Case study

Atopic eczema

• James is 18m old. He has an itchy rash on his flexural creases of his elbows, knees and wrists

• His skin is generally dry with red patches and itchiness on cheeks and neck

• His mother had eczema since being a child. Her hands and wrists show lichenification. She also has mild asthma and his father has hayfever

What information supports a diagnosis of atopic eczema?

• Diagnose atopic eczema when a child up to the age of 12 has an itchy skin condition plus 3 of the following:– Visible flexural dermatitis involving skin creases (elbows, knees) or

visible dermatitis on cheeks &/or extensor areas in children ≤18m– Personal history of flexural dermatitis or dermatitis on cheeks &/or

extensor areas in children ≤18m– Personal history of dry skin in last 12m– Personal history of asthma or allergic rhinitis (or history of atopy in 1st

degree relative of children < 4 years– Onset of signs or symptoms < 2 years

• In Asians, black Caribbean or African children the extensor surfaces may be affected and discoid (circular) or follicular (around hair follicles) patterns may be more common

What further information do you require?

• Severity of the eczema

• Effects on quality of life – sleep, everyday activities, psychosocial wellbeing

• Personal history of atopy and eczema

• Family history of atopy and eczema

• Examination – Extent, location, severity and infective elements

What would you advice about avoiding exacerbating factors?

• Avoid soaps and detergents– Use emollient soap substitute– Use gloves– Reapply emollients after wetting skin

• Avoid temperature extremes– Humidity

• Avoid abrasive clothing– Use cotton fabrics

Should you investigate for food allergens using an exclusion diet?

• Diet is a significant trigger in <10%• Common triggers include cows’ milk, eggs, soya, wheat, fish

and nuts• Consider if:– Child has previously reacted to a food with immediate

symptoms– Infants and young children with moderate or severe

eczema not controlled with optimum management, particularly if gut motility is affected

– Symptoms are associated with failure to thrive

Should they take measures to avoid dust mites and other airborne allergens?

• Measures often time consuming, difficult and costly with limited benefits

• Consider inhalant allergy if :– Seasonal flares– Children with atopic eczema associated with asthma or

allergic rhinitis– Children ≥ 3 years with atopic eczema on the face

particularly around the eyes

What should you discuss about using emollients?

• Use even when skin is clear

• Aim is to retain the skin’s barrier function and to prevent painful cracking

• The drier the skin, the more has to be applied. Greasier products have a better emollient effect

• Can also use bath products

• Optimum time to apply is after a bath

Should he use topical corticosteroids?

• Depends of the state of the skin

• Only use intermittently and for short periods (1-2 weeks)

• Tailor potency to severity

• Do not use very potent products in children without specialist advice

Would oral antihistamines help?

• Efforts to reduce dryness and inflammation should be promoted ahead of antihistamines

• Offer 1 month trial of non-sedating antihistamine to those with severe atopic eczema or those with mild or moderate eczema with severe itching or urticaria

• Review Rx every 3 months

• Use 7-14 days of a sedating antihistamine if sleep disturbance is significant

• James manages for a considerable period of time but when aged 4 he returns with a significant flare. Some patches look moist and inflamed and some have a golden yellow crust. He also has a mild pyrexia

What would you recommend?

• The skin is colonised with S.aureus in 90% of affected areas. If there are clinical signs of widespread infection, oral antibiotics are recommended

• Topical antibiotics should be reserved for cases of clinical infection in localised areas and use for no more than 2 weeks

What signs would make you suspect he had a herpes simplex infection and what would you

prescribe?

• Punched out erosion, vesicles or infected skin lesions failing to respond to oral antibiotics should raise suspicion

• If a severe infection is suspected start immediate treatment with systemic aciclovir and refer for same day specialist advice

Eczema herpeticum