Clinical Review - Atopic eczema

Contributed by Dr Robin Graham-Brown, consultant and honorary senior lecturer in dermatology at the University Hospitals of Leicester.

Section 1 Epidemiology
Atopic eczema (AE) has become more common in recent years.1 Data from the Leicester Royal Infirmary department of dermatology, for example, indicate that at least 20 per cent of children will have developed skin disorders fulfilling the UK diagnostic criteria for AE2 by the age of four years.

This has led to an increased need for advice in primary and secondary care and from other healthcare professionals, including pharmacists.

It has been a particular concern for some ethnic groups, in whom AE has only recently become an issue.3

Infected atopic eczema; almost certainly Staphylococcus aureus

Treating AE successfully is a complicated process that involves the use of several complementary elements tailored to the needs of the individual patient. There is no proven cure for AE, although many patients experience spontaneous, inexplicable clearance of their skin as childhood advances. Unfortunately, this does not happen in every case and 30-40 per cent of patients fail to clear, or see a resurgence and relapse in adolescence or adulthood.

In common with therapeutic regimens for other chronic disorders, it is therefore essential to develop a treatment programme with clear objectives in mind. In treating skin disease, we should also understand that a fourth element, quality of life, comes into play.

NICE guideline
A great deal of literature is available to help clinicians in the treatment of AE, ranging from basic research, such as the recent demonstration that there is a fundamental alteration in the skin barrier in AE,4 to numerous textbooks, professional and lay.

In this large volume of information, however, lies a significant problem, because much of it is based on assertions, supported only by the experience - or opinions - of the writer.

Patients and their carers are frequently bewildered by the conflicting statements that emerge from apparently authoritative and reliable sources. This makes it particularly helpful that NICE has published its guideline,5 to join related documents appraising topical corticosteroids6 and the calcineurin inhibitors tacrolimus and pimecrolimus.7

Section 2 Diagnosis and assessment
It is essential that the diagnosis of AE is made accurately and confidently; the NICE guideline uses the UK diagnostic criteria mentioned above.2 It is important to exclude other itchy disorders, such as scabies, before making the diagnosis of AE.

Assessment should include measures of the severity of the condition, the patient's psychological and psychosocial well-being and its effect on quality of life. The successful management of AE requires patients and carers to be in a position to take charge of their own management, or at least of the choices they have to make.

Poorly managed, AE is a miserable disorder. For example, in one recent study, mothers of children with AE rated the distress it caused as worse than that associated with having a child with diabetes, and comparable with that of mothers of children requiring home enteral feeding.8

Irritants, infection or allergens may trigger eczema outbreaks

So it is essential for treatment programmes to focus on improving quality of life, not just for the patient with AE, but for the whole family.9 The key question, though, is what to do in the consulting room to record the level of disturbance of quality of life adequately in the limited time that is available to most clinicians.

There are many assessment tools including the Patient-Oriented Eczema Measure10 and the Dermatology Family Impact questionnaire.11 Unfortunately, most are unwieldy and time-consuming.

A good proxy may be to use a question and/or visual analogue scale about itch, with queries about the effect the AE has had in the past few weeks.

Trigger factors
There is a need to take a careful history about possible triggers, including irritants, infection and allergens: contact, dietary and inhaled.

Controversially, however, the NICE guidance recommends some quite specific dietary manipulations in children with 'immediate food reactions' (which are common and not necessarily related to the eczema itself) and 'in infants and young children with moderate or severe uncontrolled atopic eczema, particularly with gut dysmotility or failure to thrive'.

This approach seems to be unsupported by the hard evidence that NICE would normally be expected to demand.

Although it is accepted that a small number of children may benefit from dietary adjustments, the looseness of the inclusion criteria means that NICE seems to be giving carte blanche for this approach to become standard practice for all but the most mildly affected children.

Stepped care plan
A stepped care plan can be adopted, using potent topical steroids, phototherapy or drugs for severe disease and flare ups, stepping down to weaker steroids, topical calcineurin inhibitors and bandages, with the frequent use of emollients as a continuing aspect of care.

Different treatments are required on the face and neck, for which potent topical steroids should essentially be avoided.

Section 3 Management
The NICE guidance covers the basics of treatment well, drawing out some interesting points. For example, it suggests prescribing emollients in large quantities, up to 2kg a month.

A special area of focus is the topical calcineurin inhibitors, tacrolimus and pimecrolimus, where NICE has reinforced its past statements that these agents should not be used first line, in mild disease or under occlusion. It is acknowledged, however, that they may play a key part in reducing exposure to topical steroids overall and have a place in managing steroid- resistant or non-responsive AE.

Literature has failed to reveal any benefit from the use of non-sedating antihistamines in the treatment of AE, which has been reflected in the NICE advice that only sedating agents should be used, usually for trial or short periods initially.

Infections
The NICE guideline also includes a useful table on dealing with Staphylococcus aureus, although it can be difficult to define infection versus carriage with accuracy. In essence, the advice is to use systemic antibiotics in short courses for all but localised infections. Flucloxacillin is the drug of first choice.

The guidance also reminds clinicians to look out for herpes simplex infections and provides some clues that might suggest its presence.

Treatment Objectives

  • Bring the disorder firmly under control.
  • Maintain control to the greatest degree possible.
  • Avoid harm from treatments as far as possible.
  • Minimise the negative impact of treatments on the patient's quality of life; topical treatments are messy and can be time-consuming to apply; this adds to the perceived burden of the condition.

Interventions in Atopic Eczema
First line

  • Irritancy reduction.
  • Emollients.
  • Topical corticosteroids.
  • Anti-infective agents.
  • Anti-itch preparations.

Second line

  • Topical calcineurin inhibitors.
  • Phototherapy and photochemotherapy.
  • Systemic immunomodulators.
  • Diet, environment, herbal and alternative therapies.
Management of staph aureus infected eczemas
Treatment
 Use forTime
Systemic antibiotics active against Staph aureus and streptococcusWidespread bacterial infections 1-2 weeks
Topical antibiotics, including those
combined with topical corticosteroids
Localised clinical infectionsMaximum of 2 weeks
FlucloxacillinFirst-line treatment of Staph aureus and streptococcal infectionsAs indicated
ErythromycinFirst-line treatment of Staph aureus and streptococcal infections in the case of allergy to flucloxacillin or flucloxacillin resistance
ClarithromycinFirst-line treatment of Staph aureus and
streptococcal infections in the case of allergy to flucloxacillin or flucloxacillin resistance and intolerance to erythromycin
As indicated
Antiseptics such as triclosan or chlorhexidineAdjunct therapy for decreasing bacterial load in cases of recurrent infected atopic eczemaAvoid long-term use

Section 4: Referral and patient education
There are occasions where referral for a second opinion would be wise. These include the suspicion of eczema herpeticum, for which an immediate referral is suggested, and when the AE is severe and not responding to treatment after one week.

Other aspects of assessment and treatment that may be undertaken by a specialist include: confirming the diagnosis, patient/carer 'dissatisfaction', significant psychological or social problems with the AE, severe recurrent disease and specialist advice on using treatments. Referral would be sensible if food allergy is suspected, although NICE does not clarify whether a trial of dietary manipulation could be carried out in primary care.

Education and information
The child and their family will need information to help them understand their disease and its management. This should include an attempt to explain the current understanding of pathogenesis, some explanation of the prognosis and a discussion of what might be achieved with treatment. An alert to the potential pitfalls in using alternative therapies is also advisable (see box).

  • National Eczema Week runs from 13 to 21 September 2008. For more information see www.eczema.org

References
1. Bleiker TO, Shahidullah H, Dutton E et al. The prevalence and incidence of atopic dermatitis in a birth cohort: the importance of a family history of atopy. Arch Dermatol 2000; 136: 274.

2. Williams H, Burney P, Hay R et al. The UK Working Party's diagnostic criteria for atopic dermatitis. I. Derivation of a minimum set of discriminators for atopic dermatitis. Br J Dermatol 1994; 131: 383-96.

3. George S, Berth-Jones J, Graham-Brown R. A possible explanation for the increased referral of atopic dermatitis from the Asian community in Leicester. Br J Dermatol 1997; 136: 494-7.

4. Palmer CN, Irvine A, Terron-Kwiatkowski A et al. Common loss-of-function variants of the epidermal barrier protein filaggrin are a major predisposing factor for atopic dermatitis. Nat Genet 2006; 38: 441-6.

5. NICE Clinical Guideline CG57. Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years. NICE, London, 2007.

6. NICE Technology Appraisal TA81. Atopic dermatitits (eczema) - topical steroids. NICE, London, 2004.

7. NICE Technology Appraisal TA82. Atopic dermatitis (eczema) - pimecrolimus and tacrolimus. NICE, London, 2004.

8. Faught J, Bierl C, Barton B et al. Stress in mothers of young children with eczema. Arch Dis Child 2007; 92: 683-6.

9. Basra M, Finlay A. The family impact of skin diseases: the Greater Patient concept. Br J Dermatol 2007; 156: 929-37.

10. Charman C, Venn A, Williams H. The Patient-Oriented Eczema Measure. Arch Dermatol 2004; 140: 1,513-19.

11. Lawson V, Lewis-Jones M, Finlay A, et al. The family impact of childhood atopic dermatitis: the Dermatitis Family Impact Questionnaire. Br J Dermatol 1998; 138: 107-13.

Patient education

Discuss the severity of each child's AE with them and their parents/carers.
Explain the following points:

- The condition often improves with time, but not all children grow out of AE and it may worsen in adult life.
- AE can be linked to asthma, allergic rhinitis and food allergy.
- The role of stress, humidity and extremes of temperature in causing flares is unclear.
- AE may make the skin temporarily darker or lighter.

  • Discuss complementary therapies with the patient and their carers. Explain that their effectiveness in AE has not been adequately assessed and they should inform their healthcare professional if they intend to use complementary therapies.
  • Explain that regular massage with emollients may improve AE.
  • Provide verbal and written information about treatments, with practical demonstrations. Explain how much to use, how often to apply them, when and how to step treatment up or down and how to treat infected AE.

Source: Clinical Guideline CG57. Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years. NICE, London, 2000.

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