Key Learning Points: PCDS Eczema

Dr Kash Bhatti Presents Five Key Learning Points from Updated Primary Care Dermatology Society Guidance on Eczema in Adults and Children

Eczema is a common, chronic, inflammatory skin disorder, which has a relapsing–remitting course, and is characterised by itch.¹ Eczema (also termed atopic eczema or atopic dermatitis) can present in any age group, with the majority of cases (approximately 60%) diagnosed before the age of 1 year.² Overall, up to 30% of children and 10% of adults may be affected.^2,3 Uncontrolled eczema can lead to chronic skin changes and predispose to secondary infection.^1,2 Beyond the skin, many deleterious sequelae can develop, such as profoundly disturbed sleep, impact on self-esteem and mood, poor physical and social development in children (including disrupted educational attainment), and loss of earnings in adults.^2,3

Although no cure for eczema exists, most patients with eczema can be managed very well in general practice. Guidance for the diagnosis and management of atopic eczema in under 12s was published by NICE in 2007,⁴ and SIGN published a guideline on the management of atopic eczema in 2011.⁵ This article distils the key learning points from the treatment pathways for paediatric and adult eczema published by the Primary Care Dermatology Society (PCDS) in 2019.^6,7

The PCDS paediatric and adult treatment pathways describe and detail how to recognise and manage specific variants of eczema that may occur in these respective groups.^6,7 The paediatric pathway describes infant facial eczema, eczema herpeticum, and discoid and chronic lichenified eczema.⁶ In adults, stasis, discoid, pompholyx, contact, and asteatotic eczema (also known as eczema craquelé) are described.⁷

1. Assess the Severity of Symptoms

Assessment begins by evaluating the presence and severity of symptoms such as itch, a hallmark of the condition, and typical skin findings. Eczema is characterised by erythematous rashes, which are usually distributed bilaterally.¹ Rashes generally have diffuse or ill-defined borders (one cannot usually draw a border around them, compared with psoriasis, for example). Scratch marks (excoriations) may be present. Skin may be thickened (lichenified), with increased skin markings, suggesting a chronic itch–scratch cycle. There may be secondary bacterial infection. The presentation of rashes may vary according to age. Eczema in infants often presents on the cheeks and extensor surfaces; with advancing age, eczema tends to localise more to flexural sites and the hands, face, and neck.^1,8,9

Eczema can have a significant impact on quality of life, and important symptoms to ask about are its effects on the patient’s sleep and wellbeing.^2,10 Caring for children with eczema can be time‐consuming: it can affect relationships, and cause sleep loss among family members of affected patients.^10,11 It is, therefore, important to recognise the widespread burden of eczema.

2. Ask About Previous Treatments

Patients often present after trying different treatments, over-the-counter medications, or natural remedies. It is important to know what they have tried, what helped and what did not, how long any treatments were used for, and what the expectations of treatments were. For example, topical corticosteroids (TCS) may have not been used long enough for any meaningful effect, or they may have been overused. Similarly, patients often try different moisturisers, and express frustration that ‘nothing works’, with the belief that moisturisers will rapidly improve inflamed patches of skin, rather than understanding that these treatments are used to repair and maintain the skin barrier. However, some moisturisers can irritate skin, as a particular ingredient may exacerbate eczema. A common reason for unsatisfactory outcomes in eczema is a lack of treatment adherence.^2,12 It is vital to understand what patients or parents believe and do. This can help frame the conversation about management and improve concordance.

3. Apply the ABC Principles of Management

The PCDS guidance breaks management down into the simple algorithm of ‘ABC’:^6,7

• avoid triggers
• bland moisturisers
• control inflammation.

Avoid Triggers

Eczema is a multifactorial disorder that principally causes a disruption to the skin barrier, leading to dry skin and inflammation.¹ Triggers such as cigarette smoke, woolly fabrics, or anything that lathers (soaps, shower gels, and bubble baths) should be avoided to minimise exacerbation of eczema.^6,7 Some patients will have specific triggers; for example, particular animals or pets, chlorine in swimming pools, extremes of temperature, or even stress.^13,14

Bland Moisturisers

Fragrance-free bland moisturisers and emollients are a fundamental mainstay of eczema management.^6,7 These facilitate skin barrier maintenance and repair, and reduce inflammation. Regular moisturiser use will reduce the frequency of flares.^15,16 Patients require adequate quantities of moisturiser to be prescribed. Typically, this will be 250–500 g a week for a child, and 500 g or more a week for an adult.^6,7 The amount needed may vary with the dryness of the skin and the severity of eczema. Not all moisturisers are created equally, and they come in different formulations: ointments are preferred for very dry skin, but are greasier and more occluding; creams are better tolerated, but may need to be applied more often; and lotions may be suitable for minimally dry and well-controlled skin, or for areas such as the face.¹⁷

Many different moisturisers are available. Generally, the aphorism ‘the best moisturiser is the one the patient will use’ holds true as it is considered to improve patient tolerance and adherence. CCGs often recommend moisturisers that are cost-effective for the NHS. For treatment-naive patients, these can be useful to start off with. Where available, patients may want to sample different moisturisers to see what they prefer to use or, if patients already have favourites, GPs are advised to continue prescribing these. Prescribing minimal amounts or treatments that patients will not use is a false economy if it leads to worsening eczema, referrals, or the need for systemic treatments or expensive biological agents. Several manufacturers can provide sample pots for patients to trial.

Moisturisers should be used as leave-on moisturisers and as soap, applied before getting the skin wet. Moisturisers can also be used as bath additives by adding a capful or two to bath water. Ideally, hair should be shampooed over a sink to avoid the detergent action of shampoos stripping moisture from the rest of the skin.^6,7 After bathing, patients should be advised to pat the skin dry and apply the moisturiser.¹⁵ It is important that moisturisers are applied in a downwards direction, i.e. in the direction of hair growth, to avoid irritating hair follicles and causing secondary folliculitis.¹⁷

Control Inflammation

Inflammation should be tackled using an appropriately potent TCS or topical calcineurin inhibitor.¹⁸ An important aspect is the titration of the TCS; a more potent preparation should be used until the eczema is settled—in other words, it is no longer red or itchy (usually 1–6 weeks)—and then the potency and frequency of application should be decreased for maintenance. An example would be reducing the frequency of TCS application from daily to twice a week on eczema-prone areas.^6,7,18

The order in which topical steroids and moisturisers are to be applied is an eternal debate, and it is hoped that research will answer this question in future.¹ In my own clinical practice, I advise patients to apply the topical steroid to the areas needed in a particular order (for example, working down the body from head to toe, applying the topical steroid to affected areas). Moisturiser is then applied in the same order as the steroid was applied. This is practical advice designed to make the application of topical preparations efficient. Other sources suggest different strategies.¹⁹

Topical calcineurin inhibitors are particularly helpful for use as second-line treatments, or on delicate areas such as the eyelids, face, or flexures, where concerns may be raised about prolonged TCS use.^6,7,18 NICE guidance on topical calcineurin inhibitors was published in 2004.²⁰ Since then, several review articles (funded by pharmaceutical companies) have been published, which assert the efficacy and safety of this class of agent.^18,21,22 Equally, warnings that topical calcineurin inhibitors may increase the risk of skin cancer or lymphoma have not been substantiated, and there is currently no clear evidence that the incidence of malignancy is any greater than that for the general population.^18,21,22

A practical point is that a few patients will experience stinging with the application of topical calcineurin inhibitors;¹⁸ in most patients, this will resolve after a week. Some may need concomitant application of a TCS of mild-to-moderate potency for the first week, or to apply cream from a cooled tube.²³ Topical calcineurin inhibitors should not be applied to weepy, clinically infected skin. It is also worth noting that topical calcineurin inhibitors should only be initiated by a specialist and are unlicensed in children aged under 2 years. GPs must prescribe within their experience and expertise; topical calcineurin inhibitors should not be viewed as exclusively secondary‑care medicines as they are invaluable adjuncts in managing eczema.

4. Take a Holistic Approach

It is very common for GPs to be faced with anxious parents or patients. They will often ask questions about allergy, particularly about food allergy.²⁴ It is important to state that eczema itself is not an allergic disorder; however, there is sometimes an association between eczema and allergic disorders. Unless there are obvious features in the history, there is no role for allergy testing in primary care, nor should exclusion diets be encouraged without dietitian or other specialist guidance.^24,25 However, infants under the age of 6 months with moderate-to-severe or difficult-to-control eczema can be offered a trial of extensively hydrolysed milk protein formula for 4–8 weeks while awaiting referral to dermatology.⁶

The PCDS recommends that TCS are not used in combination with antibiotics or antifungal agents. TCS with fusidic acid (1% hydrocortisone or 0.1% betamethasone valerate with fusidic acid) should be used only under specialist direction; misuse leads to fusidic acid resistance.^6,7

Similarly, topical antifungal and TCS combinations do not have a role in eczema. If treating a fungal infection, combination products may lead to tinea incognito, complicating diagnosis and treatment.²⁶

Sedating antihistamines may be of some benefit to some patients in the short term to improve sleep or break the itch–scratch cycle.²⁷ However, histamine is not a principal mediator in the pathogenesis of eczema, and so antihistamine agents are not disease-modifying.

A written eczema action plan is worth considering for patients. There may be a lot of information to provide, and a documented plan can serve as an aide-mémoire. Several are available online, and GPs may wish to adapt a plan to their organisation or needs.^28,29

5. Know When to Refer

Patients should be referred when there is diagnostic uncertainty, failure to respond to treatment, where there are concerns about steroid overuse or adverse effects from TCS, or where there is suspicion of allergic contact dermatitis. Urgent referral is needed for patients with severe eczema covering more than 90% of their skin (erythroderma), for patients with severe eczema who are systemically unwell, or for patients with worsening eczema herpeticum or bacterial-infected eczema that is not responding to treatments.^6,7

Summary

Eczema is the most common chronic skin disorder encountered in primary care. The condition can have severe effects on quality of life, and patients and/or parents and carers can be left frustrated. Treatments are myriad and can be confusing. The updated PCDS guidance provides up-to-date informative and practical advice to support the care of patients with eczema.

Dr Kash Bhatti

GP Principal/Trainer, GPwER Dermatology; Leeds, UK

Executive committee member, Primary Care Dermatology Society