Atopic Eczema/Dermatitis

L20.0/L20.8-9

DESCRIPTION

Eczema is an pruritic, inflammatory skin condition recognised by vesicles, weeping, and crusting in the acute phase; and thickened, scaly skin with increased skin markings known as lichenification in the chronic phase.

Assessing severity

1% of body surface is equal to the size of one hand (including the fingers) of the patient

Mild

  • Less than 5% body surface involved.
  • No acute changes.
  • No significant impact on quality of life.

Moderate

  • 5-30% body surface involved.
  • Mild dermatitis with acute changes.
  • Mild dermatitis with significant impact on quality of life.

Severe

  • More than 30% body surface involved.
  • Moderate dermatitis with acute changes.
  • Moderate dermatitis with significant impact on quality of life.

GENERAL MEASURES

  • Avoid exposure to trigger or precipitating factors, where applicable.
  • Avoid irritants such as strong detergents, antiseptics, foam (especially hot) baths, soaps and rough occlusive clothing (silk is better than cotton, which is better than nylon, which is better than wool).
  • Good personal hygiene with once daily washing to remove crusts and accretions and avoid secondary infection.
  • Keep fingernails short to minimise trauma from scratching.
  • Respect patient preference for cream or ointment topical treatment.
  • Wet wraps may help control eczema and pruritus but should not be used for infected eczema.
  • Diet modification has no role in atopic eczema treatment unless double blind challenge testing proves food sensitivity.
  • Avoid smoking.

MEDICINE TREATMENT

To relieve skin dryness:

  • Aqueous cream topical, to wash or bath.
  • Emulsifying ointment (UE), topical, applied daily to dry areas as a moisturiser.

LoEIII [6]
Moisturising soap, creams and ointments, as described above, should continue permanently as maintenance, even if the dermatitis is controlled.

To control dermatitis:
Creams are preferred to ointments on opening or oozing lesions and in intertriginous folds.

Mild eczema

  • Hydrocortisone 1%, topical, applied 12 hourly to body and face until control is achieved.
    • Can be used on face and in skin folds.
    • Apply sparingly to the face.
    • Use with caution around the eyes.

Moderate and severe eczema

  • Potent topical corticosteroids, e.g.:
    • Betamethasone 0.1%, topical, applied daily for 7 days to the affected areas.
      • Apply sparingly to face, neck and flexures.

Note: There is no clear benefit for more than once daily application.

LoEI [7]

If non-responsive:

Refer for dermatologist opinion.

  • Prednisone, oral, 0.5 mg/kg daily, for ≤ 2 weeks. Specialist initiated.

Maintenance therapy

Once eczema is controlled, wean to the lowest potency topical corticosteroid that maintains remission, applied twice a week.

Apply moisturiser as needed.

  • Emulsifying ointment (UE), topical, applied daily.

Infected eczema

This is usually due to staphylococcal infection.

Antibiotic therapy

  • Flucloxacillin, oral, 500 mg 6 hourly for 5 days.

Severe penicillin allergy: (Z88.0)

  • Clindamycin, oral, 450 mg 8 hourly for 5 days.

For sedation and relief of itch:

  • Chlorphenamine, oral, 4 mg at night as needed.

Eczema herpeticum B00.0

Therapy should be initiated without delay:

  • Aciclovir 400 mg, oral, 8 hourly for 7 days.

LoEIII [8]

If patient is unable to swallow due to odynophagia:

  • Aciclovir, IV, 5 mg/kg/dose, 8 hourly for 7 days.
    • Infuse over 1 hour.

LoEIII [9]

REFERRAL

Severe, non-responsive, or complicated cases or cases with uncertain diagnosis (e.g. severe infection including disseminated herpes simplex).