Eczema can be painful and embarrassing, but community pharmacists can help spot the signs and advise on how to manage this common condition, explains Asha Fowells
When asked to name a long-term condition, diabetes and heart disease may spring to mind. But there is a common chronic condition that is far more visible, and often painfully so for those who suffer from it: atopic eczema.
The term ‘eczema’ refers to skin that has become inflamed – the condition is sometimes referred to as dermatitis, which is descriptively more specific – and is red, itchy and dry as a result. The word ‘atopic’ means that the condition is allergic in origin, and those who have it are likely to also have hay fever, asthma or both.
There is a strong genetic element to atopic eczema, with nearly 60% of children experiencing it if one of their parents is affected, rising to over 80% if both parents are affected.1 A child of atopic parents is also more likely to have severe early disease, such as cracked skin that may weep, bleed and become infected.2
Also involved are environmental factors such as exposure to pets, house dust mites and pollen; food allergens, most commonly cow’s milk and eggs; triggers, notably stress and hormonal changes in women; a reduction in the lipid barrier of the skin that leads to increased water loss and therefore dryness; and immune responses.2,3
According to the National Eczema Society, one in five children and one in 12 adults in the UK has eczema.4 There is no difference in prevalence based on ethnicity or gender, but 80% of cases occur before five years of age, and the onset is highest in the first year of life.
Age also dictates which body parts are likely to be affected: in infancy, it is usually the face, scalp and extensor surfaces of the limbs. In children with longstanding eczema, symptoms often become localised to the limb flexures, while in adults, the hands may also be involved, alongside generalised dryness and itching.
Ask anyone who suffers from eczema what the worst part of the condition is, and they are likely to say the unpredictability of it. Sometimes the skin will appear normal, but at other times the condition flares, causing significant discomfort. Infection can occur as a result of colonisation with the bacterium Staphylococcus aureus, the herpes simplex virus and various fungi.
Other complications include the severe skin condition erythroderma, which can lead to dehydration, health failure and death, and eye abnormalities such as conjunctival irritation, keratoconus (in which the cornea becomes weakened), cataracts and retinal detachment.5
What may be overlooked is the psychological and social impact of eczema. According to the National Institute for Health and Care Excellence (NICE), pre-schoolers with atopic eczema have higher rates of behavioural problems, fearfulness and dependency on their parents than unaffected children, and school-age children may experience problems such as impaired performance, social restrictions, teasing, bullying and time away from school.
More generally, poor self-confidence and self-image can impair social development, and sleep disturbance can be a major problem for sufferers and their families.6
Atopic eczema is diagnosed if the skin has been itchy in the last 12 months and three of the following are present:
•Involvement of the skin creases.
•History of asthma or hay fever (or atopy in a first-degree relative if the patient is a child under four years).
•Dry skin generally over the last year.
•Onset under the age of two years.
•Visible flexural eczema, including symptoms on the cheeks, forehead or limb extensors in children under four.
Eczema is usually categorised according to its severity, with mild cases featuring areas of dry skin and infrequent itching with or without small areas of redness, moderate cases presenting with areas of dry skin that are frequently red and itchy and may or may not have visible abrasions and localised thickening, and severe cases complaining of incessant itching and redness that affect widespread areas of skin. There may also be skin abrasions, extensive skin thickening, bleeding, oozing, cracking and pigment changes. Severity should also take into account aspects such as sleep disturbances, and the impact symptoms are having on quality of life and psychosocial wellbeing.6
Signs of bacterial infection include eczema that is weeping and crusted, the presence of pustules or cellulitis with erythema of otherwise normal skin, symptoms that have failed to respond to the usual treatments or are rapidly worsening, and fever or malaise. A GP referral is required, though it is worth noting that swabs will usually only be taken if a large area of the body is involved, or if there is reason to believe that a resistant or atypical microorganism is involved.7
Eczema herpeticum, a viral infection due to herpes simplex, is a rare dermatological emergency. Signs include areas of rapidly worsening and painful eczema, clusters of blisters resembling early-stage cold sores, punched out erosions that are uniform in appearance and may join to form larger lesions with crusting, fever, lethargy and distress. Prompt antiviral management is required, so the patient should be referred to A&E.8
Most people seeking help from a community pharmacy for their eczema will be doing so because of an exacerbation, so the first thing to do is try to identify any triggers:
•Dietary triggers may cause a reaction immediately or hours later and other symptoms may be present such as diarrhoea, vomiting or poor weight gain. For infants, check the feeding history and with adults, suggest keeping a food diary for a few weeks. Milk, egg, wheat, soy and peanuts account for around three-quarters of food-induced atopic eczema cases.9
•Irritants can include chemicals, soaps, detergents and clothing (particularly wool and synthetics, though silk and dyes in cottons can also cause problems,10 so enquire about any recent changes).
•Inhaled irritants can be particularly problematic when pollen counts are high or if there has been exposure to pets. Other symptoms, which may be seasonal, are likely to be rhinitis, asthma or facial eczema.11
•Hormone changes cause premenstrual eczema flares in an estimated 30% of women and pregnancy can adversely affect eczema symptoms in up to 50% of patients.11
•Stress and temperature changes are other potential triggers.
Other self-care measures that should be recommended are scratch avoidance and keeping nails short, plus reassurance that eczema often improves over time in children and while flare-ups can be unpleasant, most of the time they will be episodic and controllable with appropriate treatment.
In terms of management, NICE recommends a stepped approach that tailors treatment to symptom severity.6 The mainstay of this is emollients, which should be applied generously to the whole body, both when the eczema is clear and when other treatments are required. Some individuals find that one product suits all their needs in terms of washing and moisturising, whereas others prefer to use a combination or different items according to how their skin feels at the time. It may be necessary to trial several emollients before settling on one or more that the patient is prepared to use.
As a general rule, ointments work best on very dry skin, but creams and lotions give a less greasy feel.
Ointments also have a place in washing, as they can be dissolved in warm water to make a soap substitute instead of using a bath additive or shower cream.
If a product does not come in a pump dispenser, the patient should be advised to use a clean spatula or spoon to scoop it out of the tub in order to minimise contamination. Products should be smoothed onto the skin – rather than rubbed in – in the direction of hair growth.
Topical steroids should be used for flare-ups. A product of the lowest potency should be thinly applied (see box) once or twice daily until the symptoms have been controlled and for a further 48 hours. If the usual treatment has not controlled the flare-up within seven to 14 days, infection should be excluded or a referral made for specialist advice. Pharmacists and their teams should ensure that dispensing labels for topical steroids are fixed to containers rather than to outer packaging.
Other drugs that may be used include:
•Antimicrobials if an infection is present.
•Antihistamines, which can be helpful in relieving severe itching, with sedating agents sometimes employed if disturbed sleep is a significant issue.
•Localised dry bandages, which may be used with emollients or medicated bandages if there are areas of thickened skin.
•Whole body occlusive dressings, which are usually reserved for use with topical steroids for severe flare-ups, but may be continued with emollients alone until the eczema is controlled.
•Potassium permanganate solution, which is sometimes used in exudating eczema.
•Topical calcineurin inhibitors, eg pimecrolimus and tacrolimus, which are licensed for use in atopic eczema, but are not first line.
•Systemic steroids, which are sometimes prescribed as a short course for eczema flare-ups that have not responded to topical treatment.
•Phototherapy, ciclosporin, azathioprine or mycophenolate. which may be pressed into service for severe refractory eczema.
What else might it be?
The most common conditions with a similar presentation are:
•Psoriasis, though the skin will be less itchy, and there will usually be symmetrical, reddish flat plaques with silvery scales.
•Allergic contact dermatitis, with the patient normally reporting that the symptoms arose as a result of exposure to a topical allergen.
•Seborrhoeic dermatitis, which is usually confined to areas with sebaceous glands, eg the beard area, and features red, marginated lesions with greasy scales.
•Fungal infection, which generally presents with patches or plaques that have a slightly raised border and a central clear area.
•Scabies and other infestations, with suspicions raised if more than one member of a household has an itchy rash of recent onset.
According to the British National Formulary, the potency of a topical steroid results from the formulation as well as the steroid. However, as a general rule:
•Mild-potency products usually contain hydrocortisone 0.1-2.5%. They are suitable for mild atopic eczema and most flare-ups on the face, genitals and axillae.
•Moderate-potency products include those with betamethasone valerate 0.025%, clobetasone butyrate 0.05%, fluocinolone acetonide 0.001% and aclometasone dipropionate 0.05%, and are usually used for moderate atopic eczema plus short-term management (three to five days) or severe flare-ups on the face or neck.
•Potent steroids number betamethasone dipropionate 0.05%, betamethasone valerate 0.1%, hydrocortisone butyrate 0.1%, mometasone furoate 0.1%, fluticasone propionate 0.1% and fluocinolone acetonide 0.025%, and are used for severe atopic eczema and short-term management (seven to 14 days) of flare-ups on vulnerable sites such as the groin.
•Very potent steroids are clobetasol propionate 0.05% and diflucortolone valerate, and are usually prescribed by specialists.
Good resources for patients:
•NHS Choices nhs.uk/Conditions/Eczema-(atopic)
•The British Skin Foundation britishskinfoundation.org.uk/SkinInformation/AtoZofSkindisease/Eczema.aspx
•NICE’s Clinical Knowledge Summaries cks.nice.org.uk/eczema-atopic#!prescribinginfosub:8
•The NICE pathway on eczema pathways. nice.org.uk/pathways/eczema
1 Acta Derm Venereol 1993 Feb; 73:62-3, abstract at https://www.ncbi.nlm.nih.gov/pubmed/8095756
2 J Allergy Clin Immunol 2006 Sep;118:724, full text at http://onlinelibrary.wiley.com/doi/10.1111/j.1398-9995.2006.01153.x/full
3 NICE Food Allergy Clinical Guidance CG116, published February 2011. Available at https://www.nice.org.uk/guidance/CG116
4 National Eczema Society at http://eczema.org/what-is-eczema
5 NICE clinical knowledge summaries on complications of atopic eczema at https://cks.nice.org.uk/eczema-atopic#!backgroundsub:3
6 NICE Atopic Eczema Clinical Guidance 57, published December 2007 and checked July 2016 at https://www.nice.org.uk/guidance/CG57/chapter/1-Guidance
7 NICE clinical knowledge summaries on assessing infected eczema at https://cks.nice.org.uk/eczema-atopic#!diagnosissub:4
8 Primary Care Dermatology Society information on eczema herpeticum, created May 2012, updated November 2014, at http://www.pcds.org.uk/clinical-guidance/eczema-eczema-herpeticum
9 Allergy Asthma Proc. 2010;31:392-7, abstract at https://www.ncbi.nlm.nih.gov/pubmed/20929606
10 J Fam Health Care 2008;18:63-5, abstract at https://www.ncbi.nlm.nih.gov/pubmed/18512638
11 Dermatology Online Journal 9 (2),1. Full text at http://escholarship.org/uc/item/5pw7d8bj