Atopic eczema (atopic dermatitis) is a chronic inflammatory skin condition. It is common in childhood affecting about 10% of school-aged children. Moderately severe eczema is miserable for the whole family. Itch and sleep deprivation are the main complaints. Topical treatment is messy and time consuming. Many parents who end up bringing their child to the ED will be exhausted and fed up. It is important that they get consistent, clear messages about treatment. Flares are common, and sometimes there will be a treatable exacerbating factor such as infection.
One of the commonest reasons for acute flare up is secondary infection. This is almost always with staphylococcus aureus.
- Crusted weepy areas suggest bacterial infection with S. aureus
- Take bacterial swabs to confirm sensitivities
- Treat with oral flucloxacillin for 10 days or erythromycin if penicillin allergic
- Frankly infected eczema should not be bandaged – wait 48-72 hours into antibiotic
- Treatment before starting bandaging
- Fusidic acid containing creams (Fucibet, Fucidin ) should be limited to short term use( i.e. 5 days for localised infection) because of bacterial resistance
- Herpes simplex causing ‘eczema herpeticum’ with monomorphic punched out erosions and vesicles
- Infection can rapidly become widespread and cause severe systemic upset
- Take viral fluid for slides and swabs to confirm diagnosis
- Oral treatment with aciclovir if infection localised and no systemic upset
- IV treatment If there is widespread infection or systemic upset: senior review is indicated
Taking viral samples: Need a viral testing kit: if not in ED obtain one from the lab EM gives rapid results- smear the glass slide over ruptured vesicles and send urgently to virology.
Long Term Management
Staying with simple treatments that you know well and spending time explaining and encouraging correct usage is often more effective than using yet another different preparation.
- Soap and shampoo must be avoided
- Effective cleansing can usually be achieved by applying the child’s usual emollient prior to washing and then rinsing it off
- Alternatively bath and shower oils may be preferred
- Bath: Oilatum bath additive 500mls or Balneum bath additive 500mls
- Shower: Dermol 500
- Emollients are the mainstay of treatment. It is really important to continue using these to keep the skin in good condition even when the eczema is quiet
- The best emollient is the one the patient will use adequate amounts of
- Greasy emollients are often more effective and need to be applied less often, but are sticky and mark clothing and some patients/ parents will find them unacceptable
- They should be applied generously at least twice a day, and more frequently to drier areas
- Children should use about 250g of emollient/ week
- Adolescents should use about 500g of emollient/week
Less greasy emollients:
- Diprobase cream 500gl pump dispenser
- Doublebase 500g pump dispenser
- Epaderm 500g tub
- 50/50 WSP/LP 500g tub
- Steroids are safe if used appropriately. Parents are often wary of steroids and it is common to use too little, too late
- Enough steroid should be applied to make the skin appear slightly shiny
- Almost all preparations come in a cream or ointment form, which needs to be specified when prescribing
- Cream is water based and therefore will mix with wet, weepy areas
- Ointments are greasy and better for dry areas
- Just changing the “vehicle” may make the same strength of steroid work better
- A suitable steroid regimen for moderate eczema would be:
- 1% hydrocortisone ointment/ cream (weak steroid) applied twice daily to red/eczematous areas on face and neck supplied in 30g tube
- Eumovate ointment/cream (moderately potent steroid) applied twice daily to red/eczematous areas on trunk and limbs supplied in 100g tube
Bandages are a useful adjunct to treatment. They improve the penetration of topical treatments into the skin, feel soothing, provide a barrier to scratching and prevent emollient making clothes greasy. Bandages can be used over night or continuously changing the bandages once or twice in a 24-hour period:
Dry – Tubular bandage
Wet- wet wrapping technique puts damp layer of bandages under dry layer
Paste- impregnated (sticky) bandages under tubular bandages- “Viscopaste”(zinc oxide) or “Icthopaste” (zinc oxide and icthammol)
Elasticated viscose stockinette (Tubifast, Coverflex or equivalent) to fit trunk or limbs (width ranges in size from in red stripe which fits an infant’s arm through blue, green and yellow stripe which fits a larger child’s trunk) in 10 metre lengths.
Tubifast garments can also be prescribed (vest, leggings, socks).
Paste bandages come in boxes of 12 rolls -each roll will provide one application to 4 limbs of a small child.
Patients/carers need to be shown how to bandage properly. Contact outpatient nurses in working hours to arrange this.
Antihistamines may be useful at night for sedating effect:
Piriton, Vallergan, Phenergan
Use a decent, sedative dose at bedtime. The child may get tolerant of the sedative effect, so intermittent use when most needed makes sense.