Dermatitis and Eczema

 

Eczema is a common inflammatory skin condition characterised histologically by spongiosis with varying degrees of acanthosis, and a superficial perivascular lymphohistiocytic infiltrate

The clinical features may include itching, redness, scaling and clustered papulovesicles. The condition may be induced by a wide range of external and internal factors acting singly or in combination, such as soap and detergents, over-heating, animal dander, pollens and certain foods . The terms eczema and dermatitis are generally regarded as synonymous

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Atopic Eczema

Diagnosis

Take a history. Ask about:

  1. The presence of itching — the diagnosis is unlikely to be atopic eczema if there is no itch
  2. The pattern, time of onset, and natural history of the rash — atopic eczema usually starts in infancy and is episodic in nature
  3. A family or personal history of atopy — allergic rhinitis and asthma are associated with atopic eczema
  4. Any treatments(s) tried and the response to the treatment(s)
  5. Possible trigger factors (irritant or allergic)

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Examine the rash:

  1. The distribution and appearance of the rash will be influenced by the person's age and the duration of the rash
    1. In adults, there is generalized dryness and itching, particularly with exposure to irritants. Eczema on the hands may be the primary manifestation
    2. In children and adults with long-standing disease, eczema is often localized to the flexure of the limbs
    3. In infants, eczema primarily involves the face, the scalp, and the extensor surfaces of the limbs. The nappy area is usually spared
    4. Acute eczema (flares) varies in appearance, from poorly demarcated redness to fluid in the skin (vesicles), scaling, or crusting of the skin
    5. Chronic eczema is characterized by thickened (lichenified) skin resulting from repeated scratching
  2. If eczema is weeping, crusted, or there are pustules, with fever or malaise, secondary bacterial infection should be considered. See section on 'Infected eczema' below for management information

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Atopic eczema is likely if the following criteria are fulfilled, although alternative diagnoses may need to be excluded:

  1. An itchy skin condition (or parental report of scratching) plus three or more of the following:
    1. Visible flexural eczema involving the skin creases, such as the bends of the elbows or behind the knees (or visible eczema on the cheeks and/or extensor areas in children aged 18 months or younger)
    2. Personal history of flexural eczema (or eczema on the cheeks and/or extensor areas in children aged 18 months or younger)
    3. Personal history of dry skin in the last 12 months
    4. Personal history of asthma or allergic rhinitis (or history of atopic disease in a first-degree relative of a child aged under 4 years)
    5. Onset of signs and symptoms before the age of 2 years (this criterion should not be used in children younger than 4 years of age)

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NOTE:  These criteria apply to all ages, social classes, and ethnic groups. However, in children of Asian, black Caribbean, and black African ethic groups, atopic eczema can affect the extensor surfaces rather than the flexures, and discoid or follicular patterns may be more common

NOTE:  Investigations are not required to establish the diagnosis of atopic eczema. However, they may be useful in excluding differential diagnoses, especially in people whose symptoms do not respond to treatment

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If atopic eczema is diagnosed, assess:

  • The severity of symptoms (see section on 'Assessment of severity' below)
  • The psychological impact on the person

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Assessment of severity

At each consultation, assess the severity of the eczema in order to determine the most appropriate treatment

To assess the severity of the eczema, examine all areas of affected skin, and ask about itching.  To aid in the assessment of severity, use one of the following:

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Categorize eczema as:

  1. Clear — if there is normal skin and no evidence of active eczema
  2. Mild — if there are areas of dry skin, and infrequent itching (with or without small areas of redness). See section on 'Mild eczema' below for management information
  3. Moderate — if there are areas of dry skin, frequent itching, and redness (with or without excoriation and localized skin thickening). See section on 'Moderate eczema' below for management information
  4. Severe — if there are widespread areas of dry skin, incessant itching, and redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking, and alteration of pigmentation). See section on 'Severe eczema' below for management information
  5. Infected — if eczema is weeping, crusted, or there are pustules, with fever or malaise. See section on 'Infected eczema' for management information

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Management of mild eczema

If a person presents with mild eczema (or an acute flare of mild eczema):

  1. Prescribe appropriate treatment:
    1. Prescribe generous amounts of emollients, and advise frequent and liberal use
    2. Consider prescribing a mild topical corticosteroid (such as hydrocortisone 1%) for areas of red skin. Treatment should be continued for 48 hours after the flare has been controlled
  2. Give appropriate information and advice, including general information on atopic eczema, measures to maintain the skin and reduce the risk of flares, self-care advice, and information on treatments not recommended
  3. Active follow up is rarely required for mild eczema, unless the person or carer requests it
    1. For people with persisting eczema, consider annual review of emollient use to ensure optimal usage

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Refer for a routine dermatology appointment if:

  • The diagnosis is, or has become, uncertain
  • Current management has not controlled eczema satisfactorily (for example the person is having one to two flares per month), or the person is reacting adversely to many emollients
  • Facial eczema has not responded to appropriate treatment
  • There is recurrent secondary infection

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Refer to a clinical psychologist, people whose eczema is controlled but whose quality of life and psychological well-being have not improved (this may not be directly related to the severity of the eczema)

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Management of moderate eczema

If a person presents with moderate eczema (or an acute flare of moderate eczema):

  1. Consider the need for immediate admission or referral if eczema herpeticum is suspected
  2. Prescribe appropriate treatment:
    1. Prescribe a generous amount of emollients, and advise frequent and liberal use (more than usual)
  3. Prescribe preventative treatment between flares
    1. Consider prescribing a maintenance regimen of topical corticosteroids to control areas of skin prone to frequent flares (not recommended for the face, genitals, or axillae). Options include a 'step down approach' or 'intermittent treatment'. See the section on Maintenance regimens
  4. Give appropriate information and advice, including general information on atopic eczema, measures to maintain the skin and reduce the risk of flares, self-care advice, and information on treatments not recommended
  5. Follow up:
    1. Review emollient use on an annual basis to ensure optimal usage
    2. Topical corticosteroids require regular review if there is heavy usage; however, this is unlikely to be necessary with moderate eczema. Review maintenance therapy with topical corticosteroids at 3–6 months to assess effectiveness
    3. Review the use of non-sedating antihistamines every 3 months (treatment can be stopped, then restarted if symptoms worsen)

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Refer for a routine dermatology appointment if:

  • The diagnosis is, or has become, uncertain
  • Current management has not controlled eczema satisfactorily (for example the person is having one to two flares per month), or the person is reacting adversely to many emollients
  • Facial eczema has not responded to appropriate treatment
  • Treatment (application) advice is needed (for example bandaging techniques)
  • Contact allergic dermatitis is suspected (for example if there is persistent eczema or facial, eyelid, or hand eczema)
  • Eczema is assessed as causing significant social or psychological problems (for example sleep disturbance)

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Refer to immunology, dermatology, or paediatrics if a food allergy is suspected and the expertise to diagnose and manage food allergy is not available in primary care

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Refer to a clinical psychologist, people whose eczema is controlled but whose quality of life and psychological well-being have not improved (this may not be directly related to the severity of the eczema)

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Management of severe eczema

If a person presents with severe eczema (or an acute flare of severe eczema):

  1. Consider the need for immediate admission or referral if eczema herpeticum is suspected
  2. Prescribe appropriate treatment
    1. Prescribe a generous amount of emollients and advise frequent and liberal use (more than usual)
  3. Prescribe preventative treatment between flares
    1. Consider prescribing a maintenance regimen of topical corticosteroids to control areas of skin prone to frequent flares (not recommended for the face, genitals, or axillae). Options include a 'step down approach' or 'intermittent treatment'. See the section on Maintenance regimens
  4. Give appropriate information and advice, including general information on atopic eczema, measures to maintain the skin and reduce the risk of flares, self-care advice, and information on treatments not recommended
  5. Follow up:
    1. Review emollient use on an annual basis to ensure optimal usage
    2. Topical corticosteroids require regular review if there is heavy usage. Review maintenance therapy with topical corticosteroids at 3–6 months to assess effectiveness
    3. Review the use of non-sedating antihistamines every 3 months (treatment can be stopped, then restarted if symptoms worsen)
    4. For all people who have had a severe and extensive flare requiring treatment with oral corticosteroids or oral antibiotics, review after the course has finished, and consider the need for referral

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Refer for a routine dermatology appointment if:

  • The diagnosis is, or has become, uncertain
  • Current management has not controlled eczema satisfactorily (for example the person is having one to two flares per month), or the person is reacting adversely to many emollients.
  • Facial eczema has not responded to appropriate treatment
  • Treatment (application) advice is needed (for example bandaging techniques)
  • Contact allergic dermatitis is suspected (for example if there is persistent eczema or facial, eyelid, or hand eczema)
  • Eczema is assessed as causing significant social or psychological problems (for example sleep disturbance)

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Refer to immunology, dermatology, or paediatrics if a food allergy is suspected and the expertise to diagnose and manage food allergy is not available in primary care

Refer to a clinical psychologist, people whose eczema is controlled, but whose quality of life and psychological well-being have not improved (this may not be directly related to the severity of the eczema)

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Management of infected eczema

If a person presents with severe eczema:

  1. Consider the need for immediate admission or referral if eczema herpeticum is suspected
  2. Prescribe appropriate treatment
    1. If there are extensive areas of infected eczema, swab the skin and prescribe an oral antibiotic. Routine swabbing of skin that is not infected is not recommended
    2. If there are localized areas of infection, consider prescribing a topical antibiotic
  3. Offer treatment and advice to reduce the risk of further infection

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Refer urgently (within 2 weeks) to a dermatologist if infected eczema has not responded to treatment

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Refer routinely to a dermatology department if:

  • The diagnosis is, or has become, uncertain
  • Eczema is associated with severe and recurrent infections, especially deep abscesses or pneumonia

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When to refer

Mild asthma:

  • Refer for a routine dermatology appointment if:
    • The diagnosis is, or has become, uncertain
    • Current management has not controlled eczema satisfactorily (for example the person is having one to two flares per month), or the person is reacting adversely to many emollients
    • Facial eczema has not responded to appropriate treatment
    • There is recurrent secondary infection

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Moderate eczema:

  • Refer for a routine dermatology appointment if:
    • The diagnosis is, or has become, uncertain
    • Current management has not controlled eczema satisfactorily (for example the person is having one to two flares per month), or the person is reacting adversely to many emollients
    • Facial eczema has not responded to appropriate treatment
    • Treatment (application) advice is needed (for example bandaging techniques)
    • Contact allergic dermatitis is suspected (for example if there is persistent eczema or facial, eyelid, or hand eczema). See the CKS topic on Dermatitis - contact for more information
    • There is recurrent secondary infection
    • Eczema is assessed as causing significant social or psychological problems (for example sleep disturbance)
  • Refer to immunology, dermatology, or paediatrics if a food allergy is suspected and the expertise to diagnose and manage food allergy is not available in primary care

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Severe eczema:

  • Refer for a routine dermatology appointment if:
    • The diagnosis is, or has become, uncertain
    • Current management has not controlled eczema satisfactorily (for example the person is having one to two flares per month), or the person is reacting adversely to many emollients
    • Facial eczema has not responded to appropriate treatment
    • Treatment (application) advice is needed (for example bandaging techniques)
    • Contact allergic dermatitis is suspected (for example if there is persistent eczema or facial, eyelid, or hand eczema). See the CKS topic on Dermatitis - contact for more information
    • There is recurrent secondary infection
    • Eczema is assessed as causing significant social or psychological problems (for example sleep disturbance)
  • Refer to immunology, dermatology, or paediatrics if a food allergy is suspected and the expertise to diagnose and manage food allergy is not available in primary care

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Infected eczema:

  • Refer urgently (within 2 weeks) to a dermatologist if infected eczema has not responded to treatment
  • Refer routinely to a dermatology department if:
    • The diagnosis is, or has become, uncertain
    • Eczema is associated with severe and recurrent infections, especially deep abscesses or pneumonia

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Contact Dermatitis

Diagnosis

Take an occupational history in an adult of working age presenting with contact dermatitis

  • An occupational history should include details of their job, the materials they work with, the location of the rash, and any temporal relationship with work

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In irritant contact dermatitis:

  • The main symptoms are burning, stinging, and soreness
  • The onset of reaction is usually within 48 hours. Strong irritants can produce immediate reactions, whereas mild irritants require prolonged or repeated exposure to cause a reaction
  • The rash only affects areas of skin exposed to the irritant
  • A history of exposure to friction, wet work, soap, detergents, organic or alkaline solvents, or environmental relative humidity less than 35% are key factors in supporting this diagnosis
  • Resolution often occurs within 4 days of removal of the stimulus

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In acute allergic contact dermatitis:

  • The main symptoms are redness, itch, and scaling
  • Reaction after contact occurs after a delay of many hours to several days
  • Location of the dermatitis is helpful in identifying the cause (for example dermatitis from cosmetics on eyelids and cheeks). However, it may affect areas not directly in contact with the allergen
  • Resolution may take many days, with or without treatment

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NOTE:  Atopic eczema increases the risk of irritant contact dermatitis and is a common association.  Atopic eczema is less strongly associated with allergic contact dermatitis

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Investigations

A subgroup of people with contact dermatitis will require further investigations to identify the causative stimuli and to obtain trial treatments not available in primary care

Consider referral to a dermatologist for patch testing if:

  • The person has chronic, recurring, or unrelenting eczematous or lichenified dermatitis despite appropriate avoidance measures and appropriate strength corticosteroid treatment
  • There is a suspicion of a contact dermatitis but no clear history of relevant exposure
  • There is a suspicion of occupational contact dermatitis which is resistant to corticosteroid treatment
  • Contact dermatitis is recalcitrant or chronic and not responding to corticosteroid therapy

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Differential diagnosis: 

  • Other causes of dermatitis:
    • Atopic dermatitis (onset usually in infancy or early childhood)
    • Seborrhoeic dermatitis
  • Skin infections:
    • Cellulitis
    • Tinea corporis
    • Impetigo
    • Herpes simplex
    • Varicella-zoster
    • Scabies
  • Other skin conditions:
    • Urticaria
    • Psoriasis
    • Fixed drug eruption
    • Photosensitivity
    • Lichen planus of the hands

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Assessment

If possible, identify the stimulus by taking a detailed history and examination, including:

  • Occupational, recreational, and medical history, including family history of atopic dermatitis.
  • The anatomical distribution of the rash
  • The amount of contact with the irritant or allergen
  • History of exposure to irritants, for example wet work or friction
  • Duration of contact
  • Time from contact to first presentation
  • Evolution of symptoms, for example one episode or recurrent episodes; does the skin clear completely between episodes?
  • Establish whether the pattern of distribution of the dermatitis suggests contact with a particular allergen or irritant

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Consider referral to a recognized centre for patch testing to exclude allergic dermatitis

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Assess for any indication of secondary infection, for example rapid worsening of dermatitis, tenderness, increased erythema, heat, or discharge

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Management of acute episode

  1. Advise the person to avoid contact with the stimulus
  2. Recommend frequent, liberal use of an emollient to maintain skin hydration and improve barrier repair
  3. Advise the use of a soap substitute such as aqueous cream
  4. Treat localized acute dermatitis with a topical corticosteroid
    1. Prescribe a potency appropriate to the severity and location of the dermatitis
  5. Consider short-term use of a systemic corticosteroid if there is:
    1. Significant impairment of function, such as in eczema on the hands
    2. Extensive acute dermatitis (greater than 20% of total skin surface involved)

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NOTE:  The use of antihistamines for relieving pruritus associated with acute contact dermatitis is not recommended

Further information on preventing work-related skin problems can be found at the Health and Safety Executive

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Prevention of future episodes

  1. Advise people that preventing further episodes of contact dermatitis relies on avoidance of the causative stimulus
  2. If complete avoidance is not possible, advise the person on the use of measures aimed at preventing or minimizing contact with affected areas of skin, for example:
    1. Rinsing with water or washing with soap or, preferably, a soap substitute as soon as possible after contact (overuse of skin-cleaning agents can aggravate contact dermatitis)
    2. Substituting products that contain identified allergens or irritants with other products that do not contain them
    3. Reducing the duration and frequency of contact with an irritant
    4. Using protective clothing. Most irritant contact dermatitis involves the hands, and protective gloves are the mainstay of protection

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Management of persistent symptoms

If measures to avoid the stimulus do not resolve dermatitis:

  1. Reassess the diagnosis
  2. Reassess the identity of possible allergens and irritants
  3. Refer to a recognized centre for patch testing if not already done
  4. Exclude ongoing exposure to irritants or allergens:
    1. Check compliance with avoidance measures
    2. If compliance is good, step up avoidance measures where possible
  5. Consider using a more potent topical corticosteroid if response to initial treatment is poor.
  6. Consider a contact allergy from topical medication (including allergy to topical corticosteroids) if dermatitis fails to respond or deteriorates with use:
    1. Confirm the suspicion by applying the product on skin that is unaffected by dermatitis and observing for a reaction
    2. If allergy from a topical medication is suspected, refer for patch testing to try and identify which topical medication(s) the person is sensitized to

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Refer to a dermatologist if:

  • The person has chronic, recurring, or unrelenting eczematous or lichenified dermatitis despite avoidance measures and appropriate-strength topical corticosteroid treatment
  • There is a suspicion of contact dermatitis but no clear history of relevant exposure
  • Recalcitrant or chronic contact dermatitis does not respond to first-line steroid therapy
  • There is a suspicion of occupational contact dermatitis which is resistant to corticosteroid treatment
    • Ideally such people should be seen by a dermatologist with expertise in occupational skin disease, who can give advice about workplace adjustments and liaise with their employer

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Management of secondary infection

Suspect secondary infection if clinical signs of infection are present (for example rapid worsening of dermatitis with marked erythema, discharge, or increased pain). The person will often feel unwell or feverish

  • The typical appearance of impetigo (crusted lesions that may be yellow) may be difficult to distinguish from dermatitis
  • It is common practice to have a low threshold of diagnosing infection when dermatitis is severe or unexpectedly deteriorates

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For visibly infected dermatitis, swab the skin and start oral antibiotics:

  • Flucloxacillin or clarithromycin (if the person is allergic to penicillin) is recommended first-line

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If visible infection fails to respond to a first-line antibiotic, microbiological investigations to ascertain sensitivities may be useful

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When to refer

Refer to a dermatologist if:

  • The person has chronic, recurring, or unrelenting eczematous or lichenified dermatitis despite avoidance measures and appropriate-strength topical corticosteroid treatment
  • There is a suspicion of contact dermatitis but no clear history of relevant exposure
  • Recalcitrant or chronic contact dermatitis does not respond to first-line steroid therapy
  • There is a suspicion of occupational contact dermatitis which is resistant to corticosteroid treatment
    • Ideally such people should be seen by a dermatologist with expertise in occupational skin disease, who can give advice about workplace adjustments and liaise with their employer

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Click here for images

The assess the severity of a patient's eczema, use the appropriate Patient Oriented Eczema Measure (POEM) score below:

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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