Dr Rachel Hilton explains how patient and carer education can help promote effective and safe use of emollients and topical steroids in children with atopic eczema


Atopic eczema is a common, lifelong condition that affects one in five children1 and usually first appears during infancy. It often has a profound effect on the individual and also on all family members.2 This article discusses ways to implement good management of eczema in primary care based on the guideline from NICE, Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years.3,4 The treatments that are most useful in primary care are also discussed.

Individuals with atopic eczema have a defective epidermal barrier. This results in increased transepidermal water loss (TEWL) and penetration of environmental irritants and allergens into the epidermis. Management of eczema aims to repair barrier function and reduce the resulting epidermal inflammation.

The majority of cases of childhood eczema (80%) can be managed in primary care.2 Parents appreciate the easy access to, and convenience of, seeing their GP, practice nurse, or health visitor.

Eczema lead

As with all chronic conditions, it can benefit both the practice and patients if there is a lead clinician. This may be a doctor who leads on child health promotion, or one who has some dermatology training. A practice nurse may also be suitable—nurses are often best placed to deliver advice regarding topical management.

Health visitors are in an excellent position to detect cases of childhood eczema early; they see infants regularly and are often the first person to whom a concerned parent turns. I have personal experience of successful health visitor-run eczema clinics and have seen the resultant fall in referrals to specialist clinics. This reduction in referrals happens for two reasons:

  • More individuals are managed in-house
  • Good skin care has a disease-modifying effect by improving the skin's barrier function.

Diagnostic criteria

Recognised diagnostic criteria for atopic eczema are as follows:3–5

  • Patient must have an itchy skin condition (or parental report of scratching or rubbing) during the past 12 months
  • Plus three or more of the following:
    • History of involvement of the skin creases (front of elbows, behind knees, fronts of ankles, around neck or eyes)
    • Personal history of asthma or hay fever (or history of atopic disease in a first-degree relative if child is aged <4 years)
    • History of dry skin during the past year
    • Onset before the age of 2 years
    • Visible flexural dermatitis (including cheeks, forehead, and extensor surfaces of limbs in child aged <18 months).

Management

Good eczema management (Box 1, below) should be patient-centred, taking into account both the child's and carer's preferences.3,4

Irritant reduction
It is essential to consider the products used when washing the child. All products that foam contain surfactants, which are potentially irritant. Sodium lauryl sulphate (SLS) is a common surfactant and it should be noted that SLS is also present in some emollients,5 particularly aqueous cream. It is for this reason that aqueous cream should not be used as a soap substitute, nor as a leave-on emollient. Most emollients emulsify well with water and may be used as a soap substitute.6 In my experience, one exception to this is 50/50 ointment.

Emollients as moisturisers
Emollients, particularly the greasier products, reduce TEWL. They feel soothing and smooth the roughness of dry skin, thereby having an anti-pruritic effect. The greasier the emollient, the greater the benefit, but patient preference is paramount. Allowing the child and parent to sample a range of emollients will enable those products that feel uncomfortable to be discounted.3,4Few of us would regularly apply something to our skin that we did not like the feel or smell of. Sampling products is made possible by having a range of emollients to hand in the practice, or by providing a range of small samples for the patient to try at home. All manufacturers will provide sample packs without charge.

The chosen emollient must be applied generously and frequently, at least twice but preferably four times a day. To enable this, repeat prescriptions of generous quantities of emollients must be written, ideally for 250–500 g weekly.4

After taking account of the patient's preference, using the same emollient product as both soap substitute and leave-on moisturiser will simplify the management regimen and reduce prescribing costs.7 It should not be the case that an emollient regimen is omitted and yet a topical steroid is prescribed—this would mean that more steroid is used than would otherwise be necessary.

Topical steroids
The potency of topical steroid prescribed depends on two main factors:

  • Severity of eczema
  • Body area to be treated.

A lower potency is required for the face, as skin here is naturally thinner. The presence of natural occlusion in the axillae and groin increases the penetration of steroid molecules, therefore, a lower potency is also used in these areas.3,4

The NICE guideline recommends a stepped approach to the use of topical steroids, as adapted for Table 1.3,4

Steroid phobia and side-effects
Parents are often reluctant to apply steroids to their child's skin due to the perceived risk of side-effects. Topical steroids dispensed by the pharmacist will have a label attached stating 'apply sparingly', and this along with the enclosed patient information leaflet can further increase parental fears.

The main side-effects of a topical steroid are epidermal and dermal atrophy, so-called skin thinning. Atrophic skin becomes more translucent, with increased visibility of superficial veins and capillaries. Dermal atrophy may result in the appearance of striae.8

Atrophy of the skin is very unlikely if the correct potency of topical steroid is used (see Table 1) and use is intermittent (only applied to skin when it is inflamed). Conversely, poorly managed eczema results in scarring (particularly post-inflammatory hypo- or hyper-pigmentation of pigmented skin) and lichenification.4

It is useful to provide parents with printed information listing steroids of different potencies, as they often have tubes of previously prescribed topical steroids at home. In the Ashton, Leigh and Wigan service, we use a card that can be written on to indicate which potencies can be used on which body areas.

Order of application of topical products
I advocate the following order of application, working from head-to-toe:

  • Leave-on emollient, applied generously, working from head-to-toe.
  • Topical steroid, applied accurately, not sparingly to red, itchy areas.

There is no need to wait any length of time between steps 1 and 2. As individual areas of eczema improve, they no longer need topical steroid. If the order of application is reversed, it is important to wait 30 minutes between application of steroid then emollient, to avoid spreading the steroid over a wider area than is needed. Parents do not often have this time, so will omit the 30-minute wait or will not bother to apply an emollient at all. For this reason, it is essential that the patient and carer are made aware of the correct order of treatment application for emollient and steroid.

Prescribing topical preparations
When prescribing, ensure that patients and carers have enough topical steroids to last until the next review. The principle of the fingertip unit is very useful in this respect (see Box 2).

Box 1: Atopic eczema—key management steps
  • Irritant reduction and avoidance—emollient soap substitutes
  • Improvement of skin barrier function and soothing of itch—leave-on emollients
  • Reduction of epidermal inflammation—topical corticosteroids and calcineurin inhibitors
  • Management of secondary bacterial infection—antibiotics
  • Occlusion, if required.

Topical calcineurin inhibitors
Topical tacrolimus and pimecrolimus ointments are calcineurin inhibitors not steroids, and so carry no risk of epidermal atrophy. Common side-effects of these treatments include skin irritation and increased sensitivity to the sun,9 so sun-protection is needed when used on the face. The NICE guideline recommends tacrolimus and pimecrolimus as treatment options for eczema, within their licensed indications for children;3,4 tacrolimus 0.03% is licensed for use in children aged 2–16 years and 0.1% is licensed only in children aged >16 years.9 They can be applied twice weekly (omitting topical steroids on those days) to reduce the frequency of flares. Pimecrolimus is prescribed for milder eczema, tacrolimus for more severe eczema or if pimecrolimus is ineffective.

Bacterial skin infections
Staphylococci and streptococci can penetrate the epidermis easily through cracks and excoriations, thereby causing eczema at all sites to worsen. Emollients reduce the frequency of such flares by improving barrier function. Treatment of infection requires systemic erythromycin or flucloxacillin.3,4 Erythromycin is preferable for individuals aged <12 years as it is much more palatable (patient and parent testimony). For children aged 2 years and older, twice-daily dosing is possible, which improves compliance in school-aged children.

There is much greater certainty that all areas of infection will be treated by using a systemic antibiotic. The effectiveness of a topical antibiotic/steroid product is dependent upon excellent compliance by the parent/patient in treating every eczematous area sufficiently—the infection will persist if one area is under treated.

If flares are frequent, a swab should be taken for microbiological confirmation of culture and sensitivity; a longer course (1–3 months) of antibiotic should then be considered.

Occlusion
Dry and wet occlusive bandages and garments increase the absorption and effectiveness of a topical product. However they should:

  • never be used in the presence of infection
  • only be prescribed by professionals trained in their use.
Table 1: Potency of topical steroids required for different types of eczema3,4
Severity of eczema
Impact
Potency of steroid
Face, axillae, groin
Limbs, trunk, hands, feet, scalp
Mild
Areas of dry skin, minimal or no areas of redness, infrequent itching
Mild
Mild
Moderate
Areas of dry skin, frequent itching, with or without excoriations and areas of skin thickening (lichenification)
Mild
Moderate
Severe
Widespread areas of dry, red skin, incessant itching, with or without excoriations, extensive lichenification, bleeding, oozing, cracking, or alteration of pigmentation
Moderate
Potent
Adapted from National Institute for Health and Care Excellence (NICE) (2007) CG57. Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years. Clinical Guideline 57. London: NICE. Available at: www.nice.org.uk/guidance/CG57
Box 2: The fingertip unit

One FTU is the amount of topical steroid that is squeezed out of the tube from the very end of the finger to the first crease in the finger.

All topical steroids have a standard 5 mm nozzle so the measurement is standard across all preparations. One FTU is enough to treat an area of skin the size of the flat of two adult hands with the fingers together

  • One FTU = 0.5 g
  • Topical steroids are applied twice daily (with the exception of topical mometasone)
  • Thus 1 g topical steroid will treat no more than an area the size of two adult hands (e.g. a baby's face) for 1 day.

FTU=fingertip unit


When to refer

Immediate, same day referral is necessary with eczema herpeticum—the sudden appearance of a crop of painful, monomorphic, 'punched-out' lesions—as there is a risk of developing herpes simplex encephalitis.3,4

Urgent referral is needed if severe eczema is not improving after 1 week despite optimum topical treatment, or if bacterially infected eczema is not responding to appropriate antibiotics. Routine referral is needed with:

  • diagnostic uncertainty
  • eczema that is failing to improve sufficiently with the above management and/or contact allergic eczema is suspected
  • frequent flares of eczema, despite the introduction of topical immunomodulators or a long-term systemic antibiotic
  • significant psychosocial consequences.

Prognosis

Atopic eczema will improve with time, but over years rather than months. Individuals who have had atopic eczema as a child will still be prone to it as an adult, particularly on the hand, therefore, consideration should be given before entering a trade in which contact with irritants is common, for example hairdressing, engineering, or cookery.

Implications for the practice

Consultation time
A consultation for atopic eczema takes time—usually longer than the standard 10-minute appointment. Not only does the clinician need to take a history and perform an examination, but considerable time should also be spent on:

  • discussing the management plan
  • sampling emollients
  • discussing the emollient regimen, and correct application of topical products
  • writing down the agreed plan
  • producing a prescription.

This in-depth consultation is likely to take a minimum of 20 minutes, but will be time well spent. The key aim is to enable parents and children to become experts themselves, thereby reducing the need for further appointments. Practices will need to consider the structure of appointment templates to accommodate these consultations.

Costs
The clinician will ideally have a range of emollients to hand, but this will be a small outlay compared with the savings achieved by prescribing emollients that the child and carers like and will use effectively. Emollient prescribing will increase as larger quantities are prescribed; however, topical steroid prescribing will decrease over time as skin condition improves.

The only other resources needed are patient materials, which can be printed off as required. A prescription for atopic eczema will often include five or more items. The parent is much more likely to remember the management plan and treatment regimen if they have a written copy of it. A simple list of the treatments being prescribed will often suffice—our practice uses cards that also provide useful skincare advice.

Summary

Consultations for childhood atopic eczema should aim to enable the child, parents, and family to become experts in its management. The rewards for the child and family are a reduction in the number and severity of acute flares, a reduction in the child's distress, and an increase in the family's quality of life. Consequently the clinician, who is prepared to invest the time to achieve this, stands to gain great personal and professional satisfaction.

Ten top tips—eczema management in primary care
  • Have an eczema expert in each practice
  • An eczema consultation takes time—allow for this
  • Allow patients to sample different emollients
  • Be aware of steroid phobia, counter this by explaining how to use topical steroids correctly. Explain the preferred order of application, i.e. steroid after emollient, accurately rather than sparingly
  • Provide a written management plan for the patient to take home
  • Enable parents to manage a flare of their child's eczema, by instructing them to step-up steroids and increase the frequency of emollient applications
  • Educate parents/carers so they recognise the signs of bacterial infection of their child's eczema
  • Write repeat prescriptions of suitably generous quantities of topical products
  • Encourage children to take control of their eczema management as they get older
  • Recommend that parents/carers visit the National Eczema Society website (www.eczema.org).
Useful resources

Useful resources for patients:

Useful resources for healthcare professionals:

  • The Primary Care Dermatology Society website includes clinical guidance on atopic eczema. The society also organises educational events: www.pcds.org.uk
  • Cardiff University, Diploma in Practical Dermatology—a well respected dermatology qualification that is aimed at general practitioners: www.dermatology.org.uk
  • An excellent article on the National Eczema Society website, discussing the benefits and risks of topical steroids: www.eczema.org/Steroid_Phobia_Article.pdf
  • NICE guideline on atopic eczema in children: www.nice.org.uk/CG57
GP commissioning messages

written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead

  • The NICE and SIGN guidelines contain simple algorithms and guidance that can be built into local-care pathways and made available to local clinicians
  • Map of Medicine pathways can be used as a useful decision aid within GP practices and can be adapted to local circumstances
  • Most cases of eczema can be managed in primary care, but support from a community GPwSI or specialist nurse can further increase the confidence of clinicians in this setting
  • Local formularies should:
    • cover the use of emollients, topical steroids, and other agents
    • identify cost-effective options that provide a choice for clinician and patients
  • Tariff for paediatric dermatology outpatients = £166 (new), £119 (follow up).a

awww.dh.gov.uk/paymentbyresults/


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  2. Batchelor J, Grindlay D, Williams H. What's new in atopic eczema? An analysis of systematic reviews published in 2008 and 2009. Clin Exp Dermatol 2010; 35 (8): 823–827.
  3. National Institute for Health and Care Excellence. Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years. Clinical Guideline 57. London: NICE, 2007. Available at: www.nice.org.uk/guidance/CG57nhs_accreditation
  4. National Collaborating Centre for Women's and Children's Health. Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years. Clinical Guideline. London: RCOG, 2007. Available at: www.nice.org.uk/guidance/CG57nhs_accreditation
  5. Brenninkmeijer E, Schram M, Leeflang M et al. Diagnostic criteria for atopic dermatitis; a systematic review. Br J Dermatol 2008; 158 (4): 754–765.
  6. Cork M, Danby S. Aqueous cream damages the skin barrier. Br J Dermatol 2011; 164 (6): 1179–1180.
  7. Primary Care Dermatology Society, British Association of Dermatologists. Guidelines for the management of atopic eczema. In: Hayeem N, editor. Guidelines—summarising clinical guidelines for primary care. 45th ed. Berkhamsted: MGP Ltd; October 2011. pp: 391–395. Available at: egln.co.uk/link/7875
  8. James M, Black M, Sparkes C. Measurement of dermal atrophy induced by topical steroids using a radiographic technique. Br J Dermatol 1977; 96 (3): 303–305.
  9. British National Formulary. BNF 62. September 2011. London: British Medical Association and the Royal Pharmaceutical Society of Great Britain, 2011. G

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