Dr Michael Tidman highlights recommendations from SIGN on the management of atopic eczema, which may reduce prescribing and improve patient compliance

Atopic eczema is a chronic, pruritic, inflammatory skin disorder. Its cause is complex and still not fully understood, with both genetic and environmental factors of importance. It is triggered by an abnormal epithelial barrier function, thought to underlie the condition, which makes the skin excessively permeable and more prone to damage from environmental irritants and allergens.1 Atopic eczema is common:

  • Data suggest that 15%–20% of school-aged children and 2%–10% of adults are affected at some stage2
  • In Scotland, 2.3% of the study population manifested symptoms of atopic eczema during the course of a year2
  • Although it is particularly common in children under 2 years of age, 38% of all patients with atopic eczema are adults.3

Depending on disease severity, atopic eczema may exert a considerable negative impact on the quality of life (QoL) of affected individuals and their families. Pruritus-induced sleep disturbance and impairment of concentration can be particularly disabling, and the cosmetic consequences and time spent in treating the condition are also contributing factors to the impact on QoL. There is evidence that eczema may adversely influence a child’s emotional and social development, as well as predisposing him or her to psychological difficulties.4,5 Later in life, atopic eczema may cause difficulties with relationships and, because of an increased tendency to irritant dermatitis, occupational problems.6

Need for a guideline

The impetus for developing a new guideline for atopic eczema under the auspices of the Scottish Intercollegiate Guidelines Network (SIGN 125)1 was supported by a recent study of the treatment of dermatological conditions in the community. The study demonstrated potential for improving a range of outcomes, including treatment of atopic eczema.4

There is a substantial cost to health services in the UK related to atopic eczema, which in the mid-90s was estimated at £125 million per annum.7 Add to this the estimated annual personal costs of £297 million and £43 million in lost working days per annum, and total annual UK expenditure on atopic eczema in the mid-1990s was £465 million.7 This is likely to be an underestimate of today’s cost. In 2002, the cost of community dispensed prescriptions for corticosteroids for atopic eczema was estimated at £11.6 million.2

The majority of treatment for atopic eczema is undertaken in primary care without the need for referral to the secondary sector. A guideline customised for the primary healthcare team that is not restricted to the treatment of eczema in childhood was felt to be needed because of the:1

  • impact of atopic eczema
  • fact that it is a multifaceted condition that can make it a therapeutic challenge
  • expense of treatment.

Guideline recommendations on diagnosis and management

The diagnosis of atopic eczema is not a major problem in primary care. It is based on visual assessment and patient history, and laboratory tests are not helpful. SIGN 125 outlines the UK Working Party diagnostic criteria for atopic eczema, which is the most extensively validated set of criteria.8 Although diagnosis is usually straightforward, the clinical features of atopic eczema may be complicated by predisposition to and coexistence of other dermatological disorders, such as scabies, widespread herpes simplex infection (eczema herpeticum), staphylococcal and streptococcal infection, superficial fungal infection, contact dermatitis (irritant and allergic), and hyper-IgE syndrome.1

The guideline focuses on providing recommendations for the management of atopic eczema based on current evidence for best practice. It is divided into sections that cover all the relevant therapeutic modalities for the care of atopic eczema by community based healthcare professionals. Therapies include:1

  • emollients
  • topical corticosteroids
  • topical calcineurin inhibitors
  • paste and wet-wrap dressings
  • antimicrobial measures
  • antihistamines

The guideline also analyses the evidence for the effect of environmental factors on atopic eczema, dietary intervention, and complementary and alternative therapies. The key evidence-based recommendations are listed in Box 1 (see below).1

Promoting best practice and improving patient care

Best practice in primary care will be promoted by adherence to the key recommendations and the good practice points contained in SIGN 125, as well as acting on the suggested audit topics. The most novel of the recommendations is that topical corticosteroids need to be applied just once daily, as a twice-daily regimen seems to offer no significant advantage. This should have the effect of reducing the prescribing cost of topical corticosteroids and also, importantly, improve patient compliance and minimise the potential risks of local and systemic adverse effects. Furthermore, the recommendation that topical corticosteroids can be used on a maintenance basis (applied twice weekly to eczema-prone areas) is likely to reduce the flaring of atopic eczema greatly without causing significant adverse effects. The recent inclusion of maintenance therapy in the product licence of topical tacrolimus for the treatment of atopic eczema is also reflected in this guideline.1,9

Implementing the guideline

There do not seem to be any insuperable resource implications to hinder implementation of the SIGN recommendations (see Box 1, see below). The key priority for primary care is the recommendation that topical corticosteroids should be applied just once-daily initially, and there is no apparent reason that the recommendation might not be implemented. The likely result of this would be to reduce prescribing costs, although this might be offset, to a degree, by using topical corticosteroids on a maintenance basis.

On the other hand, an increase in the use of topical calcineurin inhibitors as acute and maintenance treatment of atopic eczema would result in an increase in NHS expenditure. Additionally, there are some safety concerns on the long-term use of topical calcineurin inhibitors, on the basis that oral calcineurin inhibitors are known to increase the risk of malignancy (including skin cancers and lymphoma).1 It is largely for this reason that both available topical calcineurin inhibitors (tacrolimus and pimecrolimus) are licensed for second-line anti-inflammatory treatment (with topical corticosteroids as first-line therapy). Both NICE and the Scottish Medicines Consortium (SMC) have restricted initiation of topical calcineurin inhibitor therapy to doctors with a specialist interest and experience in treating skin diseases (such as atopic eczema); this may include GPs.10,11

An ongoing study, APPLES (A Pediatric Longitudinal Evaluation to Assess the Long-Term Safety of Protopic for the Treatment of Atopic Dermatitis), aims to assess the long-term safety profile of topical tacrolimus,12 but in the meantime the hurdle to use of topical calcineurin inhibitors in primary care that the NICE and SMC restrictions create, may be overcome by the use of shared-care protocols with secondary care.

Conclusion

The strength of the SIGN guideline development process is that its recommendations are based on contemporaneous evidence. However, in the context of atopic eczema, a number of traditional therapeutic options lack support from evidence derived from unbiased measures, and the management of this condition has historically relied heavily on clinical consensus and the preferences of individual clinicians. This is particularly the case for paste dressings and ‘old-fashioned’ topical antiseptics, which, despite general agreement among dermatologists as to their efficacy and usefulness, have a disappointingly (but understandably) low profile in this guideline. A corollary of the SIGN process, when it is applied to any medical area, is that it may act as a catalyst to promoting the generation of new data for important clinical topics where an evidence base is lacking. It is to be hoped that this will be the case for aspects of the management of atopic eczema.

Box 1: Key recommendations from SIGN1
  • Referral:
    • Emergency referral to secondary care should be arranged where there is clinical suspicion of eczema herpeticum
    • Patients should be referred to secondary care when there is uncertainty regarding the diagnosis, the condition is poorly controlled or it has not responded to appropriate topical treatments, or if there is psychological upset, sleep problems, or recurrent secondary infection
  • Emollient therapy:
    • Emollients are the mainstay for the ongoing treatment of atopic eczema
  • Topical corticosteroid therapy:
    • Patients with atopic eczema should be advised to apply topical corticosteroids once (rather than twice) daily, and emollient therapy should be continued in addition to corticosteroids
    • Twice-weekly maintenance therapy with topical corticosteroid to areas of eczema-prone skin should be considered in patients with moderate to severe atopic eczema experiencing frequent relapses
  • Topical calcineurin inhibitors:
    • Topical tacrolimus should be considered in patients aged 2 years and older for short-term, intermittent treatment of moderate to severe atopic eczema that has not been controlled by topical corticosteroids, or where there is a serious risk of important adverse effects from further topical corticosteroid usage particularly skin atrophy
  • Oral antibiotics:
    • Oral antibiotics are not recommended in the routine treatment of non-infected atopic eczema.
Adapted from Scottish Intercollegiate Guidelines Network. Management of atopic eczema in primary care. SIGN 125. Edinburgh: SIGN, 2011. Available at: www.sign.ac.uk/guidelines/fulltext/125/index.html

  • The SIGN guideline identifies simple practical guidance that can be adapted into local pathways
  • A simple algorithm for the treatment of eczema that identifies local formulary choices of medication could be devised and shared with practices or incorporated into Map of Medicine
  • Local guidance on which clinicians can initiate topical calcineurin agents and when these therapies can be prescribed would be useful
  • Commissioners could investigate funding a community dermatology specialist nurse who can help both educate local primary care teams and also support them with challenging cases:
    • this post could help avoid referrals to hospital outpatients and tariff charges
  • Tariff charges for dermatology outpatient = £119 (first), £67 (follow up).a

awww.dh.gov.uk/paymentbyresults/

  1. Scottish Intercollegiate Guidelines Network. Management of atopic eczema in primary care. SIGN 125. Edinburgh: SIGN, 2011. Available at: www.sign.ac.uk/guidelines/fulltext/125/index.html nhs_accreditation
  2. Green C, Colquitt J, Kirby J et al. Clinical and cost-effectiveness of once-daily versus more frequent use of same potency topical corticosteroids for atopic eczema: a systematic review and economic evaluation. Health Technol Assess 2004; 8 (47): iii, iv, 1–120.
  3. Herd R, Tidman M, Prescott R, Hunter J. Prevalence of atopic eczema in the community: the Lothian atopic dermatitis study. Br J Dermatol 1996; 135 (1): 18–19.
  4. Kerr O, Tidman M, Walker J. The profile of dermatological problems in primary care. Clin Exp Dermatol 2010; 35 (4): 380–383.
  5. Absolon C, Cottrell D, Eldridge S, Glover M. Psychological disturbance in atopic eczema: the extent of the problem in school-aged children. Br J Dermatol 1997; 137 (2): 241–245.
  6. Reitamo S, Luger T, Steinhoff M. Textbook of atopic dermatitis. London: Informa Healthcare, 2008.
  7. Herd R, Tidman M, Prescott R, Hunter J. The cost of atopic eczema. Br J Dermatol 1996; 135 (1): 20–23.
  8. Williams H, Burney P, Hay R et al. The UK Working Party's diagnostic criteria for atopic
    dermatitis. Br J Dermatol 1994; 131 (3): 383–396.
  9. Astellas Pharma Ltd. Protopic 0.1% ointment. Summary of product characteristics. 2011. Available at: www.medicines.org.uk/emc/medicine/8816
  10. National Institute for Clinical Excellence. Tacrolimus and pimecrolimus for atopic eczema. NICE Technology Appraisal 82. London: NICE, 2004. Available at: www.nice.org.uk/guidance/TA82
  11. Scottish Medicines Consortium. Tacrolimus 0.1% ointment (Protopic®). Edinburgh: SMC, 2010. Available at: www.scottishmedicines.org.uk/files/tacrolimus_01_ointment_Protopic_FINAL_March_2010_Amended_310510.pdf
  12. Astellas Pharma Inc. A paediatric longitudinal evaluation to assess the long-term safety of Protopic for the treatment of a topic dermatitis (APPLES study). Ongoing study. Information available at: clinicaltrials.gov/ct2/show/NCT00475605G

Topics