It is a dermatitis/Eczema on a background of atopy. Hence there is often a personal or family history of atopic disease (asthma, hay fever or atopic dermatitis).
Clinical presentation
- Pruritus - face in children, flexures, nape
- Chronic or chronic recurrent course
- Positive personal or family history of atopy
- Acute forms are weepy, chronic forms are lichenified, scaly
Acute Atopic Eczema
Atopic Dermatitis-Lichenified and Scaly
Investigations
- FBP, prick test, patch test, Ig E levels
Non-pharmacological Treatment
- Education about chronicity of problems
- Remove any obvious precipitant e.g. skin irritants or allergens (avoid irritants e.g. medicated soap, wool and extremes of temperature).
- Generous use of emulsifiers (skin moisturizers)
- Bath oils/soap substitutes
Pharmacological Treatment
A: promethazine (PO) 25mg at bedtime increased to 50mg if necessary, for 2weeks
OR
A: cetirizine (PO) 10mg 24hourly for 2weeks
OR
C: loratadine (PO) 10mg 24hourly for 2weeks
AND
A: hydrocortisone 1% ointment (topical) 12hourly (if mild disease, or on face)
OR
C: betamethasone valerate cream/ointment (topical) 0.1% or 0.25% 12hourly for other parts of the body.
OR (in severe cases)
D: clobetasol propionate cream/ointment (topical) 0.05% 12hourly for up to 8weeks
OR
S: tacrolimus ointment (topical) 0.03%/ 0.1% 12hourly not less than 1month
In case of skin atrophy on the face and in children >1 year
D: prednicarbate cream (topical) 0.1 % 24hourly for
For severe cases- Erythroderma
Extensive involvement of the whole body
Patient needs admission
Oral antibiotics as in impetigo
Short course of systemic steroid therapy-
A: prednisolone (PO) 0.5 -1mg/ kg 24hourly for 1-2weeks then taper.
For recalcitrant cases
S: methotrexate (PO) 7.5- 20mg weekly for not less than 3months
OR
S: cyclosporine 3-5mg/kg/day up to 3months
Phototherapy
Treat any infection (usually bacterial, but occasionally viral - eczema herpeticum).
Choice of skin preparations depends on whether lesions are wet (exudative) or dry/lichenified (thickened skin with increased skin markings).
If eczema is “weepy”, use saline baths or bathe in:
A: Potassium permanganate 1:4000 (0.025%) solution 24 hourly for 2-4 days until dry.
Where large areas are involved give a course of antibiotics for 5-10 days (as for impetigo)
- After the lesions have dried, apply an aqueous cream for a soothing effect.
Start with mild topical steroid cream for wet lesions and use ointment for dry skin lesions.
If the skin starts scaling (condition becomes chronic), add/apply an emollient such as: emulsifying ointment or liquid paraffin.
Note: Potent topical corticosteroids may cause harmful cutaneous and systemic side effects especially if the use is prolonged or involves extensive body surface. Striae, acne, hyperpigmentation and hypopigmentation, hirsutism and atrophy may result. Therefore, avoid long term use; don’t use on weepy or infected skin. Advise patients NOT to use them as cosmetics (eg for skin lightening purposes)
Example of Classes of Topical steroids;
- Very Potent (0.05% clobetasol propionate)
- Potent (0.1% betamethasone valerate Mometasone furoate)
- Moderately Potent (0.05% clobetasol butyrate)
- Mild (1% hydrocortisone)
