The Basics - Managing eczema

Patient education plays an important role in the management of eczema, explains Dr Nigel Stollery.

Atopic eczema reduces the barrier function of the skin
Atopic eczema reduces the barrier function of the skin

Atopic eczema is a common inflammatory skin condition that can develop at any age. The majority of cases (approximately 70 per cent) first present under the age of five and many will have cleared by the mid- adolescence (60-70 per cent).

Although the more severe cases require referral to secondary care, the majority can be managed in the primary care setting.

1. Education
As with any chronic condition, education plays an important role in the management of eczema, and should be started from the point of diagnosis.

As most cases of atopic eczema will develop in the under fives, education will usually be focused toward the parents. Some parents may have had other children with the condition and have a good understanding of the disease, for others the diagnosis may be completely new and they will have a lot of questions and possible misconceptions that will need to be discussed.

Education should include discussion on avoiding irritants and the importance of compliance.

Practice nurses and health visitors will often be in a good position to help and parents should be encouraged to ask questions and discuss their ideas, concerns and expectations.

The impact of eczema on both a patient and their family must not be underestimated and patients and their family need to know that support is available.

2. Emollients
The skin works as a barrier against pathogens, water loss, allergens and the environment. In atopic eczema one of the fundamental problems is a reduction in the barrier function of the skin, leading to dryness.

Emollients aim to correct this problem by replacing the deficient barrier, reducing water loss and in turn increasing the moisture content of the skin. This barrier also reduces the effects of irritants and protects the skin from pathogens.

Emollients come in many forms including creams, gels, lotions, ointments and aerosols, and there are many different brands.

When considering which emollients to use, it is important to ensure patient compliance and therefore, patient choice is very important. Both children and adults will be reluctant to use a preparation that they do not like.

Although the greasier emollients are the most effective, many patients will object to having shiny, greasy skin. For some, this may be acceptable at night and when at home, but not when out of the house. Giving the patient or their carers a selection of starter samples usually works well so that they can choose which type they prefer.

Patients should be advised on how much to use and on arranging repeat prescriptions.

3. Topical steroids
Topical steroids, derived from naturally occurring cortisol from the adrenal cortex, have both anti-inflammatory and immunosuppressant effects, both of which are important in the treatment of eczema.

They are available in a variety of forms, including creams and ointments, and in a range of strengths from mild to superpotent.

Many parents have concerns when steroids are mentioned with fears of skin thinning and growth retardation. Education is important to ensure compliance and their correct use.

The fingertip unit system and a stepwise approach to different strengths will help reduce the risk of side-effects.

Topical steroids are usually applied once a day. Hydrocortisone and clobetasone butyrate are at the lower end of the strength spectrum and are available for purchase without prescription. Hydrocortisone is mildly potent and clobetasone butyrate is moderately potent.

Potent topical steroids include betamethasone and very potent topical steroids include clobetasol. Care needs to be taken when prescribing very potent steroids and regular review is recommended.

4. Topical calcineurin inhibitors
These topical immunosuppressant ointments are steroid free and are derived from fungi. Although available in primary care, they are expensive and care needs to be taken to avoid their use when there is infection present, such as herpes labialis.

There are two strengths available: pimecrolimus and the stronger tacrolimus, both of which can be applied daily to affected areas.

5. Antibiotics and antihistamines
Secondary bacterial infection from Staphylococcus aureus is very common in eczema and should always be considered when normal treatments are not working as expected. Skin swabs are of limited value and, in general, oral antibiotics are preferable to topical preparations.

Emollients containing antiseptics can be helpful in cases of recurrent infection.

The use of antihistamines is not generally recommended for the treatment of atopic eczema except at night when, in some cases, the use of a sedative antihistamine can reduce nocturnal pruritus and aid sleep.

6. Referral to secondary care
In patients where topical treatments are not enough to control their eczema, phototherapy and oral agents such as ciclosporin may be offered in secondary care.

Careful monitoring, including bloods tests (renal, liver and lipids) and BP, are usually required and patient education is very important.

7. Complementary therapies
Many patients will explore other areas of treatment which may include homeopathy and Chinese herbal medicine. It is advisable to enquire about these when reviewing the condition as patients may feel embarrassed discussing them.

Some patients will find them helpful but care needs to be taken to make sure any herbal products bought are from reputable sources, as it is not always clear what the preparations contain.

  • Dr Stollery is a GP and a clinical assistant in dermatology at the Leicester Royal Infirmary.
Key Points
  • Patient education plays an important role in the management of eczema.
  • When prescribing an emollient, patient choice is vital in order to ensure compliance.
  • Consider oral antibiotics for secondary bacterial infection from Staph aureus.
  • If topical treatments do not work, consider referral to secondary care for phototherapy.

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