ATOPIC ECZEMA AND ALLERGY Dr. Archna Mathur GP with special interest in Paediatric Allergy
ORIGIN Mid 18 th 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 House Dust Mite Egg Pollens Nuts – peanut & treenuts Moulds and other aeroallergens Wheat Sesame Animal Dander Soya Cat Dog Fish Horse Shellfish Rabbit, etc. Novel foods (kiwi, pulses, chicken)
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 of 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 opical 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 o 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 MILD Hydrocortisone 0.1-2.5% steroid Daktacort Fucidin H (with antimicrobials) Synalar 1 in 10 dilution Ideally should be applied 30 mins after the emollient to aid MODERATE Betnovate RD, absorption (od / bd) Eumovate Synalar 1 in 4 dilution Trimovate (with antimicrobial) Maintenance therapy (twice weekly) - reduces relapse rates POTENT Betnovate Elocon Ointments work better than Fucibet creams as the grease forms a VERY POTENT barrier preventing evaporation of Dermovate Clobetasol with neomycin water and delivering the st eroid more effectively
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 The weals are measured with a ruler to give us a ‘mm’ reading (clinic letters) RAST / Sp IgE blood tests – when? Poor skin integrity / Eczema Eczema can Increase incidence of inaccurate results (false positives and negatives)
RESULTS & MANAGEMENT PLANS Positive Results for FOOD ALLERGENS Allergy likely Avoidance of allergen Antihistamines, Adrenaline pens (Epipen & Jext) Positive Results for AEROALLERGENS AND ANIMAL DANDER Avoidance where possible 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 opical 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
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