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Eczema - Coggle Diagram
Eczema
Identify Triggers
Inhalant allergens - symptoms around pets and pollen. Sensitivity to airborne allergens may result in presentations with flares on the head and neck.
Hormonal triggers - premenstrual and pregnancy.
Contact allergens - preservatives in topical medications, perfume-based products, metals and latex.
Climate - extremes of temperatures
Skin infections
Concurrent illness/disruption to family life - teething, emotional stress, ill health, lack of sleep.
Ask about irritant clothing: some fabrics can be irritants such as synthetic fabrics and wool, silk can be irritant due to airflow restrictions. Cotton is usually recommended.
Dietary factors - itch/redness following certain foods, diarrhoea/vomiting and/or poor weight gain.
Ask about irritant allergen: changes in soap and detergents.
Most people do not need allergy testing.
The identification of trigger factors is crucial for the management of atopic eczema as avoidance may allow for longer periods of symptom remission.
Manage food allergy in primary care, if other allergy suspected refer to secondary care as appropriate.
Many different factors have been proposed as triggers for atopic eczema
Management: Treatment
Bandaging and oral corticosteroids are unsuitable for maintenance treatment.
Treatment options include mild, moderate and potent topical corticosteroids, topical calcineurin inhibitors, bandages, phototherapy and oral corticosteroids/antihistamines. Certain stepped up treatments require specialist advise/referral/secondary care input to commence.
Treatment should follow the Stepped approach recommended by NICE. Treatment will step up or down depending on severity. Flares will often require temporarily 'upping' the intensity of treatment.
Ensure information is given on the correct use and amount required of topical treatments.
Give appropriate information and advise.
Topical calcineurin inhibitors, phototherapy, and ciclosporin are less suitable for the acute treatment of flares.
Prescribe generous amounts of emollients, and advise frequent/liberal use in all severity of eczema.
Follow up/referral should be dependent of severity/treatment/their health and age.
Give advise on maintaining the skin and reducing the risk of flares.
Admit to hospital if eczema herpeticum is suspected
Diagnosis: Examination
Adults: generalized dryness and itching. On hands may be the main manifestation
Child (with long standing disease): often localized to the flexure of the limbs.
Rash distribution and appearance will be influenced by the age, ethnicity, duration of rash and presence/absence on infection.
Infants: Primarily involves the face, scalp and extensor surfaces of the limbs (nappy area is usually spared)
Acute eczema (flares): varies in appearance can have demarcated redness to fluid in the skin (vesicles), scaling or crusting of the skin.
Chronic eczema: characterized by thickened (lichenified) skin resulting from repeated scratching. Follicular hyperkeratotic papules (keratosis pilaris) typically asymptomatic may be present on the extensor surfaces of the upper arms, buttocks and anterior thighs.
If weeping, crusting or there are pustules with fever or malaise, secondary bacterial infection should be considered.
NICE criteria for atopic ezcema to be likely (exclude differentials): itchy skin condition plus 3: visible flexural eczema involving skin creases, (cheeks and/or extensor areas in children), personal history of flexural eczema, personal history of dry skin in the last 12 months, personal history of asthma/allergic rhinitis, onset of signs/symptoms before the age of 2 years.
Management: Severity
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).
Infected - if eczema is weeping, crusted, or there are pustules, with fever or malaise.
Moderate - if there are areas of dry skin, frequent itching, and redness (with or without excoriation and localized skin thickening).
Consider use of validated tools to assess severity such as visual analogue scale and Patient-Orientated Eczema Measure.
Mild - if there are areas of dry skin, and infrequent itching (with or without small areas of redness).
Clear - if there is normal skin and no evidence of active eczema
Assess severity at each consultation to determine most appropriate treatment.
Stepped approach to management is recommended.
Management: Psychological
None — no impact on quality of life.
Mild — little impact on everyday activities, sleep, and psychosocial well-being.
To assess ask about the impact on daily activities (school, work and social life), sleep and mood. Categorize the impact.
Severe — severe limitation of everyday activities and psychosocial functioning, and loss of sleep every night.
There is not necessarily a direct correlation between the severity of the eczema and impact of quality of life.
Moderate — moderate impact on everyday activities and psychosocial well-being, and frequently disturbed sleep.
Assess the psychological impact of atopic eczema at each consultation
Consider use of validated tool to assess impact such as Infants Dermatitis Quality of Life Index, Children's Dermatology Life Quality Index and Dermatitis Family Impact. There may also be impact on well-being and quality of life of parents/carers.
Differential Diagnosis
Food allergy
Scabies of other infestation
Fungal infection
Seborrhoeic dermatitis
Allergic contact dermatitis
Psoriasis
Diagnosis: History taking
Family or personal history of atopy
Any treatments and response to treatment
Pattern, time of onset and history of rash
Possible trigger factors (irritant or allergic)
The presence of itching - eczema unlikely if no itch present.
Diagnosis: Investigations
Not required to establish diagnosis
May be useful to exclude differential diagnosis
Atopic eczema (also known as atopic dermatitis) is a chronic inflammatory skin condition that affects people of all ages, although it most frequently presents in early childhood (mostly before 5 years of age). Characteristics include: dry, pruritic skin. Typically a disease of exacerbations, although for some it may be continuous.