ECZEMA

ECZEMA

History:

• Pruritus
• Family history of atopy
• Other pre-existing atopic conditions.

On examination:

• Dry skin (xerosis)
• Lichenification (increased skin markings due to chronic rubbing)
• Excoriations caused by scratching
• Ill defined erythema
• Atopic dirty neck (darkened skin on neck looking like dirt)
• Hyperlinear palms (present in 28-88%) are seen

Infants tend to get eczema on the face. Older infants get it on extensor surfaces. From walking age, antecubital and popliteal fossae.

Eczematous skin is predisposed to staph aureus infection, and treatment with steroid emollients alone reduces staph carriage, hence a vicious circle exists. Steroids are not contra-indicated, but consider a steroid-antibiotic combination e.g. Fucibet, tailing down to steroid only over a week as things improve. If severe, topical corticosteroids with oral flucloxacillin would be a good option.

A rough guide to the amount of steroid to use: 1 FTU (fingertip unit) covers area of 2 palms = 0.5 G. It is important to remember that undertreatment can be just as damaging as overtreatment. Strengths of steroid:

• Mild e.g. hydrocortisone
• Moderate e.g. Eumovate
• Potent e.g. Betnovate
• Very potent, superpotent e.g. Dermovate

Tacrolimus 0.03% ointment has been licensed for use in children with moderate to severe atopic dermatitis unresponsive to conventional therapies. Application is twice a day at first for up to 3 weeks, reducing to once daily after three weeks until the atopic dermatitis is clear. No skin atrophy was observed when patients used it daily for up to 2 years. Should only be prescribed by doctors with adequate experience of treating with immunomodulatory agents. For unresponsive patients, referral to a dermatologist for wet-wrap bandaging, a short course of cyclosporin or ultra-violet treatment, in-patient care.

Chronic, relapsing course in childhood and then improves with 60-90% of children clear by 10-16.

BMJ 1999;318:1600-4