Eczema - Leeds Pathway

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1. Background Information / Important Principles

Quick info:
Important Principles:

  • Compliance - review compliance with treatment to ensure treatment is being followed as recommended.
  • Realistic treatment aims need to be discussed with the patient and parents. The condition waxes and wanes and is characterised by flares.
  • For all types of eczema consider secondary bacterial infection. Infection should be suspected whenever eczema worsens. The commonest infecting organism is Staph aureus. Signs include:
    • Severe inflammation
    • Weeping
    • Crusting
    • Good practice to swab prior to treatment.
  • Recurrent infection - consider nasal carriage.

Steroid Ladder
Emollient Ladder
Fingertip Unit Guidance
General Notes on Prescribing Dermatology Products

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2.  Information Resource for Patients and Carers

Quick info:
Patient Support Group:
National Eczema Society
Hill House
Highgate Hill
London
N19 5NA

Tel: 020 72813553
Eczema information Line: 0870 241 3604 (1-4pm Mon-Fri)
www.eczema.org

Patient Information Leaflets:
British Association of Dermatologists - Atopic Eczema PIL
British Association of Dermatologists - Eczema Herpeticum PIL
British Association of Dermatology - Hand Dermatitis PIL

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3. Development and Updates to this Pathway

Quick info:
Developed July 2014

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4. Training and Further Resources

Quick info:
Additional Resources:

Derm Net NZ: The Dermatology Resource
British Association of Dermatologists
Primary Care Dermatology Society
Steroid Ladder
Emollient Ladder
Fingertip Unit Guidance
General Notes on Prescribing Dermatology Products

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6. Hand Eczema

Quick info:
Clinical Features:
A Endogenous Eczema (e.g. atopic)
B Exogenous Eczema

  • Irritant Contact Eczema ICD. Due to substances coming into contact with the skin, usually repeatedly, causing damage and irritation. Substances such as:
    • water
    • detergents
    • shampoos
    • hand gels
    • household cleaning products
  • Allergic Contact Dermatitis (ACD) Due to type IV allergic reaction to a substance the skin is in contact with.

All types of endogenous and exogenous eczema can present with either 'wet' (blistering and weeping) or 'dry' (hyperkeratotic and fissured) eczema.

Patient Information:
British Association of Dermatology - Hand Dermatitis PIL

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7. Atopic Eczema

Quick info:
Clinical Features:
Atopic eczema is a common disease affecting up to 15% of children.
Involvement of the face frequently occurs in infants with adoption of a characteristic flexural distribution by the age of 18 months. Spontaneous improvement tends to occur throughout childhood with complete clearance by teenage years in about two thirds of patients.
Realistic treatment aims need to be discussed with the patient and parents.

Patient Information:
British Association of Dermatologists - Atopic Eczema PIL

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8. Eczema Herpeticum Suspected

Quick info:
Dermnet: eczema herpeticum
PCDS: eczema herpeticum

Patient Information:
British Association of Dermatologists - Eczema Herpeticum PIL

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9. Treatment

Quick info:
Avoidance of irritants
Soap substitutes should be used. Gloves e.g. household rubber or PVC gloves should be used for wet work such as dish washing. Gloves may also be required for dry work e.g. gardening.

Emollients
Emollient Ladder
These should be applied frequently. There are a variety of emollients available. Different patients will prefer different preparations. See emollient guidance on Leeds Health Pathways

Topical Steroids
Steroid Ladder

Often it is necessary to use a potent topical steroid short term. Prescribe a cream formulation if 'wet' and ointment if 'dry.' Potassium Permanganate (Permitabs) soaks may sometimes be helpful.

Antibiotics (topical/systemic) Exclude secondary infection and treat if appropriate. Use of cotton gloves at night improves efficacy of treatment.

Other skin conditions can mimic eczema and should be kept in mind. It is usually worth examining the patient's skin all over as this can provide clues to other diagnoses (e.g. plaques in extensor distribution in psoriasis, scabetic nodules in scabies.

All persistant or severe hand dermatitis should be referred to Secondary care for patch testing.

If an eczematous looking rash is present on only one hand, a fungal infection needs to be excluded by taking skin scrapings for mycology.

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10. Treatment

Quick info:
General treatment measures:

  • Soaps and detergents including bubble bath and shower gels should be avoided.
  • Cotton clothing should be used and avoid wool next to the skin
  • Fingernails should be kept short to reduce skin damage from scratching
  • Bathing is not harmful but an emollient has to be used

Emollients
Emollient Ladder
Emollients should be prescribed in all cases. Added to the bath or used in the shower. Used directly on the skin during and after bathing or showering

Greasier preparations are better at hydrating the skin

Some patients have a preference and you may have to supply several until the patient finds something they like and will therefore use. Please advise patients as to the frequent need for reapplication.

For usual prescribed amounts see General Notes on Prescribing Dermatology Products

Topical Corticosteroids
Steroid Ladder

Although potent preparations can cause skin atrophy, mild corticosteroids such as 1% Hydrocortisone do not and are safe to use

in the long term. Hydrocortisone 1% is the strength of choice for the face and flexures. Topical corticosteroids are often underused because of concern about the side effects.

Note potent steroids can be used safely for up to 4 weeks (except face and flexures.) Use to control flares then step down to a maintenance regime, either alternate days then twice weekly use or reduce to mild/moderately potent steroid. Emollients to be used at all times.

Topical Immunomodulators (pimecrolimus (Elidel), tacrolimus (Protopic))
These can be used as second line treatment, as steroid sparing agents especially in sites such as the face. They can be used in the same way as steroids for acute exacerbations and for maintenance treatment, providing there is no indication of infection.

Antihistamines
Sedative antihistamines. Suitable for short-term use to control itch especially at night.

Infection Control

  • Consider antiseptic moisturiser combinations
  • If the infection is widespread or severe treat with systemic antibiotics
  • If recurrent infections occur take nasal swabs from the family members

Garments can be prescribed to help emollient treatment efficacy.
Wet wrap dressings may also be helpful particularly at night in small children.

Suspected Allergy in Children
Food Allergy: If you have a strong suspicion from the history of food allergy in children, refer to the secondary care Paediatric Allergy clinic. It is not generally helpful to carry out blood tests in Primary Care as false positive and negative results may occur.

Airborne Allergy: If airborne allergies (e.g. dust/pets/pollen/grass) are suspected (these often cause reactions on exposed skin) referrals should be directed to Secondary Care Paediatric Dermatology Service if there are skin problems, or the the Paediatric allergy service of the reactions are non-skin related (e.g. respiratory, eye etc.)

Contact Allergy: If contact allergy is suspected, referrals should be directed towards the Secondary Care Dermatology Patch Test Service, based at Chapel Allerton Hospital.

Suspected Allergy in Adults
If contact allergy is suspected, referrals should be directed towards the Secondary Care Dermatology Patch Test service, based at Chapel Allerton Hospital. Consider this diagnosis in patients with severe chronic eczema unresponsive to the above management (to exclude allergy to topical treatment) or if facial eczema dominant (airborne allergens and those that may be transmitted from the hands by touching the face.)

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11. Refer Acutely to Hospital via PCAL

Quick info:
Leeds Primary Care Access Line (PCAL)
Telephone: 0113 2065996

Operational Hours:
Monday - Friday 7.00am - 10.00pm
Weekends and Bank Holidays 8.00am - 10.00pm

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12. Community Clinic Referral Criteria

Quick info:
Criteria for referral to community dermatology clinic if Primary Care management has failed:

  • Mild to moderate cases that have failed to respond to the above treatment

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13. Secondary Care Referral Criteria

Quick info:
Criteria for referral to Secondary Care:

  • All persistant or severe hand dermatitis should be referred to Secondary care and have patch testing.
  • Occupational difficulty. If an occupational health opinion is needed

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14. Community Clinic Referral Criteria

Quick info:
Criteria for referral to Community Dermatology Clinic:

  • Mild to moderate eczema
  • Failure to respond to recommended treatment above.

Note: Eczema herpeticum - refer acutely to hospital via PCAL to on call dermatology registrar

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15. Secondary Care Referral Criteria

Quick info:
Criteria for referral to Secondary Care:

  • Moderate to severe eczema that has failed to respond to appropriate use of emollient and potent topical steroid therapies, or if excessive amounts of topical steroids are being prescribed (more than 30g per week) These patients are likely to require phototherapy or systemic therapy.
  • Recurrent infection with bacteria and treatment with an oral antibiotic plus a topical corticosteroid has failed.

Note: Eczema herpeticum - refer acutely to hospital via PCAL to on call dermatology registrar

Contact dermatitis is suspected and confirmation requires patch testing. Medicament allergy (preservatives/ingredients in topical preparations) can present as a failure of eczema to respond to topical treatment.

Key Dates
Published: 18-Dec-2014, by Leeds
Valid until: 01-Jun-2016

References
This is a list of all the references that have passed critical appraisal for use in the care map Dermatology - Eczema

ID  Reference

  1. Map of Medicine (MoM) Clinical Editorial team, and independent reviewers invited by Map of Medicine. London: MoM; 2011.
  2. National Institute for Clinical Excellence (NICE). Frequency of application of topical corticosteriods for atopic eczema. Technology appraisal 81. London: NICE; 2004. http://www.nice.org.uk/nicemedia/pdf/ta081guidance.pdf
  3. National Institute for Clinical Excellence (NICE). Tacrolimus and pimecrolimus for atopic eczema. Technology appraisal 82. London: NICE; 2004. http://www.nice.org.uk/nicemedia/pdf/TA082guidance.pdf
  4. Clinical Knowledge Summaries (CKS). Eczema - atopic. Version 1.4. Newcastle upon Tyne: CKS; 2008.
  5. National Collaborating Centre for Women's and Children's Health. Management of atopic eczema in children from birth up to the age of 12 years. London: Royal College of Obstetricians and Gynaecologists (RCOG); 2007. http://www.nice.org.uk/nicemedia/pdf/CG057FullGuideline.pdf
  6. Primary Care Dermatology Society and British Association of Dermatology (BAD). Guidelines for the management of atopic eczema. London: BAD; 2009.
  7. Langan SM, Silcocks P, Williams HC. What causes flares of eczema in children. Br J Dermatol 2009; 161: 640-6. http://www.ncbi.nlm.nih.gov/pubmed/19656150
  8. Royal College of Nursing (RCN). Caring for children and young people with atopic eczema: guidance for nurses. London: RCN; 2008. http://www.rcn.org.uk/   data/assets/pdf_file/0018/156006/003228.pdf
  9. Bath-Hextall F, Delamere FM, Williams HC. Dietary exclusions for improving established atopic eczema in adults and children: systematic review. Allergy 2009; 64: 258-64. http://www.ncbi.nlm.nih.gov/pubmed/19178405
  10. William HC. Established corticosteroid cream should be applied only once daily in patients with atopic eczema. BMJ 2007; 334: 1272. http://eprints.nottingham.ac.uk/863/1/once_daily_TCS.pdf
  11. Bath-Hextall F, Birnie AJ, Ravenscroft JC et al. Interventions to reduce Staphylococcus aureus in the management of atopic eczema: an updated Cochrane review. Br J Dermatol 2010; 163: 12-26. http://www.ncbi.nlm.nih.gov/pubmed/20222931
  12. National Institute for Health and Clinical Excellence (NICE). Alitretinoin for the treatment of severe chronic hand eczema. Technology appraisal guidance 177. London: NICE; 2009. http://www.nice.org.uk/nicemedia/pdf/TA177Guidance.pdf
  13. National Institute for Health and Clinical Excellence (NICE). Grenz rays therapy for inflammatory skin conditions. Interventional procedure guidance 236. London: NICE; 2007. http://www.nice.org.uk/nicemedia/pdf/IPG236Guidance.pdf
  14. Scottish Intercollegiate Guidelines Network (SIGN). Management of atopic eczema in primary care. A national clinical guideline. SIGN publication no. 125. Edinburgh: SIGN; 2011. http://www.sign.ac.uk/pdf/sign125.pdf

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