ATOPIC ECZEMA AND ALLERGY Dr. Archna Mathur GP with special - - PowerPoint PPT Presentation

ATOPIC ECZEMA AND ALLERGY

• Dr. Archna Mathur

GP with special interest in Paediatric Allergy

ORIGIN

Mid 18th century The word eczema comes from the Greek word

ekzein meaning "to boil out, break out”

The Greek word ek means "out," while the Greek

word zein means "boiling.”

WHAT IS ECZEMA?

Eczema is "a general term for any superficial

inflammatory process involving the epidermis

Primarily marked early by redness, itching, minute

papules and vesicles, weeping, oozing and crusting.

Later by scaling, lichenification and often

pigmentation.

TYPES OF ECZEMA

Atopic Dermatitis Contact Dermatitis Seborrhoeic Dermatitis Dyshidrotic Eczema Nummular Eczema (discoid eczema) Neurodermatitis (lichen simplex chronicus) Stasis Dermatitis

ATOPIC ECZEMA

1 in 5 children and 1 in 12 adults an inflammation of the skin; flare-ups from time to time It can start in early childhood, and severity can range from mild

to severe

There is no cure Treatment can usually control or ease symptoms. Emollients (moisturisers) and steroid creams or ointments are

the common treatments

About 2 in 3 children with atopic eczema grow out of it by

their mid teens.

ECZEMA TRIGGERS

ALLERGENS

 Cow’s Milk Protein  Egg  Nuts – peanut & treenuts  Wheat  Sesame  Soya  Fish  Shellfish  Novel foods (kiwi, pulses, chicken)  House Dust Mite  Pollens  Moulds and other aeroallergens  Animal Dander

 Cat  Dog  Horse  Rabbit, etc.

WHEN MAY ALLERGY BE A CONCERN

 ‘Difficult to treat’ eczema, despite optimal management and

treatment

 Issues with development, difficult feeding  FTT or unexplained weight loss  Family concerns and anxieties  Impact on family: tiredness, lack of sleep, relationship problems

and upheavel

THE ALLERGIC CASCADE

Mast cells (connective tissue) Basophils ( a type of white blood cell)

• both contain histamine; potentially devastating substance

7-10 days of sensitizing exposure for the mast cells and basophils to become primed with IgE antibodies. The IgE antibodies bound to the surfaces of basophils and mast cells recognize the protein surface markers of the allergen. The IgE antibodies react by binding to the protein surface markers while remaining attached to the mast cells or basophils. This binding alerts a group of special proteins called the complement complex that circulates in the blood.

SIGNS AND SYMPTOMS

When mast cells and basophils are destroyed, their stores

• f histamine and other allergy mediators are released into

the surrounding tissues and blood.

• Dilation of surface blood vessels and a subsequent drop in blood pressure.
• The spaces between surrounding cells fill with fluid. (Angioedema)

Depending on the allergen or the part of the body involved,

this brings on the various allergy symptoms

• COMMON: Itching (body, eyes, nose), Hive, Sneezing, Wheezing, Nausea,

Vomiting, diarrhoea

• ANAPHYLAXIS : respiratory distress and arrest, hypotension and shock

MANAGEMENT OF ECZEMA

 Emollients  Steroid therapy  T

• pical Calcineurin Inhibitors

 Antibiotics  Other therapies  Optimise Eczema Treatment

Atopic eczema has been the subject of a SIGN guideline in 2011 based on a new systematic review of the evidence and a recent editorial in the BJGP (BJGP2011;61;246).

• ‘Good eczema care may prevent development of other atopic

conditions ‘

• ‘Hypotheses that the change in the skin barrier in early life are

central to the development atopy. The lack of an adequate skin barrier allows exposure to allergens through the skin, leading to the sensitisation of T cells which subsequently migrate to airways and nose.’

EMOLLIENT THERAPY

 Education: importance of using them; frequency of application  Emollients should form the basis of all atopic eczema management  Should always be used, even when the skin is clear of eczema  Applied liberally, at least 2-4 times daily  Using 200-500g a week! esp. particularly during and after bathing  T

• optimize adherence creams, ointments, lotions or combinations may be

used

 Emollients can become contaminated with bacteria; Use of pump

dispensers minimises risk

 Some emollients may irritate the skin, particularly aqueous cream (BJGP

2011;61:246) which can be used as a soap substitute but not as a ‘leave on’ emollient.

STEROID THERAPY

• Continuing to use the emollients

increases the efficacy of the steroid

• Ideally should be applied 30 mins

after the emollient to aid absorption (od / bd)

• Maintenance therapy (twice

weekly) - reduces relapse rates

• Ointments work better than

creams as the grease forms a barrier preventing evaporation of water and delivering the steroid

more effectively

MILD Hydrocortisone 0.1-2.5% Daktacort Fucidin H (with antimicrobials) Synalar 1 in 10 dilution MODERATE Betnovate RD, Eumovate Synalar 1 in 4 dilution Trimovate (with antimicrobial) POTENT Betnovate Elocon Fucibet VERY POTENT Dermovate Clobetasol with neomycin

TOPICAL CALCINEURIN INHIBITORS

Tacrolimus (ointment) / Pimecrolimus (cream)

Evidence support for short-term, intermittent treatment in

moderate to severe atopic eczema that has not been controlled by steroids or where there is a high risk of skin atrophy (they do Not thin the skin)

The most common adverse effects are skin burning and

irritation

Sunlight sensitive Increased risk of skin malignancy and they should not be

used where infection is suspected.

should only be used by doctors wSI and experience

(including GPs)

ANTIBIOTICS

 Little evidence for the use of topical abx or steroid-antiobiotic mixtures  Can cause allergic contact dermatitis  Umbilicated pustules ; eczema herpeticum (emergency referral)  Evidence recommends the use of short term oral abx for clinically

infected eczema

 Flucloxaciilin  Erythromycin

OTHER THERAPIES

 SEDATING ANTIHISTAMINES

• Chlorphenamine / Ucerax
• Consider short-term sedating antihistamines where sleep is disturbed

 DRESSINGS

• The evidence supports using a dry, occlusive dressing in non-infected

moderate and severe eczema to retain the emollient and provide a barrier to scratching

MANAGEMENT OF ALLERGIES

 History

 Clear cut IgE reaction to certain foods  Non-specific reactions; pruritis, flare ups  Other atopies (eczema, asthma, hayfever)  Family history

 Examination

 Skin  Auxology  Systemic examination  General well-being of patient

TESTING

 Skin Prick T

esting

 RAST / Sp IgE blood tests – when?

 Poor skin integrity / Eczema  Eczema can Increase incidence of inaccurate results (false positives and negatives)

The weals are measured with a ruler to give us a ‘mm’ reading (clinic letters)

RESULTS & MANAGEMENT PLANS

Positive Results for FOOD ALLERGENS

 Allergy likely  Avoidance of allergen  Antihistamines, Adrenaline pens (Epipen & Jext)

 Positive Results for AEROALLERGENS AND ANIMAL

 Avoidance where possible

DANDER

 Use of antihistamines



Pre-exposure (animal dander)



Daily (HDM; pollens)

 Optimise eczema treatment

NEGATIVE RESULTS

 What should we do??

 Driving Force of allergens

• 4-6/52 allergen-free period
• hypoallergenic milk formulas (NICE)

 Separate times for each allergen  Dietician  Community Nurses and Family Support

 Regular follow –up and continued multidisciplinary approach for all.

IMPROVING OUTCOME

 Must take into account individuals needs and preferences  Good communication between healthcare professionals, patients and their

parents or carers is essential. Support for all family.

 Education  Realistic expectations about outcome  Recognition and management of flares (increased dryness, itching, redness,

swelling and general irritability)

 Can step up and down according to the severity of symptoms.  Supported by evidence-based written information in different languages

TAKE HOME MESSAGE

 Optimising treatment of eczema in infancy may prevent the development of

atopy

 Emollients should be used frequently, upto 200-500g per week  Use pump dispensers (to prevent bacterial contamination)  Aqueous cream can irritate skin (and may even thin skin) and should not be

used as a stay-on emollient

 T

• pical steroids should be used once or twice daily on well-moisturised skin

 T

wice weekly maintenance therapy

 If infected, use short-term oral antibiotic courses  In Infants with moderate and severe eczema, think about allergies  Excellent leaflets on www.patient.co.uk and www.eczema.org  www.itchysneezywheezy.co.uk website