Management of eczema

Please see NICE TA81: Frequency of application of topical corticosteroids for eczema

Emollients are an essential component in the treatment of atopic eczema and psoriasis and can reduce the need to use topical steroids. All patients with dry skin conditions should be using an effective and cosmetically acceptable emollient regimen. Soaps and detergents should also be avoided by using substitutes such as those listed in section 13.1 Dry and scaling skin conditions

Topical steroids should not be used routinely on clinically infected skin, unless the infection is being treated. A short course of a suitable oral antibiotic maybe indicated.

“To be spread thinly" is a cautionary warning that must legally be included on the label of topical steroid preparations. This can mean different things to different people and can worry some patients. Therefore, it is important to counsel patients on the correct application and ensure adequate coverage of affected areas.

Treatment guidance

Mild eczema

  1. Emollients (see 13.1 Dry and scaling skin conditions)
    1. Important in the treatment of eczema as the skin is usually dry and lacks the natural oily protective barrier. They also soften and smooth the skin and improve itching that may be present. They must be used frequently, at least twice daily, on all areas of the skin even where there is no visible sign of eczema. They should be used every 2 hours when the condition is florid.
  2. Mild potency topical steroid (can be used on all areas including face and neck) (see section Corticosteroids (topical))
    1. Useful where there is an inflammatory component to the disease and to reduce itching. The strength and type of steroid prescribed depends on the age of the patient, the site affected, the severity of the eczema and whether or not infection is present.

Moderate eczema

  1. Emollients (see 13.1 Dry and scaling skin conditions)
  2. Moderate potency topical steroid (use for 7-14 day bursts only for flares in axillae and groins, and for 3-5 day bursts only for flares on face and neck) (see section Corticosteroids (topical))
  3. Topical calcineurin inhibitors (see section 13.5.2 Preparations for psoriasis)
  4. Other treatments applying a dry tubular bandage over topical treatments can be helpful when proving difficult to control. Seek advice from dermatology specialist nurses.
    1. Bandages / garments
    2. Phototherapy
    3. Systemic therapy

Severe eczema

  1. Emollients (see 13.1 Dry and scaling skin conditions)
  2. Potent topical steroid for 7-14 day bursts (do not use on face, neck, axillae, groins, or elbow and knee flexures). Do not prescribe potent topical steroids in children younger than 12 months, or very potent topical steroids younger than 16 years in primary care without specialist dermatological advice. (see section Corticosteroids (topical))
  3. Topical calcineurin inhibitors (see section 13.5.2 Preparations for psoriasis)
  4. Other treatments applying a dry tubular bandage over topical treatments or using a wet or paste bandage on severe eczema can be helpful when proving difficult to control. Seek advice from dermatology specialist nurses.
    1. Bandages / garments
    2. Phototherapy
    3. Systemic therapy

Antihistamine treatment

The use of oral antihistamines can be effective in the treatment of itching associated with eczema. Itching is generally worse in the warmth of the bed and can often interfere with sleep. Sedating antihistamines are therefore useful in this situation.

Infected Eczema

Infection of broken skin is common making the patient feel unwell and limiting movement. Clinical signs of infected eczema include weeping, pustules, crusts, fever and malaise, or atopic eczema failing to respond to therapy or rapidly worsening atopic eczema.

Take swabs from infected lesions of atopic eczema only if you suspect microorganisms other than Staphylococcus aureus or if you think antibiotic resistance is relevant. Staphylococcus aureus infection is the commonest cause of acute flare up of atopic eczema and should be treated accordingly (see Chapter 5, skin and soft tissue infections)

Explain that topical treatments in open containers can be contaminated with microorganisms and act as a source of infection.

Extensive bacterial infection

Use oral antibiotics plus appropriate potency topical corticosteroid (see Skin and soft tissue infections)

Localised bacterial infection

  • Use combined topical antibiotic/corticosteroid preparation for maximum of 2 weeks only.
  • Do not prescribe these preparations for maintenance therapy.
  • Fusidic acid resistance is a widespread problem due to inappropriate use.
  • Swabs should be taken at the same time as prescribing a fusidic acid based product.

Fucidin® H cream (hydrocortisone 1% / fusidic acid 2%)

  • Apply twice daily (max 14 days)

Fucibet® cream (fusidic acid 2% / betamethasone valerate 0.1%)

  • Apply twice daily (max 14 days)

For skin flexures and genital area

Trimovate® cream (clobetasone / oxytetracycline / nystatin)

Other Preparations

Antimicrobial and emollient combinations

The following is for second line use when skin has not responded to alternative antiseptic/antibacterial products, when the skin is very weepy or there is persistent infection.

Potassium permanganate solution (1 in 10,000)

Reducing bacterial infections

Ensure appropriate potency of topical corticosteroid is being used. Inadequate control of the underlying atopic eczema is the most frequent cause of repeated infections.

Consider antiseptic emollients / shower / bath preparations (e.g. Dermol® range) to reduce bacterial colonisation.

Eczema herpeticum

Suspect if:

  • areas of rapidly worsening, painful eczema
  • possible fever, lethargy or distress
  • clustered blisters (often in one area) consistent with early-stage cold sores
  • punched-out erosions (usually 1-3 mm) uniform in appearance which may coalesce.

Management

  • Take viral swabs
  • Treat with aciclovir tablets
  • If you suspect secondary bacterial infection, start treatment with appropriate systemic antibiotics as well.
  • Refer immediately (same day) for specialist dermatological advice

 

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