Atopic Eczema/Dermatitis

Impetigo (bacterial infection)

Flare up (adult)

Pharmacological Treatments

Flucoxacillin

Hydrocortisone

Pharmacological Treatments

Topical corticosteroids

Pimecrolimus

Methotrexate

Prednisone

Tacrolimus

Ciclosporin

Non-Pharmacological Treatments

Clinical Features

Non-Pharmacological Treatments

Who gets it?

Causes

Non-Pharmacological Treatments

Emollients

Phototherapy

Narrowband UVB phototherapy can be used to treat severe atopic dermatitis

Coal tar

Distillate from coal used in a variety of topical preparations including shampoos, lotions, and creams, sometimes mixed with a topical steroid to treat scaly atopic dermatitis

Genetic and environmental factors

Acute dermatitis is red (erythematous), weeping/crusted (exudative) and may have blisters (vesicles or bullae)

Over time, dermatitis becomes chronic and the skin becomes less red but thickened (lichenified) and scaly. Cracking of the skin (fissures) can occur

Inflammation in atopic dermatitis is associated with immune-mediated and inherited abnormalities in the skin barrier. This barrier failure causes increased permeability of the skin and reduces its antimicrobial function; main inherited abnormality causing disordered barrier function is mutated filaggrin expression.

Often an imbalance, with far more Th-2 cells and their associated chemical messengers (cytokines). In some children, there are also high levels of IgE antibodies and eosinophils (the white blood cells associated with allergy) - Th2 associated cytokines contribute to the loss of skin barrier function

Typically affects people with an ‘atopic tendency’ clustering with hay fever, asthma, and food allergies

Some races are more susceptible to developing atopic dermatitis

Usually starts in infancy, 80% of children affected develop it before the age of 6 years. All ages can be affected. Although it can settle in late childhood and adolescence, little prevalence in young adults up to 26 yrs old

Topical moisturising agents used to alleviate itchiness and hydrate (dry) skin and other discomforts associated with eczema; fill cracks in dry skin and forming an occlusive barrier, promoting moisture retention, and maintenance of normal skin integrity and appearance to keep skin hydrated, flexible, and protected from irritants. Their use has been associated with reduced frequency of flares and reduced use of topical corticosteroids.

Education points: apply 2 or more times per day when required; may be used all over body, including face; if contains paraffin = clothing, bedding or dressings covered in paraffin-based emollients are at risk of catching fire; don't smoke, use naked flames (or be near people who are smoking or using naked flames)

Mild

Moderate

Potent

Very potent

Hydrocortisone

Triamcinolone acetonide

Clobetasone butyrate

Betamethasone valerate

Betamethasone dipropionate (Diprosone® cream/ointment; Daivobet® ointment/gel)

Diflucortolone valerate

Hydrocortisone butyrate

Mometasone furoate

Methylprednisolone aceponate

Clobetasol propionate

Betamethasone dipropionate (Diprosone OV® cream/ointment)

Prescription; 250mg, 500mg capsules; 125mg/5mL, 250mg/5mL powder for oral liquid

Dose: Adult 500 mg every 6 hours for 5 days; Children 1 month-18 yrs 12.5–25 mg/kg (usually up to 500 mg; max. 1g) 4x daily

Belongs to a group of antibiotics called penicillins. Penicillins are antibacterials that attach to penicillin binding proteins to interrupt cell wall biosynthesis, leading to bacterial cell lysis and death

Adverse effects: Nausea, vomiting, diarrhoea

Monitoring: during prolonged treatment regular monitoring of hepatic and renal functions is recommended; with high-dose treatment >5 days, monitor full blood count and electrolyte balance (risk of hypokalaemia and sometimes hypernatremia with high doses)

Education points: Best taken on an empty stomach, 1h before eating food as body may absorb less flucloxacillin after a meal, making it less effective; capsules: swallow whole with a glass of water

Good hygiene measures (e.g. cut nails and keep hands clean)

Cleansing wound (using moist soaks to remove crusts gently)

Daily moisturising

Washing new clothes before use to remove formaldehyde and other chemicals

Use mild liquid detergents (rather than powders) and a second rinse cycle to remove residual detergent

Showering after swimming in chlorinated pools and apply emollients

Dressing children in loose cotton clothing, avoiding wool and synthetics next to the skin if possible

Always choose fragrance-free hypoallergenic products for “sensitive skin”

Avoid topical products containing alcohol or other astringents

Test new sunscreen or new skin product on a small patch of skin, before application over all skin (covering up is the best protection while out in the sun)

Who gets it?

Clinical Features

Most commonly affects children 2-6 yrs, but adults with low immunity to bacteria can also get it

Pre-disposing Factors

Atopic eczema

Scabies

Skin trauma: chickenpox, insect bite, abrasion, laceration, thermal burn, dermatitis, surgical wound

Primary mainly affects exposed areas, e.g. face, hands, may also affect trunk, perineum and other body sites. Presents with single or multiple, irregular crops of irritable superficial plaques. These extend as they heal, forming annular or arcuate lesions. Although many children are otherwise well, lymphadenopathy, mild fever and malaise may occur.

Characterised by pustules and honey-coloured crusted erosions ('school sores'). 2 types: Bullous and Non-Bullous

Causes

Most often by Staphylococcus aureus. Non-bullous impetigo can also be caused by group A beta-haemolytic streptococcus (Streptococcus pyogenes).

Topical antibiotics

Rarely used due to the increased risk of bacterial resistance and the potential for contact dermatitis.

May be considered as a second-line option for treating a small, localised area of impetigo (e.g. less than 3 lesions), e.g. if topical antiseptic is unsuitable (e.g. impetigo around the eyes) or been ineffective (first-line management with hygiene measures and topical antiseptics has not resolved the lesions within an appropriate timeframe, e.g. 5-7 days).

Pharmacy only, Pharmacist only, Prescription; 0.5%, 1% Cream

Dose: Apply to the affected area 1–2 times daily; prolonged or frequent use (more than 2 weeks or more than once or twice daily) should be monitored by prescriber

Mild inflammatory skin disorders

Dose: apply to the affected area 1–2x daily for up to 4 weeks; max. 50g of 0.05% preparation per week; prolonged or frequent use (more than 2 weeks or more than once or twice daily) should be monitored by prescriber

Short-term treatment only of severe resistant inflammatory skin disorders such as recalcitrant eczemas unresponsive to less potent corticosteroid

Prescription except hydrocortisone

0.05% Application, Cream, Ointment

Adverse effects: skin thinning; Stretch marks (striae) in armpits or groin; easy bruising (senile/solar purpura) and tearing of the skin; enlarged blood vessels (telangiectasia); localised increased hair thickness and length (hypertrichosis)

Decrease inflammation by reducing production of inflammatory proteins (e.g. cytokines), increasing synthesis of anti-inflammatory proteins (e.g. lipocortin-1), and inhibiting the response of inflammatory cells. They produce local vasoconstriction and are immunosuppressive

Education points: prolonged or frequent use (>2 weeks or more than once or twice daily) should be monitored by your doctor; if an emollient and a steroid cream or ointment are prescribed at the same time, apply the emollient 15–30 minutes before the steroid; wash hands, then apply to the affected area as directed and rub in gently and wash hands again after applying the cream or ointment, unless your hands are the affected area; apply using FTU (0.5g)

Dose: apply to the affected area 3–4 times daily; prolonged or frequent use (more than 2 weeks or more than once or twice daily) should be monitored by prescriber

0.02% Cream, Ointment

Wet wraps

Wet bandages wrapped over emollients and/or topical steroid creams to areas of red, hot, weeping eczema (most often due to atopic dermatitis)

Cooling effect (as water gradually evaporates from bandages = cools the skin and helps relieve inflammation, itching and soreness)

Moisturising effect (emollients covered over with wet bandages are deeply absorbed into the skin to provide a longer lasting moisturising effect) and enhance steroid absorption (into both the superficial and deeper layers of skin where inflammation is present)

Bandages provide protection from the itching and scratching cycle so that skin gets a chance to heal properly

Severe inflammatory skin disorders such as eczemas unresponsive to less potent corticosteroids

Dose: apply to the affected area 1–2 times daily; prolonged or frequent use (more than 2 weeks or more than once or twice daily) should be monitored by prescriber

0.1% Application, Cream, Ointment, Lotion

Dose: initially apply to the affected area 2–3 times a day, reducing to once daily as condition responds; prolonged or frequent use (more than 2 weeks or more than once or twice daily) should be monitored by prescriber

0.1% Cream, Ointment, Lotion

Dose: apply to the affected area 1–2 times daily; prolonged or frequent use (more than 2 weeks or more than once or twice daily) should be monitored by prescriber

0.05% Cream, Ointment

0.05% Modified Cream, Modified Ointment

0.1% Cream, Ointment

Dose: apply to the affected area once daily; prolonged or frequent use (more than 2 weeks or more than once or twice daily) should be monitored by prescriber

0.1% Cream, Ointment, Lotion

Dose: apply to the affected area once daily for up to 12 weeks; prolonged or frequent use (more than 2 weeks or more than once or twice daily) should be monitored by prescriber

0.1% Cream, Ointment

Short-term treatment only of severe resistant inflammatory skin disorders such as recalcitrant eczemas unresponsive to less potent corticosteroids

Dose: apply to the affected area 1–2 times daily for up to 4 weeks; maximum 50 g of 0.05% preparation per week; prolonged or frequent use (more than 2 weeks or more than once or twice daily) should be monitored by prescriber

0.05% Application, Cream, Ointment

Severe atopic dermatitis

Dose: initially 2.5 mg/kg daily in 2 divided doses, if good initial response not achieved within 2 weeks, increase rapidly to maximum 5 mg/kg daily; initial dose of 5 mg/kg daily in 2 divided doses if very severe

Prescription; 25mg, 50mg, 100mg Capsules; 100mg/mL Oral liquid

Immunosuppressant - selectively blocks/inhibits calcineurin which reduces T-cell activation and the activity of the immune system

Education points: Oral liquid - mix with orange juice, apple juice, or other soft drink (to improve taste) immediately before taking (and rinse with more to ensure total dose). Do not mix with grapefruit juice; Capsules - swallow whole with a glass of water

Monitoring: dermatological and physical examination, including blood pressure and renal function measurements required at least twice before starting; during treatment, monitor serum creatinine every 2 weeks for first 3 months then every month, reduce dose by 25–50% if serum creatinine increases more than 30% above baseline (even if within normal range) and discontinue if reduction not successful within 1 month.

Drug interactions: simvastatin and atorvastatin; NSAIDs; antibiotics; anticonvulsants; antifungals; anticoagulants; St John's wort

Adverse effects: stomach or intestinal upset; headache and muscle aches; nephrotoxicity; hepatotoxicity; new or worsening hypertension; increased risk of infection; paraesthesia (tingling), commonly affecting the hands, feet, or lips

Prescription; 1% Cream

Dose: apply thinly twice daily until symptoms resolve (stop treatment if eczema worsens or no response after 6 weeks)

Short-term or intermittent treatment of atopic eczema when other therapy ineffective or inappropriate

Calcineurin inhibitor - topical steroid-free medication with immune-modulating and anti-inflammatory properties

Adverse effects: burning sensation, pruritus, erythema, skin infections

Education points: don't drink alcohol; avoid excessive exposure to sunlight and sunlamps; don't use occlusive dressings; wash hand after application

Monitoring: stop using pimecrolimus cream once signs or symptoms resolve, use an emollient as maintenance therapy – this can be applied immediately after using pimecrolimus cream

Short-term treatment of moderate to severe atopic dermatitis (including flares) in patients unresponsive to, or intolerant of conventional therapy (initiated by a specialist)

Dose: apply thinly twice daily until symptoms resolve, reduce to once daily use if condition allows (If no signs of improvement are seen after two weeks of treatment, consider other treatment options)

Prescription; 0.1% Ointment

Calcineurin inhibitor - topical steroid-free medication which decreases T-cell activation and inflammatory cytokine release, resulting in anti-inflammatory and immunosuppressant effects

Adverse effects: application site reactions; paraesthesia’s and dysesthesia’s; local skin infection; alcohol intolerance

Monitoring: initial treatment will be for a short period to assess the response, if effective, may be continued long-term (6-12 months) if required; once inflamed skin has returned to normal, the ointment may be discontinued, to prevent frequent recurrences, it may be helpful to apply it to previously affected areas two or three times weekly.

Education points: avoid excessive exposure to UV light; don't apply to mucous membranes; don't use occlusive dressings; emollients should not be applied to the same area within 2 hours of applying tacrolimus ointment.

Autoimmune or inflammatory diseases

Dose: 5–60 mg once daily or in divided doses; taper dose according to response; usual maintenance 5–20 mg daily; in 2–4 weeks, the dose is reduced

Prescription; 1mg, 2.5mg, 5mg, 20mg tablets

Systemic corticosteroid - suppress inflammation by regulating gene expression to reduce expression of pro-inflammatory genes and increase expression of anti-inflammatory genes, and by decreasing synthesis of pro-inflammatory proteins (e.g. cytokines)

Education points: best taken as a single dose in the morning, which is thought to reduce steroid-induced suppression of the pituitary-adrenal axis compared to evening dosing; take with or just after food, or a meal; if take in large doses or for a long time, it is dangerous to stop taking it suddenly. Your doctor may reduce the dose gradually when it is time to stop.

Adverse effects: sleep disturbance; increased appetite; weight gain; Increase in postprandial blood sugar; increase in postprandial blood sugar; psychological effects, including increased or decreased energy

Monitoring: Esp. with high doses, can alter mood and behaviour early in treatment = contact doctor if worrying psychological changes occur

If flucoxacillin is not well tolerated (i.e. taste, esp. in children), try cefalexin

Prescription; 2.5mg, 10mg Tablets

A folic acid antagonist, inhibits DNA and RNA synthesis in rapidly diving cells. Also has immunosuppressant properties.

Used in low doses to treat inflammatory skin conditions, including eczema/dermatitis, esp. if troublesome or extensive

Dose: Methotrexate - Low dose (<25mg) once a week; Folic acid - 5mg once a week taken on a different day to methotrexate

Adverse effects: due to the inhibition of folate metabolism, including nausea, stomatitis and bone marrow suppression - these symptoms can be reduced with oral folic acid tablets without affecting efficacy of methotrexate; methotrexate toxicity - bone marrow suppression, hepatoxicity, pulmonary toxicity

MM = Methotrexate on Monday; FF = Folic acid on Friday

Monitoring: A full blood count, renal and liver function tests and in some cases, chest x-ray and respiratory function, need to be checked before treatment is started. Laboratory monitoring needs to be repeated at regular intervals until the patient is stabilisedand then on an ongoing basis so that the patient can be
clinically evaluated, and to identify methotrexate toxicity

Contraindications: active infection, alcoholism, peptic ulcer disease, poor nutritional status, ecent exposure to chickenpox or herpes zoster infection, pregnancy and breastfeeding

Education points: don't take any NSAIDs or trimethoprim; limit alcohol intake to 1–2 standard drinks once or twice a week; limit the amount of time you spend in the sun - don't use sunbeds; swallow tablets whole, with food and a glass of water; may not notice effects of methotrexate straight away - it can take several weeks before you start to feel better