Transcript Notes
Management of Eczema Practical approach Heulwen Wyatt R.G.N. R.S.C.N. Dip. Prof. Prac. (Derm) MSc Clinical Nurse Specialist in Paediatric Dermatology Atopic Eczema • Increasing incidence • Affects approximately 1:5 children • Familial tendency • Associated with asthma and hayfever • Most outgrow by the age of 7yrs Normal Barrier Function Increased trans-epithelial water loss Role of steroids Role of Emollients Moisturisers • Emollients tend to increase the efficiency of the epidermis • Barrier function Enhance the effects of emollients with occlusion - bandages, wet wraps Bath Oils or Soap Substitutes • Bath additives – use daily • Oily preparations • Float on water or emulsion • Increasingly soap substitutes preferred Steroids • • • • • Available in 4 strengths mild - e.g. hydrocortisone moderate - e.g. eumovate potent - e.g. cutivate, betnovate very potent - e.g. dermovate • 9 month baby • Seen 2 months ago and given 500g Aqueous cream, 60g Hydrocortisone 1% cream. • Never clear, awake every night. • What would you prescribe? Treatment • Swabs, Flucloxacillin • Eumovate ointment 200g for 4 week peroid • 1kg emollient • Soap substitute or bath oil • TIP - split base of earlobe first sign eczema in many babies - avoid soaps Aqueous Cream • Not suitable as a moisturiser • Only prescribe as a soap substitute Facial Eczema in Children • Calm down skin with steroids • Immunomodulators • Reduce stinging by using both steroids and immunomodulators for five days • Remember – Tomato sauces and baby wipes!! How would you approach management? • 2 year old with extensive low grade eczema • Skin very dry • Mum states he’s allergic to all moisturisers as skin goes red and he screams • Refuses to go in bath Top Tips • Explain that very dry skin takes pale scaly apearance • Any water based emollients may sting dry skin • Ointment soap substitute before bath Don’t • Don’t alter diet • Don’t use soaps • Don’t bother with housedust mite measures • Don’t advise allergy tests Olive Oil • Contraindicated on the skin • Damages the barrier function of stratum corneum • Use mineral oil or sunflower oil • 7yr old with eczema since aged 1 • Used Eumovate ointment daily for 2 weeks • Scratching at night • Has ointment emollient but won’t use it as makes skin feel sticky. Treatment • • • • Viscopaste bandages Coban or actifast Offer variety of emollients - cream form Antibiotics? Occlusive bandages • Hands before treatment and one week after treatment with occlusive bandages, eumovate and flucloxacillin Hands • Viscopaste to individual fingers or wet mitts over emollients Generalised severe eczema • If good compliance and appropriate treatment, consider wet wraps • TIP - check for scabies! Wet Wraps • Steroids and emollients under damp bandages • Ready made garments Prognosis • Poor: • Severe disease in childhood, family history, asthma, rhinitis, late onset (after 2 yrs), atypical pattern, hand involvement, xerosis STEROIDS - cream or ointment? • Ointment (oil based) - steroid of choice. Less additives. Helps re-hydrate the skin. • Cream (water based) - use on weeping eczema or when cosmetic acceptability is an issue. Steroid Quantities • 1 finger tip unit (f.t.u.) = 1/2g = 2 adult hand’s worth of eczema Steroid quantities • • • • Twice daily application of steroid all over 6 month old = 9.5g daily = 66.5g weekly 4 year old = 19.25g daily = 134.75g weekly 7 year old = 24.5g daily = 171.5g weekly Typical Daily Routine • • • • • • • • 07.20 Wash (soap substitute) 07.30 Steroid to all patches 08.00 Moisturiser all over 12.00 Moisturiser all over 15.30 Moisturiser all over 18.30 Bath with oil / soap substitute 18.45 Steroid to all patches 19.15 Moisturiser all over Typical Month’s Prescription • Example • • • • • extensive flare of moderate eczema in a 3 year old Moisturiser - 1.5kg Soap substitute - 500g Bath oil - 500mls Steroid - 300g +/- antibiotics, bandages etc What would you do? • Known eczema patient. • Flare last three days. Treated with cutivate. Generally unwell. Eczema Herpeticum • • • • • Dermatology emergency Stop steroids Acyclovir - oral or iv Opthalmic opinion Admit if unwell Happy customers