A parent’s guide to the management and care of
Atopic Eczema
Atopic Dermatitis (Eczema).
Atopic dermatitis (AD) is among the commonest types of eczema. It is a
condition that is often linked to a family (genetic) tendency to eczema,
asthma or hayfever (atopy). It usually presents in the first year of life and
rarely after the age of 5 years. Patients with AD are at increased risk of
developing asthma, hayfever and/or an allergy.
AD is common affecting 20% of children. For the majority the condition is
mild (85%). 50% of children with AD grow out of the tendency by 5 years of
age, and >60% by 10 years.
In patients with AD the skin is dry (like a brick wall where the mortar has
dried out and weakened) . This in turn allows irritants, allergens and
infections to penetrate the skin surface and trigger the body’s immune
system. In AD the body’s immune system over reacts, forming lots of a
blood protein called Immunoglobulin type E (IgE). This results in
inflammation (redness and weeping) and itching. Chronic scratching and
rubbing leads to thickening of the skin with exaggerated skin creases, and
raw/broken areas.
Ref: Illustrations from Adams Healthcare Ltd.
Location of Eczema:
AD can occur anywhere however in babies it often involves the face, in
children most commonly the creases (elbows, wrists, backs of knees, and
ankles) and in adults, the face, creases, and hands.
Triggers:
There are 4 factors which can trigger a flare of AD:1 - Stress
2 - Dry Skin
3 - Infection
4 - Irritants & Allergies
Trigger 1 - Stress
Stressful triggers include any illness, immunisation, teething and tiredness as
well as the more obvious. Even children and babies can be affected by stress
and can also have worries of their own which you may not realise e.g. new
baby in the home, new nursery etc.
Trigger 2 - Dry Skin
In eczema the skin has lost its natural ability to moisturise, leaving it dry,
and very itchy. This leads to breaks in the skin, worsened by
scratching or rubbing, and inflammation. Once the skin is broken, and with
repeated scratching secondary infection is common, and the skin tends to
become weepy, crusty and sore.
To prevent any dryness it is therefore essential that you apply moisturiser
(emollient) at least twice a day, even when the skin is clear. This enables the
skin to hydrate and close any openings caused by the shrinking of each
dehydrated skin cell. It also leaves a layer of grease over the surface of the
skin, forming a protective barrier to prevent infection. The greasier the
moisturiser the better!
Trigger 3 – Infection
Any infection on the skin can trigger eczema to worsen however 3 infections
are particularly common.
a) Impetigo-type bacteria
A bacterium called Staphylococcus Aureus can be found on many people’s
skin. However it can cause active infection, particularly in AD skin. If the
skin is dry, flaky or cracked the bacteria can multiply and trigger
inflammation in the skin making the eczema worse, producing a viscous
circle.
Signs of Staphylococcal infection:
- broken, weeping skin
- yellow crusts or / and pus-filled spots
- sore skin
- red and hot skin
Treatment & Prevention:
If the infected area is small antiseptics or antibiotics can be applied directly
on to the skin. Sometimes antibacterials will be added to other topical
treatments e.g. moisturisers or steroids. If the area of infection is larger or if
the infection is more severe, it may be treated with antibiotic syrup or tablets.
A skin swab is often taken before treatment is started.
This bacterium can sometimes live in the skin lining the nose. If this occurs
an antibiotic nasal ointment is prescribed.
Antiseptic bath or shower gels together with soap substitutes help to prevent
the risk of infection by reducing the number of living bacteria on the skin.
Antibacterial ointments can also be applied to broken/ cracked skin to help
prevent infection.
b) Herpes (cold sore) viral infection
People who suffer from eczema are susceptible to the Herpes Simplex virus,
the cause of cold sores and contact with the virus should be avoided
wherever possible. In eczema the virus may spread dramatically over a wide
area of skin and even in to the eye if the face is involved. The infection can
become quite severe and cause permanent skin or eye scarring.
Signs of infection:
Painful small blisters often around the mouth, face and neck (occasionally
fingers) spreading to other areas of the body.
Treatment:
Antiviral medicine or tablets.
c) Candida (Thrush) fungal infection
Candida is a yeast which tends to live on the skin in the moist skin folds e.g.
groins, nappy area, neck creases etc. Areas which are wet and warm are
prone to this infection e.g. around the mouth or the neck in children who are
dribbling. The infection can trigger/worsen eczema. Sometimes antibiotic
therapy can predispose to a flare.
Signs of infection:
Infection tends to make the skin very glazed red, shiny and sore and
occasionally little pussy spots are seen. Occasionally infants may also have
mouth soreness due to Candida.
Treatment:
Antifungal cream.
Trigger 4- Irritants and Allergies
Common Irritants:
Heat
Wool
clothing
Biological washing
Dust
Also: Cold dry weather
Central Heating
Low Humidity
powder & conditioners
CConditio
ners
Common Allergies:
Not all patients with AD will have an allergy, however allergies are more
common in atopic patients and can cause eczema to flare. Allergies can be
due to proteins reaching the skin via the air, by direct contact with the skin,
or in the diet.
i) Airborne allergies:
Animals – House dust mite, Cat, Dog etc
Pets
Plants – Grasses and Tree Pollen
Moulds
House Dust mite
ii) Contact allergies:
Everyday products that come in contact with the skin can sometimes trigger allergy e.g.
cheap metals in jewellery, fragrances etc. If contact allergy is suspected then patch tests can
be arranged in the hospital dermatology department.
iii) Possible dietary allergy factors:
Most Common:Dairy produce, Eggs, Nuts, Wheat,
Soya, Cod fish
Most children with AD do not have food allergy, however food allergies can
be an exacerbating factor in some children. Food allergies usually trigger an
urticarial (nettle-rash) type skin reaction to the specific food(s), often with
other symptoms such as vomiting, diarrhoea, swelling or wheezing. Food
allergy is most common in little children. If food allergy is suspected further
tests can be carried out and if confirmed avoidance under the supervision of a
paediatric dietician instituted.
EMOLLIENTS
Emollients are the most important part of preventing and treating eczema.
They should be applied to the skin on a regular daily basis to PREVENT the
skin from drying out. If the skin is still dry more emollients are required.
Quantity of Emollient to be used per week:
Amount (g)
Infant
125
Small Child
250
Large Child
500
Emollients should be applied to ALL areas of skin (not simply the dry or
eczematous areas). This will reduce the risk of drying which in turn reduces
the risk of eczema, itching and secondary infection.
Emollients come in 2 forms:
Ointments: These are greasy emollients. They penetrate dry skin more
effectively and do not contain preservatives that can lead to stinging and
redness in some patients.
Creams: These are creamy white emollients. They are less greasy/sticky and
therefore often more cosmetically acceptable and less messy to apply.
However all creams contain preservatives and these added chemicals can
cause local stinging and occasionally sensitisation in patients with more
severe eczema or in those with the most sensitive skins. If stinging occurs
then switch to an ointment emollient is best.
Some patients have in addition to their eczema a genetic tendency to very dry
skin (ichthyosis). If this is the case then increased quantities and frequency of
emollients will be needed.
For most patients emollients should be applied twice daily. For those with
mild eczema once daily may be sufficient. For those with more severe
eczema and dry skin they should be applied 3 to 4 times daily.
EMOLLIENTS/MOISTURISERS:
Plain Ointments and Creams
Greasy
Emulsifying ointment
Hydromol ointment
Epaderm ointment
50/50-(Emulsifying ointment & liquid paraffin)
Yellow/White soft paraffin
Diprobase Ointment
Creamy Paraffin
Diprobase Cream
Unguentum Merck
Oilatum Cream
Doublebase Cream
Hydromol Cream
Aveeno Cream
Dermol 500 lotion
Balneum Plus cream
E45 Cream
Aqueous Cream
Creamy
N.B. Creams contain preservatives and these can sometimes cause stinging.
If this occurs change to a greasy ointment (clear) emollient.
STEROIDS
Although moisturisers are the first-line of treatment for eczema, steroids are
necessary to treat acutely inflamed or highly itchy areas of skin. Steroids
should always be used with moisturisers and not instead of. When used
correctly and monitored by a medical or nursing professional working in
dermatology, steroids are safe to use and usually very effective.
(See Finger tip unit guide for steroids on next page)
When & where to use steroids:
Steroids should be used if the skin is red, itchy or has some form of spots or a
rash, (signs of eczema). Avoid applying steroids to healthy skin.
How to use steroids (see FTU guide):
Steroids should be applied 20-30 minutes before a moisturiser to enable the
steroid to be absorbed into the skin and to avoid the spreading of the
moisturiser moving the steroid onto healthy areas of skin. The steroid should
be measured to a ‘Finger tip unit’ and dabbed along the appropriate size area
of eczema, then smoothed together into the skin in the direction of the hair
growth.
Which steroid to use:
See the ‘Topical Treatments For Eczema’ guide (page ).
If eczema is mile use a mild steroid twice a day to avoid having to use a
stronger steroid if left untreated. Treating with mild steroids for longer
periods is safer than treating frequently with stronger steroids.
If the eczema does not improve after 3-4 days, you may need to step up to a
stronger steroid if this has been suggested and explained on a personal care
plan from your dermatologist. When the eczema has been improving for 2-4
days, you can reduce the strength of steroid. Once the eczema has cleared
you can reduce the mild steroid to once a day or alternate days for 2-3 days
after the skin has cleared to ensure the eczema is not active more deeply in
the skin. Failure to do so may result in the eczema returning once the steroid
is stopped. Ointments are preferred for eczema as they are more hydrating
for the skin and are less likely to produce local stinging and sensitization.
References:
(1) Patient Information Leaflets, Steve Gill, Paediatric Dermatology Liaison nurse, Birmingham,
1998.
(2) Dr Newton-Bishop J et al. The Yorkshire Atopic Eczema Management Guidelines. NHS Northern
& Yorkshire Region, 2004.
STEROIDS:
FOR THE FACE – AVOID using POTENT steroids the face!
MILD
Steroid
Steroid+antiseptic
Steroid+antibiotic
Steroid+ antifungal
0.5%-2.5%
Hydrocortisone
Vioform HC
Fucidin HC
Daktacort
MODERATE
Steroid
Steroid+antiseptic
Steroid+antibiotic
Steroid+ antifungal
Trimovate
Trimovate
Canesten HC
Eumovate
Haelan
FOR THE BODY / LIMBS
MILD
Steroid
Steroid+antiseptic
Steroid+antibiotic
Steroid+ antifungal
0.5%-2.5%
Hydrocortisone
Vioform HC
Fucidin HC
Daktacort
MODERATE
Steroid
Steroid+antiseptic
Steroid+antibiotic
Steroid+ antifungal
Trimovate
Trimovate
Canesten HC
Steroid+antiseptic
Synalar C
Betnovate C
Locoid C
Steroid+antibiotic
Synalar N
Fucibet
Betnovate N
Steroid+ antifungal
SUPER POTENT
Steroid
Steroid+antiseptic
Dermovate
Steroid+antibiotic
Dermovate NN
Steroid+ antifungal
Dermovate NN
Eumovate
Haelan
POTENT
Steroid
Metosyn
Betnovate
Elocon
Cutivate
Finger Tip Unit Guide For Steroids
Squeeze the steroid from the end of your finger to the first crease.
Ref:Long C. A Guide to Finger Tip Units for Children. Br J Dermatol, 1998.138 p.293
OTHER TOPICAL TREATMENTS
TOPICAL ANTIBIOTICS:
(no steroid)
Bactroban
Metronidazole/Metrotop
TOPICAL ANTIFUNGALS
(no steroid)
Canestan
Nystatin
SCALP PREPARATIONS:
Shampoos
Capasal
Polytar (tar based)
T-Gel (tar based)
Nizoral (antifungal)
Steroid Lotions
Elocon Scalp lotion
Betnovate scalp lotion
Betacap
Betamousse
Synalar Gel
Diprosalic scalp lotion
Non-steroid Scalp Preparations
Cocois
Olive oil
DRESSINGS:
BANDAGES:
Duoderm
Lyofoam
Granuflex
Aquacel
Mepitel
Allevyn
Icthopaste (Icthammol)
Zincoband (Zinc)
Zip-Zoc stocking (Zinc)
Quinaband (Steroid)
Tarband (Tar)
Treatment Plan.
Bath Additive: (Never use
bubbles!)
Soap Substitute:
Moisturiser (Emollient)
Each week use at least:
Steroid / Immunosuppressant (cream/ointment)
(See FTU Guide. Never use more than twice a day).
Ointment /cream
Part of body
Use:
Scalp:
If skin looks infected:
Antibiotics/Antihistamines:
Other Treatments:
Dr S. Clark. Jan 2000.
Treatment Plan.
Bath Additive: (Never use
bubbles!)
Soap Substitute:
Moisturiser (Emollient)
Each week use at least:
Steroid / Immunosuppressant (cream/ointment)
(See FTU Guide. Never use more than twice a day).
Ointment /cream
Part of body
Use:
Scalp:
If skin looks infected:
Antibiotics/Antihistamines:
Other Treatments:
Dr S. Clark. Jan 2000.
Treatment Plan.
Bath Additive: (Never use
bubbles!)
Soap Substitute:
Moisturiser (Emollient)
Each week use at least:
Steroid / Immunosuppressant (cream/ointment)
(See FTU Guide. Never use more than twice a day).
Ointment /cream
Part of body
Use:
Scalp:
If skin looks infected:
Antibiotics/Antihistamines:
Other Treatments:
Dr S. Clark. Jan 2000.
Treatment Plan.
Bath Additive: (Never use
bubbles!)
Soap Substitute:
Moisturiser (Emollient)
Each week use at least:
Steroid / Immunosuppressant (cream/ointment)
(See FTU Guide. Never use more than twice a day).
Ointment /cream
Part of body
Use:
Scalp:
If skin looks infected:
Antibiotics/Antihistamines:
Other Treatments:
Dr S. Clark. Jan 2000.
Quick Guide to Emollient Wraps.
NOTE:
X Do not use over POTENT steroids for more than 1 WEEK.
X Do not use on WEEPY or openly INFECTED eczema.
X Do not use on a child who has CHICKENPOX or appears ‘CHESTY’.
Use EVERY 24HRs until skin is much improved and then gradually
reduce applications to once weekly and then once/twice a month.
BANDAGE LENGTHS:
(See bandage boxes for sizes/colour).
4 x ARMS - Shoulder to fingertips + 8cm.
4 x LEGS - Thigh to tips of toes + 8cm. (Cut 2 arms & 2 legs double length and
twist back over limb, ensuring they are not too tight, if hands & feet are
to remain bandaged).
2 x TRUNK- Top of neck to base of bottom.
STAGES:
1) Cut bandages to size.
2) Cover child with soap substitute and
bathe in a warm bath with oil, for 20 mins.
3) PAT child dry and apply steroid
(see FTU guide,) or antibiotic ointment to
affected areas and allow to soak in (10 mins).
4) Spread moisturiser liberally all over
in the direction of the hairs. DO NOT
MASSAGE IN.
5) Apply the 1st layer of bandages to the
trunk and then limbs.
6) If skin is extremely dry spread second layer of moisturiser, liberally over the
bandage on one part of the body and then apply 2 nd layer of bandage.
7) Make holes in both layers of bandages and tie them together with strips of
bandage.
8) Cut holes for the big toes and thumb, making sure they are not too tight.
NOTE:- Wraps to be kept on for 12 to 24hrs (where possible or overnight if not tolerated in
the day). Bandages can be peeled back to apply more moisturiser onto the 1 st layer of
bandages to keep them moist during the 24hrs.
Ref:
Bridgman, A. Parent’s guide to wet wraps, SSL international PLC.
Handy Hints!
Clothing:
*
*
*
Try to wear cotton clothes whenever possible. Nylon and man-made
fabrics make you sweat and wool clothes make you itch.
Use non-biological washing powders without conditioners.
Occasionally use biological washing powder on a hot rinse when
empty to remove grease from your washing machine.
Environment:
*
Avoid heat as this increases the itching and central heating causes
drying of the skin due to the lack of humidity.
*
Use a high factor sunscreen for sensitive skin.
House Dust Mite: (HD Mite droppings can cause an allergic reaction).
*
House dust mites like warm places and thick textiles. Use lino, tiles or
wooden flooring.
*
Clean with a damp cloth rather than polishing.
*
Wash clothes and bedding, weekly at 60oC.
*
Vacuum curtains weekly or replace them with blinds.
*
Avoid fluffy toys or wash weekly at 60 oC. Alternatively place them
in a plastic bag and place in the freezer over night.
*
Keep a cover over the bed through the day, removing it carefully at
night and shake the dust off outside.
*
You can purchase special breathable covers for mattresses and
pillows to protect from HD Mite.
Scratching:
*
*
*
*
*
File finger nails and cut them regularly to keep them very short.
Cover hands with gloves or mittens over night. Use tape to help keep
them on.
Keep the bedroom cool to minimise the itch. Use cotton sheets and
blankets rather than quilts.
Gently pinch the skin rather than scratching it.
Avoid products with fragrances and use hypoallergenic products. Try
any new products first with a very small patch on your arm and wait
for 2-3 days for any reaction.
Swimming:
*Apply moisturiser before and after swimming. Use a water soluble product
such as emulsifying ointment. Remember – ‘Slippery when wet!’
Contacts
Dermatology Appointments:
Tel: ETC