By Erica Donovan (for references email firstname.lastname@example.org)
Eczema (or atopic dermatitis) is a clinically diagnosed inflammatory skin condition categorized by itch, erythema and edema. Symptoms may range from mild to severe and can occur acutely or chronically. The word eczema is defined from the Greek word for ‘to boil over’ and as someone who has been diagnosed, that feels pretty apt at times when your skin feels hot and volatile. Eczema is a common presentation that Paediatric Nurses encounter, so it’s important to know a bit about the management and possible complications.
There is often the thought that children ‘grow out’ of eczema, which in some sense is true, 60% of children go into remission by adolescence (Barker, Palmer & Zhao, 2007). It is not a contagious disease, but there may be a genetic link for some individuals.
The causes of eczema are not fully understood, but is thought that inflammatory cytokines and Langerhans Cells play a role, causing the inflammatory symptoms that manifest in the skin (Stanway, 2004). Those with eczema typically have impaired skin barrier function. There are a myriad of triggers, depending on the individual. Common triggers are stress, itching, dry and temperate environments, irritants in household products, and certain fabrics such as wool. House dust mites and animals may also be a trigger for some patients (Australasian Society of Clinical Immunology and Allergy, 2018).
For anyone out there who struggles with, or has a family member who struggles with eczema, you know that it always seems like you’re constantly looking for ‘the one’. And by ‘the one’ I mean the one treatment to rule them all.
It seems like every month there’s a treatment on the pharmacy shelves. At one point I even did a clinical trial for a skin cream made from New Zealand natural ingredients.
Those of you in general practice, public health or school nursing may be familiar with the Asthma Action plans, and there is actually a similar document for eczema available from the Australasian Society of Clinical Immunology and allergy. These outline the personalized treatment plan, ways to prevent infection and othe tips for parents.
Eczema treatment is generally provided in primary care; however poor healing, treatment failure or severe cases may be referred through to dermatology through the public or private system.
Emollients for eczema:
Emollients are preparations that moisturize and soften the skin. The texture may vary from lotions to heavy ointments (Dermnet, 2008). As for the most efficacious preparation? Bpacnz (2009, p. 28) says that it would be the one most preferred by the patient, as they are more likely to apply it regularly! A Cochrane Review also found no overwhelming evidence for the benefit of one preparation over others, but there was evidence that using a steroid in combination with emollients was more effective than steroid alone (van Zuuren, Fedorowicz, Christensen, Lavrijsen & Arents, 2017).
Topical steroids and eczema:
These creams act to decrease and inhibit the inflammatory proteins responsible for skin symptoms, while increasing the production of anti-inflammatory. production However, their very benefits can also cause their harms, as inhibition of T- lymphocytes can cause immunosuppression (New Zealand Formulary, n.d). Patients should be advised against facial application unless advised by their prescriber, but if they are required to use on the face, to use them for shortest duration possible and avoid use around the eyes (Medsafe, 2005). Despite having eczema from early childhood, it wasn’t until attending a pediatric assessment course that I heard about how much steroid cream to actually apply –the Fingertip units rule. A table guideline for this is available from patient.info and gives the measurement for children and adults (https://patient.info/health/ste roids/fingertip-units-for- topical-steroids).
Avoidance of soap related products is something that is mentioned in many advise sheets for patients. Soaps can be really irritating on the skin, and also contain other things like fragrances that some people react to. A common treatment soap alternative is ‘fatty cream’; like many other eczema products, it is available over the counter, but is also subsidized on prescription.
This method involves covering the skin areas with steroid or anti-inflammatory creams, followed by emollients, then wet tubular bandages. A guide to doing this can be found here: https://www.rch.org.au/upload edFiles/Main/Content/derm/W et_dressings_eczema.pdf
This method may be time- consuming, but for some, it may be worth considering (Andersen, Thyssen & Maibach, 2015, p. 938).
Occlusive dressings for eczema:
This is one method I’ve found to be effective, after being introduced to it via an Occupational therapist friend. This method allows topical preparations to sit on the skin, then be covered with a film dressing such as Tegaderm or Hyperfix. A benefit to this approach is the dressing does not absorb the ointment and the areas of irritation remain covered.
Systemic treatments for eczema:
At times, topical treatments are inefficient at controlling systems and systemic treatments should be tried. While topical steroids are a common treatment, some patients do require short courses of oral steroids. Like any steroid prescription, patients need to understand the role of tapering the doses to end the course. Steroids are endogenous hormones, and increased levels can cause altered fat deposition and decreased bone density, as well as the aforementioned immunosuppression.
After consultation with dermatology medications such as azathioprine, methotrexate, or biologics may be prescribed to those with eczema. However, they may not be suitable for all patient groups due to side effects or contraindications (Gooderham et al, 2017). Though nurses may not be involved in prescribing of these drugs, we may be responsible for administering, sending out testing recalls or taking blood for testing. For example, methotrexate requires close monitoring of liver function, renal function and complete blood count (Waitemata District Health Board, 2017).
Some patients may also respond well to phototherapy. In a study of dermatologists, phototherapy was preferable to systemic medications in moderate to severe eczema (Taylor, Swan, Affleck, Flohr & Rynolds, 2016). Though respondents would like further studies to be done.
Possible future treatments for eczema:
There are many studies and meta-analyses on the use of probiotics or prebiotics in the management of eczema (Dang et al, 2013; Cuello-Garcia et al 2015). Cuello-Garcia et al (2015) feel that although their meta- analysis noted a reduction in eczema rates with prenatal supplementation or post-natal infants, they also acknowledge that further and more rigorous studies should be conducted on the topic. Many blogs and websites also hype the role of other supplements, but further study is required.
Any areas of broken skin have the potential to develop infection, and eczema is no exception. The most common infective pathogen is Staphylococcus aureus, typically found in on our skin within our regular skin flora (bpac nz, 2017, p.1). Antibiotic resistance has been a hot topic for several years, and there certainly has been a push towards topical antibiotics in recent years, but they are also not without risk as reactions or resistance may still occur (Everts, 2017, p.4).
Stress to patient and family:
Dang et al (2013, p. 1437) state that “high rates of recurrence, bleeding, scarring and even infection (due to scratching) can seriously affect health-related quality of life”. Body image issues can occur in both adults and children. Sufferers may modify their clothing choices to cover up their skin or avoid activities where their eczema presents. As someone who has eczema ever since I remember, this is a very real disruption. There are times that I’ve felt embarrassed, both at the severity of my skin problems and for the areas that they present in. At several points, swelling and irritation has sprung up on my face, which was very disruptive. I also had to take time off work due to not being able to work when my skin was infected as it can become an occupational health and safety issue. For some sleep may also be disrupted due to itch or pain, and for some, there may be a benefit to sleep aids, such as sedating antihistamines.
Having a child with eczema may also impact the wider family unit. The treatment can be ‘time consuming and tedious’ but best results will be achieved if regimes are regularly maintained (Eczema Association of Australasia Inc, n.d). Children may have absences from school or miss out on activities such as camps and sports (Mackey, 2018).
For families there is support available from groups such as the Eczema Association Australasia and other groups. There’s also heaps more great information on the RCH, or Starship Hospital websites.