Eczema

Atopic eczema is a common disease affecting up to 15% of children.

  • Both genetic and environmental factors play a role
  • Atopic dermatitis usually occurs in people who have an 'atopic tendency'. This means they may develop any or all of three closely linked conditions; atopic dermatitis, asthma and hay fever (allergic rhinitis). Often these conditions run within families with a parent, child or sibling also affected
  • Current evidence points to mutations in the filaggrin gene being likely to underlie almost half the cases of atopic eczema. Filaggrin is critical to the conversion of keratinocytes to the protein / lipid squames that compose the stratum corneum, the outermost barrier layer of the skin. A primary defect in the skin barrier function therefore appears to underlie atopic eczema, and immunological changes are probably secondary to enhanced antigen penetration through a deficient epidermal barrier. The relevance of this finding is that it reinforces the importance of the regular use of emollients to help manage eczema
  • Involvement of the face frequently occurs in infants with adoption of characteristic flexural distribution by the age of 18 months
  • Spontaneous improvement tends to occur throughout childhood with complete clearance by teenage years in 50%.
  • Realistic treatment aims need to be discussed with the patient and parents.

Referral Criteria:

Referral for specialist dermatological advice is recommended if:

  • the diagnosis is, or has become, uncertain
  • management has not controlled the atopic eczema satisfactorily based on a subjective assessment by the child, parent or carer (for example the child is having 1–2 weeks of flares per month or is reacting adversely to many emollients)
  • atopic eczema on the face has not responded to appropriate treatment
  • the child or parent/carer may benefit from specialist advice on treatment application (for example, bandaging techniques)
  • contact allergic dermatitis is suspected (for example, persistent atopic eczema or facial, eyelid or hand atopic eczema)
  • atopic eczema is associated with severe and recurrent infections, especially deep abscesses or pneumonia

Assessment

History and Examination

Although eczema presents most frequently in childhood it can present at any age, and one third of all new cases arise in adults

  • A personal or family history of atopy is common
  • Itch is very common
  • Many patients have more troublesome symptoms in winter as a result of central heating drying out the skin
  • Most children out grow atopic eczema as they get older. In approximately 65% of children the eczema has gone by the time they are seven years of age and in approximately 74% of children the eczema will have disappeared by 16 years of age. It is not possible to tell whether children will or will not out grow their eczema, although generally speaking those with more severe eczema are less likely to outgrow it
  • There is quite a lot of variation in the appearance of eczema related to the presence / absence of infection, the age of the person, their ethnic origin and the treatments used
  • Distribution - changes with age
  • The face is a common site in infants, this is then followed by flexural involvement
  • In some patients it can become widespread
  • Morphology
  • Ill-defined areas of erythema
  • Dry skin with areas of fine scale (scale does not normally develop in flexures due to friction)
  • During flare-ups the skin will appear red, sometimes with vesicles and weepy / crusted patches
  • Excoriations
  • Lichenification
  • In darker skin prominent follicular involvement is common
  • Other affected sites
  • Scalp - may be generally erythematous with fine scale. Beware of nits presenting as scalp eczema
  • Any body site can be affected

Investigations

Allergy testing

  • No tests are available to confirm or refute food allergy as a cause of worsening eczema
  • RAST tests and skin prick tests are not helpful
  • House dust mite can worsen eczema in some children

Food allergy

  • Food allergy e.g. to egg or dairy is rarely a cause of worsening eczema
  • Consider exclusion diets only in refractory eczema and abandon if no improvement after 2-4 weeks
  • If exclusion required for more than 2-4 weeks then dietetic advice is needed
  • Food allergy is often temporary so the foodstuff should be rechallenged every few months

Referral

Referral Criteria:

Referral for specialist dermatological advice is recommended if:

  • the diagnosis is, or has become, uncertain
  • management has not controlled the atopic eczema satisfactorily based on a subjective assessment by the child, parent or carer (for example the child is having 1–2 weeks of flares per month or is reacting adversely to many emollients)
  • atopic eczema on the face has not responded to appropriate treatment
  • the child or parent/carer may benefit from specialist advice on treatment application (for example, bandaging techniques)
  • contact allergic dermatitis is suspected (for example, persistent atopic eczema or facial, eyelid or hand atopic eczema)
  • atopic eczema is associated with severe and recurrent infections, especially deep abscesses or pneumonia

Referral instructions

e-Referral Service selection:

  • Specialty: Dermatology
  • Clinic Type: Eczema and Dermatitis
  • Service: DRSS-Western-Dermatology-Devon CCG-15N

Referral forms

DRSS Referral form

Supporting Information

Patient Information

Evidence

South and West Devon formulary - Skin

The Primary Care Dermatology Society.

Pathway Group

This guideline has been signed off by the Western Locality on behalf of NEW Devon CCG.

Publication date: 30 January 2017

 

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