Types of Eczema

Types of Eczema • • • • • • • Atopic Seborrhoeic Discoid Varicose Contact Pompholyx Asteatotic Eczema (Eczema Craquele) Atopic Eczema • Atopic dermatitis (AD) is a chronic inflammatory skin disease with a prevalence of 10% to 20% in children and 1% to 3% in adults • AD has a complex aetiology that encompasses immunologic responses, susceptibility genes, environmental triggers, and compromised skin-barrier function. Incidence of Atopic Eczema • 1960 incidence was said to be 3% • Now 20% in industrialised countries • Is paralleled by increase in asthma • But not all the children are atopic by definition – no raised IgE levels Possible Reasons for increase • Due to lack of exposure to bacteria/viruses • Due to passive smoking • Pollution a factor – not reflected in Eastern Europe • Early weaning esp. early cows milk • Central heating / less ventilation and more House Dust Mite • Overuse of soaps and detergents which degrease the skin and make it drier Atopic Eczema • Starts in first 6 months of life in 45% • 60% start before 1 year old • 85% start before 5 years old • 40 - 60% clear by puberty Seborrhoeic Eczema • Starts in the newborn up to age of 6 months • It usually presents a cradle cap • Can affect skin creases such as armpits and groin – type of napkin dermatitis • Gives non itchy salmon pink flaky patches on face, trunk and limbs • Usually clears before the baby is 6 months and rarely persists after 1 year • Usually will just need emollients +/hydrocortisone Discoid Eczema Round or oval lesions. Needs strong topical steroids to control. Often treated as fungal. Can be very itchy Varicose Eczema Elevation Support Hose Regular Walking Vascular referral Contact Eczema Localised Eczema. Need to take a good history. Confirmed by patch testing Pompholyx Eczema Felt to due to abnormal sweating Can be due to nickel Needs potent topical steroids as soon as itch starts Irritant Eczema Peeling red hands from too much wet work Dribble rash in a baby Often secondarily infected Lick Eczema Ointment Moisturisers and sometimes antibiotics. No topical steroids Keratosis Pilaris Very common. No need for topical steroids. Moisturisers and exfoliate with nylon buffer or loofah. Should improve as gets older. Worse in the winter. Lichen Simplex Chronic itch/scratch Isolated plaques of very itchy skin Needs potent topical steroids to switch off itch Otitis Externa Swab for infection, avoid long term antibiotic/antifungal Rx, may need moderate/potent topical steroid to control itch. No ear buds May need patch tests Juvenile Plantar Dermatosis Sole of foot shiny and glazed Painful cracks under toes and ball of foot Related to friction Due to synthetic shoes – trainers and sweating Moisturisers Steroid creams rarely effective Wear sandals Pityriasis Alba • • • • • • Mild form of dermatitis Seen in darker skins Unknown cause Seen in the summer Skin tans unevenly Lasts months to 2-3 years • No Rx necessary Moisturisers • • • • • Much more important than topical steroids Underused Not prescribed in big enough quantities When settles use is tailed off and stopped Need to give the patient choice to find the best one for them – bag of samples • Lotions and creams for mild/moderate/wet • Ointments for very dry skin/or severe • Lotions for hairy areas Aqueous Cream Journal Report The Pharmaceutical Journal (Vol 271) 29 November 2003 Adverse drug reactions to aqueous cream in children with Atopic Eczema Dr Michael Cork Aqueous cream was initially designed as a wash product rather than a “leave on” emollient. It was stated that some children in the audit reported stinging with aqueous cream when used as “leave on” but not when used as a wash product. Moisturisers Face 15-30g 100mls Both Hands 25-50g 200mls Scalp 50-100g 200mls Both Arms or legs 100-200g 200mls Trunk 400g 500mls Groins and genitalia 15-25g 100mls Whole body 605 - 805g 1300mls This is BD use for an adult for 1 week Moisturisers • Adults – 500g – 800g a week • Children – 250g- 500g a week • Infants - 125g -250g a week Moisturisers Get to know a few moisturisers well. Take a sample home to try it. Need several strengths in your repertoire 1) 2) 3) 4) 5) 6) 7) Aqueous Cream Dermol 500 E45 Cream Cetraben Epaderm Hydromol Ointment 50/50 white soft paraffin/liquid paraffin Thinnest Thickest Topical Steroids • • • • Ointments better than creams Less preservatives and better for dry/scaly areas Mild Hydrocortisone Moderate Betamethasone 0.25% (Betnovate RD) Clobetasone butyrate 0.05% (Eumovate) • Potent Betamethasone 0.1% (Betnovate) Hydrocortisone Butyrate 0.1% (Locoid) Mometasone Furoate 0.1% (Elocon) • Very potent Clobetasol propionate 0.05% (Dermovate) How much Steroid to Use Face Both Hands Scalp Both Arms Both Legs Trunk Groins and genitalia 15-30g 15-30g 15-30g 30-60g 100g 100g 15 - 30g Whole body 290g-380g This is BD use for an adult for 1 week Steroid Creams For a 3-6 month old child Entire face and neck - 1 FTU An entire arm and hand - 1 FTU An entire leg and foot - 1.5 FTUs The entire front of chest and abdomen - 1 FTU The entire back including buttocks - 1.5 FTUs For a 1-2 year old child Entire face and neck - 1.5 FTUs An entire arm and hand - 1.5 FTUs An entire leg and foot - 2 FTUs The entire front of chest and abdomen - 2 FTUs The entire back including buttocks - 3 FTUs Steroid Creams For a 3-5 year old child Entire face and neck - 1.5 FTUs An entire arm and hand - 2 FTUs An entire leg and foot - 3 FTUs The entire front of chest and abdomen - 3 FTUs The entire back including buttocks - 3.5 FTUs For a 6-10 year old child Entire face and neck - 2 FTUs An entire arm and hand - 2.5 FTUs An entire leg and foot - 4.5 FTUs The entire front of chest and abdomen - 3.5 FTUs The entire back including buttocks - 5 FTUs Topical Steroid in Adults Area of skin to be treated (adults) A hand and fingers (front and back) A foot (all over) Front of chest and abdomen Back and buttocks Face and neck An entire arm and hand Size is roughly: FTUs each dose (adults) 1 FTU 2 FTUs 7 FTUs 7 FTUs 2.5 FTUs 4 FTUs About 2 adult hands About 4 adult hands About 14 adult hands About 14 adult hands About 5 adult hands About 8 adult hands An entire leg and foot About 16 adult hands 8 FTUs When to Apply Steroids • After moisturiser • To the red areas • Can apply to raw, scratched areas • Can apply to thickened skin Topical Steroids • Most patients/parents underuse steroid creams and ointments. • Don’t use enough • Or often enough • In the right strength • Better to use a weaker steroid in correct quantities rather than underuse a stronger steroid Skin absorption of topical steroids • • • • • • • • Steroids are absorbed at different rates from different parts of the body. A steroid that works on the face may not work on the palm. But a potent steroid may cause side effects on the face. Forearm absorbs 1% Armpit absorbs 4% Face absorbs 7% Eyelids and genitals absorb 30% Palm absorbs 0.1% Sole absorbs 0.05% Topical Steroid Side Effects • Large amounts of topical steroid can cause fluid retention, raised blood pressure and diabetes • If more than 50g of clobetasol propionate (Dermovate) or 500g of hydrocortisone per week this can result in adrenal gland suppression and/or eventually Cushing's syndrome. • The main concern is with growth in children who need frequent courses of strong topical steroids. Need to plot growth regularly in children What to do for a Flare Up • It is likely to be due to infection • Swabs and antibiotics – oral or topical • Go over their regime and who applies it • Check the amounts being used – get them to bring the tubes in to show you • ORAL STERIODS ARE NOT NEEDED Prescription Audits? • Antibiotic/Steroid combinations on repeat • Ratio of emollient/moisturisers to steroid quantities prescribed - should be 10 to 1 Eczema Treatments • Need time to explain • Help of dermatology trained nurses • How to deal with flares/ how to cope and manage their long term condition • Information booklets • Job advice – especially teenagers • Web sites www.dermnetnz.org www.eczema.org/ Problems in Eczema • More prone to bacterial and viral infections – Impetigo – Molluscum – Herpetic – Tinea Incognito – Viral warts • Poor sleep – patient and family • School performance • Psychological problems Impetigo Impetigo can be mild or severe. It is usually caused by Staph but less commonly can be caused by Strep Bullous Impetigo is caused by Staph Infection • Eczema sufferers are more prone to infection • Even normal looking skin has increased levels of Staph. Aureus • If not sure swab skin – wet swab Swabs Accurate prescribing of antibiotics Picking up antibiotic resistance Finding community acquired MRSA Patient and parent information Fusidic Acid • Resistance to fusidic acid is rising • Was less than 10% is now 50% • The resistance is not stable and will fade if drug stopped Fusidic acid must be used for short courses and stopped and not used regularly. Can be used for 2 week courses every 6-12 weeks if necessary. Topical Antibiotics Fusidic Acid Resistance In a general non dermatology population 9.6% In a dermatology population 50% In inpatients with Atopic Eczema 78% BJD 2003 Molluscum Contagiosum Eczema sufferers are more prone to molluscum and tend to have more lesions Worth trying Crystacide – hydrogen peroxide 1% Eczema Herpeticum Regular polygonal often crusted lesions. If mild topical aciclovir. Where do Immune Modulators fit in? • Pimecrolimus is licensed for mild to moderate eczema • Formulation is a cream. One strength 1% • From 2 years old • Can lower resistance to infection • Long term side effects unknown but likely to be less than tacrolimus • Use when steroids best avoided esp. face Where do Immune Modulators fit in? • Tacrolimus topically is for moderate to severe eczema unresponsive to conventional treatment. • Can lower resistance to infections • Shouldn't use if skin infected • Two strengths of ointment 0.1% and 0.03% • No licence under 2 years old • 0.03% strength for children • Not really a primary care drug • BD use. Not under occlusion • Long term use not advised. Sun protection Is it Eczema? • If the treatment does not seem to be working and the patient is using adequate quantities of treatment • • • • Up the topical steroid dose for short time Possibly try occlusion Rethink infection – Swabs – skin and nose Rethink the diagnosis Differential Diagnosis • • • • • • • • • Tinea Incognito Scabies Psoriasis Blistering diseases Dermatitis Herpetiformis Granuloma Annulare Other causes of red face Mycosis Fungoides Beware of the Single Patch of Eczema Causes of Red Face • • • • • • • Contact Allergy – esp. Nickel, Perfumes Rosacea Seborrhoeic Eczema DLE Sun Damage Psoriasis Autoimmune disease NICE referral guidelines Audit of Hospital Referrals • 90% of children referred with eczema had secondary infection of the skin • 92% were improved with simple measures - emollients/topical steroids and antibiotics Allergy • On recent surveys 20% of all adults believe they have food allergies • The true incidence is 1-2% • Less than 10% of children with eczema may have a food allergy but it is one of many factors and not usually the most important factor • House dust mite is likely to be a much bigger factor The Atopic March • Eczema can act as an entry point for allergic diseases • Asthma usually presents later than that of eczema • If eczema is treated enthusiastically it may prevent the child developing asthma later Lactobacillus may protect immune system • Finnish study May 2003 • A special strain of lactobacillus was given to pregnant mothers in last few weeks of pregnancy and first 6 months of breast feeding • The treated group were 40% less likely to develop eczema than the placebo group • Further studies awaited The Lancet - Vol. 361, Issue 9372, 31 May 2003 Oral Probiotics • 56 toddlers • Moderately severe eczema • Randomised double blind trial • Oral supplements of Probiotic Lactobacillus fermentum or placebo for 8 weeks • Probiotic group showed improvement in extent and severity of their eczema (Archives of Disease in Childhood 2005;90:892-7) Cancer Risk and Immune Modulators • 19,000 pimecrolimus-treated patients - 2 cancers, and 1 was a squamous cell carcinoma • 4000 patients treated with either topical corticosteroid or vehicle - 5 cancers - 4 in corticosteroid-treated patients and 1 in a vehicletreated patient • Primate study showed lymphoma development in monkeys BUT that study used an oral formulation of pimecrolimus that was 30 times the highest dose ever recorded in a human with topical use. Skin Cancer Risk and Immune Modulators • 5125 atopic dermatitis patients treated with topical tacrolimus for up to 4 years • Thirteen adult patients developed nonmelanoma skin cancer • 12 over 40, and 1 patient was age 26 • This is no higher than would be expected in a normal population • Ten of the 13 were diagnosed within 90 days of initiating application of tacrolimus therefore unlikely to be causal Skin Cancer Risk and Immune Modulators • Seven of the 13 skin cancers were not at the sites of application of the medication • Seven of the skin cancers were in areas of sun exposure where you'd expect skin cancers • 7 of the patients had had previous nonmelanoma skin cancers. They had been on ciclosporin and/or had received phototherapy – a high risk group Cancer Risk and Immune Modulators • In 1.7 million tacrolimus-treated patients there were 11 lymphomas of which 6 of those were cutaneous T-cell lymphomas (CTCLs) – likely misdiagnosed as eczema • A panel of 5 independent oncologists found no definitive link between pimecrolimus and tacrolimus and increased risk of lymphoma Pimecrolimus Cream and Infection • 1133 patients 3 - 23 months of age with mild to severe atopic dermatitis were treated for up to 2 years • Treatment with 1% pimecrolimus cream was not associated with an increase in the overall incidence of non skin infections • The incidence rates for total bacterial, fungal, parasitic, and viral skin infections were comparable for patients treated with 1% pimecrolimus cream and patients who received the vehicle Pediatrics. 2006 Jan;117(1):e118-28 When to use Pimecrolimus • Good for facial eczema – gets around the topical steroid problems on the facial skin • Good for itch • Good for peri-oral problems which are exacerbated by steroids • Good for around the eyes Pimecrolimus and Pruritis • 198 patients with mild to moderate atopic dermatitis and moderate to severe pruritus treated with pimecrolimus cream 1% or vehicle for 7 days • Within 48 hours of treatment 56% of patients treated with pimecrolimus and 34% of vehicle-treated patients were at least 1 point lower on the pruritus score. Allergy 2006;61:375-381 When to use Tacrolimus • On steroid damaged skin • If poor control with reasonable doses and amounts of topical steroids • For quick fix • To break itch/scratch cycle • To wean off strong topical steroids FDA May 2005 • Short term use only • Second line treatment – in people who have failed other treatments or cannot tolerate other treatments • Not under the age of 2 • Not in adults or children with a weakened or compromised immune system • Use the minimum amount to control the symptoms Protopic Advice April 2006 • Use for short term and intermittent long term therapy of moderate or severe atopic dermatitis not adequately responsive to or intolerant of conventional therapies • Not under 2 years old • 0.03% only in children • Not in the immunocompromised • Avoided in pre malignant skin lesions (CTCL) Genetic Basis to Atopic Eczema • Filaggrin, is an important epidermal barrier protein • The authors identified two loss-of-function variants -- R510X and 2282del4 -- in the gene encoding filaggrin that were strongly predictive of atopic dermatitis • Not only are these variants common, seen in about 9% of people of European descent, but they also correlate with asthma in the context of eczema. March 12th 2006 issue of Nature Genetics. Educational Programmes • Structured Group Educational Programmes in 7 centres in Germany weekly for 6 weeks • 992 children randomised • 3 age groups of atopic dermatitis sufferers • Parents of 3months - 7years and parents of 812 years and teenagers 13-18 years • Significant improvement in severity, itching and quality of life in the education group BMJ 22nd April 2006 332:933-936