Dr Tom Poyner explains how the PCDS developed guidelines for the management of atopic eczema that are clinically relevant to primary care


   

The most frequent dermatological consultation in primary care is for a child with atopic eczema.1 The prevalence of atopic eczema in children is 15–20% and increasing, and most cases in children are of mild severity.2,3 In adults, the prevalence is 2–10% and the condition is a cause of significant morbidity.

By far the largest number of patients with atopic eczema are managed in primary care. New outline guidelines for the management of atopic eczema, from the Primary Care Dermatology Society (PCDS) are designed to help optimise this care.

Development of the guidelines

The PCDS wanted to develop guidelines for the management of atopic eczema that would be clinically relevant to primary care. The aim of the guidelines was to help GPs manage patients in their own practices.

A working party consisting of five GPs with dermatological expertise and two with guidelines and governance expertise was drawn up (see Box at end). The working party planned to review the best currently available evidence to produce provisional clinical practice guidelines, which would then be reviewed by the Society's committee and membership.4

There were already validated diagnostic criteria for atopic eczema.5 Previous guidelines for the management of atopic eczema existed, but they were becoming dated and had not been formulated specifically for primary care.6

Dr Julia Newton-Bishop, based in Leeds, had used a multidisciplinary approach and national opinion leader input to develop comprehensive guidelines for eczema treatment in the hospital sector.7 These are currently undergoing discussion and review, prior to publication.

This work was kindly made available to our group. There was a very limited amount of relevant evidence-based medicine; however, any relevant information will be incorporated as it becomes available.8 The referral guide for children with atopic eczema produced by NICE, which is currently being piloted at various sites around the country, was used as a basis for referral guidelines.9

Subsequent to the meeting of the PCDS working party, the documents were presented to and accepted by the PCDS committee.4 Following the British Association of Dermatology's lead, the provisional guidelines were circulated to the entire PCDS membership for their comments.10 Hywel Williams, Professor of Dermato-Epidemiology, also made some suggestions.11

The final guidelines and summary are now available. They are accompanied by an audit sheet developed and used by secondary care workers at Nottingham (see Figure 1,below). The summary and audit sheet are presented in this article.

Figure 1: The Nottingham atopic eczema datasheet for patients12
The Nottingham atopic eczema record sheet
The Nottingham atopic eczema record sheet

The information on treatment and management of atopic eczema should be considered as broad guidelines only. Treatment of an individual patient should always be modified according to need and circumstances and may involve a multidisciplinary approach.

Diagnosis and referral

Atopic eczema is diagnosed on clinical grounds, based on the clinical manifestation of the eruption, and the patient and family history. The diagnostic criteria are shown in Tables 1 and 2. Guidelines for referral are summarised in Table 3.

To provide a comprehensive service to patients with eczematous and dry skin conditions, a practice should involve relevant, appropriately trained personnel.

The GP and the primary care team of nurses and health visitors are responsible for all aspects of management: diagnosis, education, demonstration of techniques (e.g. wet wraps), patient review and monitoring, audit and patient support.

The general principles of primary care management are summarised in Table 4.

Table 1: Diagnostic criteria for atopic eczema

Must have:

An itchy skin condition (or report of scratching or rubbing in a child)

Plus three or more of the following:

  • History of itchiness in skin creases such as folds of the elbows, behind the knees, fronts of ankles, or around neck (or the cheeks in children under 4 years)
  • History of asthma or hay fever (or history of atopic disease in a first-degree relative in children under 4 years)
  • General dry skin in the past year
  • Visible flexural eczema (or eczema affecting the cheeks or forehead and outer limbs in children under 4 years)
  • Onset in the first 2 years of life (not always diagnostic in children under 4 years)

IF IT DOES NOT ITCH IT IS VERY UNLIKELY TO BE ECZEMA

 

Table 2: Diagnosis and patient assessment

Enquiry about and discussion of the following:

  • Family and personal history of atopy and eczema
  • Distribution of disease
  • Onset of disease
  • Exposure to pets within the household
  • Aggravating factors such as exposure to irritants
  • Sleep disturbance due to itching/rubbing
  • Previous treatments
  • Effect on school work, career, or social life
  • Most distressing thing for the patient or family
  • Patient's or family's expectations from treatment and their understanding of optimal use
  • Evidence of clinical infection, suggested by the presence of crusting or weeping in bacterial infection, or grouped vesicles and punched out erosions indicative of herpes simplex infection
  • Other considerations are the impact on the quality of life, dietary restrictions tried and other medications being taken (e.g. steroids for asthma)
  • A growth chart should be completed and updated in children with chronic severe eczema

(A copy of a patient audit questionnaire developed by the Nottingham group is shown in Figure 1,below)

 

Table 3: Recommendations for referral to secondary care
  • Severe infection with herpes simplex (eczema herpeticum) is suspected
  • 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
  • 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 parent
  • The patient or family might benefit from additional advice on application of treatments (bandaging techniques)
  • Contact dermatitis is suspected and confirmation requires patch-testing (this is rarely needed)
  • Dietary factors are suspected and dietary control is a possibility
  • The diagnosis is, or has become, uncertain

 

Table 4: The general principles of primary care management

Keep the patient/parent informed

  • Explain the condition and its treatment
  • Educate the patient on the use of topical treatments with details of application and quantities
  • Ideally demonstrate how and when to use
  • Back this up with written information and practical advice

Avoid exacerbating factors

  • Avoid anything that is known to increase disease severity where practicable
  • Crude lanolin is a weak sensitiser. However, the sensitising potential of hypo-allergenic ultra-purified lanolin has been shown to be minimal
  • Advise avoidance of extremes in temperature, avoiding irritating clothes containing wool or certain synthetic fibres
  • Advise keeping nails short
  • Avoid use of soaps or detergents, replace with emollient substitutes

Keep skin hydrated

  • Use of baths and bath additives
  • Reduce water loss by the use of sufficient appropriate emollient therapy used liberally

Treat secondary infection early

  • Use of appropriate topical and oral therapy

Treat exacerbations

  • Use of appropriate topical steroids on acute basis

Principles of treatment

Emollients are the first step and the one constant in the treatment of eczema. They are indicated for all types of eczema and are the first-line therapy to which others are added. In this respect, patient choice and the associated compliance are essential, as are good patient education and training in product use.

Most children with mild/moderate eczema can be controlled by the intense use of complete emollient therapy most of the time, and a resultant steroid-sparing effect of emollients has been demonstrated.

A primary strategy to help improve the patient's eczema is management of the itch-scratch cycle. Poor patient compliance, inappropriate selection of emollient type or types, and a lack of patient education all contribute to gross under-utilisation of emollients in primary care, and may have led to an overuse of steroid creams.

Application of an emollient cream/ointment, 250g/week for a child, and 500g/week for an adult, is recommended in the British Association of Dermatology guidelines.

The use of emollients is summarised in Table 5, below.

Table 5: Use of emollients
  • Emollients are best applied when the skin is moist but they can and should be applied at other times
  • Many patients underestimate the quantity needed and frequency of application to achieve maximal effect
  • Emollients should be applied as liberally and frequently as possible and continual treatment with complete emollient therapy (combinations of cream, ointment, bath oil and emollient soap substitute) will help provide maximal effect
  • An additional approach is to add a local anaesthetic substance such as lauromacrogols to the emollient to provide antipruritic activity to help break the scratch-itch cycle
  • Ideally the frequency of application of emollients should be every 4 hours or at least 3–4 times per day
  • Emollients should be prescribed in large quantities with the recommended quantities used in generalised eczema being 500g/week for an adult and 250g/week for a child
  • Intensive use of emollients will reduce the need for topical steroids. It should be emphasised to all patients that emollient use in quantity and frequency far outweighs other therapies they may be given
  • A general rule of thumb is that emollient use should exceed steroid use by 10:1 in terms of quantities used for most patients

Education on how to use emollients is essential to ensure maximal rehydration of the skin.

Topical steroids

Topical steroids are a beneficial intervention in atopic eczema. They provide a treatment for 'exacerbation and flare-ups' of atopic eczema and should be regarded as acute short-term therapy for this purpose.

The principles of treatment with topical steroids are summarised in Table 6, below.

Table 6: Principles of treatment with topical steroids
  • As a rough guide, steroid use should be limited to a few days to a week for acute eczema and up to 4–6 weeks to gain initial remission for chronic eczema
  • The weakest steroid should be chosen to control the disease effectively; this may include either a step-up approach, low to more potent, or a step down approach, more potent to less potent
  • In each approach, regular review of steroid use in terms of potency and quantity, (especially when using potent steroids) is essential
  • Very potent steroids should not be used in children with atopic eczema in primary care. Very rarely their use may be indicated in resistant severe eczema on the hands and feet of adults, again with regular review of use
  • Patients using moderate and potent steroids must be kept under review for both local and systemic side-effects
  • Take care which strength of steroid is entered into your patient's repeat prescription

Bacterial infection

Flares or exacerbations of eczema may result from bacterial infection, which is suggested by the presence of crusting, weeping, pustulation and/or surrounding cellulitis with erythema of otherwise normal looking skin, or a sudden worsening of the condition.

Staphylococcus aureus is believed to be an important exacerbating factor in atopic eczema. Swabs for bacteriology are particularly useful if patients subsequently do not respond to treatment, in order to identify antibiotic-resistant strains of S. aureus or detect additional streptococcal infection.

Emollient-antimicrobial preparations are widely used to prevent infection, with some evidence of an antimicrobial effect.

Tubs of ointments should not be left open, and simple clean procedures should be used by patients and parents when applying the creams, such as removing cream with clean spoons from the jar. Pump dispensers may also be useful.

Oral antibiotics are often necessary in moderate to severe infection. A 14-day course is required. Oral flucloxacillin is usually the most appropriate antibiotic for treating S. aureus infection.

Erythromycin or one of the new macrolides with possibly better tissue penetration is an alternative. These latter drugs can also be used if there is penicillin allergy or resistance. Penicillin should be given if beta-haemolytic streptococci are isolated.

Steroid-antibiotic combinations are effective in clinical practice, although evidence for superiority in efficacy is lacking.

The management of sensitive and problem dry skin and eczema is summarised in Figure 2.

Figure 2: Summary of the management of sensitive and problem dry skin and eczema
flow chart: sensitive and problem dry skin and eczema management

 

Review of the guidelines

The guidelines need to withstand the rigours of daily practice: they are not cast in stone and will need constant revision. I have volunteered to act as custodian to provide a focal point for further suggestions and updating of the guidelines.

Members of the PCDS working party

Thomas Poyner Stockton-on-Tees (Chairman)

Amal Brahmachari Telford, Shropshire

John Buchan Rhayader, Powys

Basil Hainsworth Newtown Linford, Leicestershire

Dilys Harlow Winterbourne, South Gloucestershire

Peter Hick Stockport

Tim Mitchell Bristol

  • The guideline development process was facilitated by Strategen, a healthcare communications consultancy
  • For further information on the full guidelines, contact the Primary Care Dermatology Society, PO Box 6, Princes Risborough, Bucks HP7 9XD.

References

  1. Royal College of General Practitioners. Morbidity Statistics from General Practice. Fourth National Study 1991-92. London.
  2. Kay J, Gawkrodger DJ, Mortimer MJ, Jaron AG. The prevalence of childhood atopic eczema in a general population J Am Acad Dermatol 1994; 30: 35-9.
  3. Emmerson RM, Williams HC, Allen BR. Severity distribution of atopic dermatitis in the community and its relationship to secondary care. Br J Dermatol 1998; 139: 73-6.
  4. Shekelle P, Woolf S, Eccles M, Grimshaw J. Developing guidelines. Br Med J 1999; 318: 593-6.
  5. Williams HC, Burney PG, Pembroke AC, Hay RH. The UK working party's diagnostic criteria for atopic dermatitis III. Independent hospital validation. Br J Dermatol 1994; 131: 406-17.
  6. McHenry PM, Williams HC, Bingham. Management of atopic eczema. Br Med J 1995; 310: 843-7.
  7. Newton-Bishop J. Personal written communication, February 2000.
  8. Charman D. Clinical evidence: atopic eczema. Br Med J 1999; 318: 1600-4
  9. National Institute for Clinical Excellence. Referral Practice. A guide to appropriate referral from general to specialist services. May 2000. Version under pilot. Atopic eczema in children. Referral advice.
  10. Griffiths C. Development of management guidelines for skin disease. BAD Newsletter 1997, 20-1.
  11. Williams HC. Personal communication, September 2000.
  12. Shum KW. Personal written communication, November 2000.

Guidelines in Practice, January 2001, Volume 4(1)
© 2001 MGP Ltd
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