The BAD/PCDS guideline on atopic eczema will help GPs with diagnosis, management, and treatment of this common condition explains Dr Stephen Hayes
Eczema/dermatitis in all its forms is the most common rash seen in primary care, affecting 15–20% of school age children and 2–10% of adults,1 and causes significant morbidity. The British Association of Dermatologists (BAD)2 and the Primary Care Dermatology Society (PCDS)3 have produced a joint guideline for management of atopic eczema, which is the most common form of the complaint.1 This article assesses the guideline from the point of view of a GPwSI in dermatology.
The guideline from BAD/PCDS on management of atopic eczema advises on the basic principles. Treatment can be modified within these criteria as required according to clinical judgement, patient preference, and circumstances.
Diagnosis and symptoms
Diagnosis is usually straightforward. Patients complain of itchiness and are unhappyÑa non-itchy rash is unlikely to be eczema. The skin may be excoriated, and there is often a family history of eczema (or hay fever and asthma, which are genetically related atopic problems). The patient's skin may tend to be generally dry.
Examination usually reveals erythema of the flexor aspects of limbs (ante-cubital and popliteal fossae). Other clinical signs include the following:4
- lichenification—a thickening and increased emphasis of the skin creases caused by rubbing
- excoriation—marks caused by scratching as a consequence of the intense itch of eczema
- fissures—splits in the skin that are characteristic of eczema
- vesicles—small, usually less than 1 mm diameter, clear, fluid-filled blisters that are strongly indicative of eczema and are often missed unless looked for under a good light with a lens.
In children, onset of an itchy skin condition before the age of 2 years may indicate eczema. The most likely misdiagnosis is scabies, which should always be borne in mind. A child may be diagnosed with eczema and hydrocortisone prescribed, only for them to return 2 weeks later with a worsening of the condition and reporting similarly affected siblings. Burrows on the hands and nodules on the scrotum are diagnostic.4
A complete history of the onset of the eczema should be obtained from the patient. This should include the following:
- family and personal history of eczema and related atopic conditions
- distribution and onset of disease
- exposure to aggravating factors, such as irritants or pets in the household
- whether quality of life for the patient or his/her family is affected—effects on schoolwork, career, social life, disturbed sleep as a result of itching or rubbing
- evidence of bacterial infection with crusting or weeping
- any signs of herpes simplex infection, such as clusters of vesicles or punched out lesions
- previous treatments that have been tried and what the patient's or his/her family's expectations are of the current treatment
- any modifications to diet that have been tried
- what other medications, if any, are being taken, such as asthma treatments.
A growth chart should be completed for children with chronic severe eczema.
All forms of eczema/dermatitis share common principles of management, which are then tailored to suit the particular patient. It is common practice to try several ways of tackling the condition before finding the one that works for that individual. The GP and his or her team can make a difference in providing continuity of care and family support as well as medicine.
Once diagnosis is made, it is important that the patient does not make it worse. The skin is dry in eczema, and all forms of soap (including hypoallergenic soaps) are detergents, which work by dissolving grease on the skin, and will have a further drying effect. Similarly, bubble bath should not be used at all. Instead patients should use soap substitutes, such as emulsifying ointment, aqueous cream, or proprietary compounds.1
It is important to keep the patient informed and, in the case of children, the family. It is common for mothers to feel guilty and that the eczema was caused by something they did or failed to do. Reassurance should be offered that this is not the case. Breastfeeding (although recommended on other grounds), or not, is irrelevant.
Despite popular mythology and anecdotes, food allergies rarely, if ever, cause atopic eczema, and faddish diets can only increase stress and will not cure the condition. In rare cases the help of a dietician may be of use.1
It is common sense to ensure that the fingernails are kept as short and smooth as possible to minimise skin damage from scratching. Some clothing, such as wool, irritates the skin more than others and should be avoided.1
Use of moisturisers
Emollients/moisturisers do not put water into the skin but prevent it from leaving by restoring the integrity of damaged epidermis. Emollients are greasy, creamy, or somewhere between the two. The greasy ones, typified by Vaseline (white soft paraffin), are preferable as they last longer on the skin and contain no preservatives or emulsifiers, however, they may be less cosmetically acceptable as a result of the inherent stickiness/greasiness. On the other hand, aqueous cream or proprietary equivalents are light and acceptable, but are also less effective and may sting—this is a result of preservatives and stabilisers, which are not found in paraffin-based emollients.
Many proprietary compounds have been developed to try to achieve the effectiveness of white soft paraffin and the comfort of light creams—the GP should try many emollients on their own skin and also ask patients about their experience, in order to get a feel for the differences between products and be better placed to advise patients. No emollient suits everyoneÑthe old cliche remains trueÑfind out which emollient the patient likes, then prescribe enough of it.
Emollients should be applied as liberally and frequently as possible, ideally after bathing while the skin is still moist, but they can and should also be applied at other times.1 Recommended use in generalised eczema is 600 g/week for an adult, and 250 g/week for a child. It is also essential to offer advice to patients on how best to use the emollient in order that the skin receives maximal hydration.
Topical corticosteroids remain indispensable, but patients may be wary of their effects and they should be reassured about the appropriate use and benefits.1 These are anti-inflammatory drugs and should be used accordingly. Excessive steroid use (too much, too strong, too long) may cause skin thinning, steroid rosacea on the face, or even adrenal suppression and Cushing's disease in extreme cases of prolonged widespread application of highly potent steroids.
Steroids vary in potency from mild (1% hydrocortisone) to most potent (clobetasol propionate). The correct potency must be judged for each patient, either by starting weak and stepping up until the right effect is obtained, or starting strong and stepping down by reducing either potency or frequency of application. Most dermatologists today favour the latter approach, as it works faster. Nothing stronger than 1% hydrocortisone should be used on the face, and milder steroids should be used in flexures as the skin folds touching each other retains the steroid in place, increasing potency.4
In cases of severe inflammation of the hands or feet, it is acceptable to prescribe as strong a drug as mometasone for 3 or 4 days. In an infant, potent steroids should only be prescribed on advice from a specialist.1 Where a potent steroid is prescribed, all patients should be kept under close review and should always be referred to a specialist if an improvement is not seen.1 The GP has a duty of care and should make careful notes in the patient's record of prescription of potent steroids. Above all, big tubes of potent steroid should never be put on repeat prescription.
Tacrolimus, and the milder pimecrolimus, are alternatives to topical steroids and are similar in effect to ciclosporin. They do not thin the skin as steroids can, but may cause a transient sensation of warmth or burning.1 This diminishes after a week's use, but some patients find it intolerable from the first dose. The GP should advise appropriately and suggest patients try a thin application to one small area at first.
Experience of oral tacrolimus in Japan suggests that, as is the case with the related fungal-derived immunosuppressant ciclosporin, the long-term incidence of skin cancer, particularly squamous carcinoma, is increased. Patients, especially those with red hair and who burn easily, should be advised to minimise sun exposure in view of this theoretical increased risk. More will be known only after long-term studies have been carried out. The risk from these agents is probably not high, but only long-term studies, which are not yet available, will provide evidence either way. As advised by the manufacturers, these agents should be avoided in the presence of herpes1 or other infections as they are immunosuppressants. At present it is recommended that their use should only be initiated by a specialist or GPwSI.1
Treatment of bacterial infectionScratching of an eczematous rash produces multiple portals of entry, and infection is not uncommonly introduced via auto-inoculation from nose or perineum. Staphylococcus aureus infection can cause the eczema to flare up. The GP should consider a course of oral antibiotics (usually flucloxacillin, or in cases of penicillin allergy or resistance, erythromycin) for very red, widespread, angry eczema or if there is yellow crusting.1 Resistance to fusidic acid is commonly reported and its routine use topically is questionable. Whether alone or in combination with steroids, courses of antibiotics should be for a week only; prolonged intermittent use is most likely to lead to antibiotic resistance.1
Eczema herpeticum, is a fast-spreading herpes simplex infection that may be diagnosed in atopic patients, and should be treated as an emergency requiring urgent hospital referral for antiviral treatment.1
Referral is also indicated in the following cases where:
- the diagnosis is in doubt control
- cannot be achieved by the methods outlined above
- excessive amounts of topical steroid are being used
- social or psychological problems arise—school absenteeism, sleeplessness
- advice on special techniques, such as bandaging, is required
- a contact allergic cause is suspected—such as from pets or irritating clothing.1
The referral letters should detail past and present treatments and the reason help is being sought.1 The vast majority of cases of atopic eczema can and should be managed in primary care.
Antihistamines are often prescribed without effect, and non-sedating antihistamines are of limited benefit in atopic eczema. However, sedating antihistamines (e.g. chlorpheniramine or promethazine, which have been used at the Southampton practice) may be used, ideally intermittently, for exacerbations, and may help with sleeplessness and reduce scratching.
Many eczema sufferers turn to complementary and alternative medicine (CAM) which is not so well researched and regulated as conventional medicine, but GPs should respect their patients' preferences. Therapies such as homeopathy, herbalism, and aromatherapy can be useful placebos and can result in the patient feeling better without any harm being done. However, belief in CAM may prevent the patient or parent accepting effective conventional therapies. Furthermore, not all CAM is as safe as homeopathy—for example, Chinese traditional medicine, which is often linked with eczema, has been known to contain dexamethasone.5
ConclusionEczema is a common problem, which can seriously diminish quality of life, but management of the condition is often sub-optimal. Some cases do require referral to a specialist, but most can be managed in primary care, which is quicker, cheaper, and easier for the patient. The BAD/PCDS guideline on the management of atopic eczema, which is based on a consensus of sound practice, will help. In particular, GPs must be aware of the importance of advising the patient to come back if their eczema has not improved sufficiently. It is also important that GPs should not be afraid to prescribe a strong steroid to treat severe inflammation—careful advice and early review will prevent steroid side-effects, fears about which, on the part of both patient and doctor, often deny patients relief. As always, if the patient is not improving they should be referred. However, if these guidelines are followed confidently this will often not be necessary.
Further information or support on dealing with atopic eczema can be obtained from several sources, including:
- Patient support group: National Eczema Society, Hill House, Highgate Hill, London, N19 5NA: Tel: 020 7281 3553
- Eczema information line: Tel: 0870 241 3604
- Patient advice leaflets on atopic eczema (nominal price, batches of 260, price £9.95—no VAT is payable) :British Association of Dermatologists, 4 Fitzroy Square, London, W1T 5HQ.
- Eczema is a very common condition which can usually be managed in primary care
- Referral is rarely needed for eczema — especially if the guideline is followed
- Tariff price: dermatology outpatient = £118 (new), £58 (follow-up)1
- Dermatology services can easily be provided in the community by GPwSIs or consultants at less than tariff price
- Dermatology is one of the key target areas identified suitable for service redesign2
- Primary Care Dermatology Society and British Association of Dermatologists. Guidelines for the management of atopic eczema. In: Foord-Kelcey G, editor. Guidelines—summarising clinical guidelines for primary care. Edition 28. Berkhamsted: MGP Ltd; February 2006, pp. 372–378.
- British Association of Dermatologists www.bad.org.uk
- Primary Care Dermatology Society www.pcds.org.uk
- Ashton R, Leppard B. Differential diagnosis in dermatology. 3rd edition. Abingdon: Radcliffe Publishing, 2005.