used.
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Gloves e.g. household rubber or PVC gloves should be used for wet work such as dishwashing.
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Gloves may also be required for dry work e.g. gardening
Emollients
- These should be applied frequently.
- There are a variety of emollients available - different patients will prefer different preparations.
Topical Steroids
- The strength of topical steroid required varies from case to case.
- Often it is necessary to use a potent topical steroid short term.
- Prescribe a cream formulation if ‘wet’ and ointment if ‘dry’.
Potassium permanganate
- Diluted in water to pale pink (Rose wine colour) and soak for fifteen minutes 2 to 3 times daily for acute wet eczema until blistering weeping has dried.
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Make up a pale pink/rose colour using crystals, tablets or liquid in warm water.
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Manufacturers’ instruction often too strong.
Antibiotics (topical/systemic)
- Exclude secondary infection and treat if appropriate.
Referral Threshold
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Severe chronic hand dermatitis, which is unresponsive to treatment described above.
