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Dermatology > Eczema > Flashcards

Eczema Flashcards

1
Q

What are the symptoms of eczema?

A
  • Itchy, dry, erythematous skin condition
  • FH of atopy
  • Involvement of flexures in school age child is characteristic
  • Cheeks are often the first place to be involved in infants
  • Can be vesicular
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2
Q

When do you diagnose atopic eczema in children?

A

When they have itchy skin + 3 or more of:

  • Visible flexural dermatitis involving the skin creases, such as the bends of the elbows or behind the knees (or visible dermatitis on the cheeks +/or extensor areas in children = 18 months)
  • Personal hx of flexural dermatitis (or dermatitis on the cheeks +/or extensor areas in children = 18 months)
  • Personal hx of dry skin in the last 12 months
  • Personal hx of asthma or allergic rhinitis (or hx of atopic disease in 1st degree relative of children aged <4yrs)
  • Onset of signs + symptoms <2yrs (this criterion should not be used in children <4yrs)
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3
Q

How does eczema affect Asian, black Caribbean and black African children?

A

Affects the extensor surfaces rather than flexures + discoid (circular) or follicular (around hair follicles) patterns may be more common.

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4
Q

What are the effects of itching on children?

A

Can massively impact sleep - causing irritability, impaired concentration + slowed development (faltering weight/growth). A child’s sleep pattern being affected usually affects the whole family.

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5
Q

What are endogenous types of eczema?

A
  • Atopic eczema
  • Varicose eczema
  • Seborrhoeic dermatitis
  • Discoid eczema
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6
Q

What are clinical features of eczema?

A
  • Golden crusting: golden exudate or crust makes one suspicious of secondary infection
  • White dermographism: pale wheals on areas that have been firmly stroked or scratched (seen in atopy)
  • Pompholyx: acute presentation of eczema where tiny vesicles appear typically on the lateral aspects of the fingers and toes, it is intensely itchy
  • Lichenification: increased skin markings, seen in chronic eczema
  • Erythematous plaques: plaques are raised lesions >1cm in size, not a feature of eczematous eruptions + may suggest a psoriatic picture.
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7
Q

What are the signs/symptoms of atopic eczema bacterial infection with staph or strep?

A
  • Weeping (pus filled blisters)
  • Pustules
  • Crusts
  • Eczema unresponsive to therapy
  • Rapidly worsening atopic eczema
  • Fever and malaise
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8
Q

What are the clinical features of eczema herpeticum?

A
  • Atopic eczema can be infected either by bacteria (staphylocococcal and Streptococcal infections) or viruses in particular with Herpes simplex (eczema herpeticum)
  • Hx of close contact with someone who has recently had a cold sore
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9
Q

What are the signs of eczema herpeticum?

A
  • Areas of rapidly worsening, painful eczema
  • Clustered blisters consistent with early stage cold sores
  • Punched out erosions (circular, depressed, ulcerated lesions) usually 1-3mm that are uniform in appearance (may coalesce to form larger areas of erosion with crusting)
  • Possible fever, lethargy or distress
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10
Q

What is the treatment for infected eczema in a child?

A
  • Fucidin H cream applied topically every 12hrs - this combines topical abx with a mild potency topical steroid to treat both secondary infection and underlying eczema in a child.
  • Care should be taken to only prescribe this combination when bacterial infection is diagnosed
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11
Q

What are possible complications of eczema herpeticum?

A
  • Multi-organ failure: particularly important to remember if the patient is on immunosuppressants
  • Systemic herpes simplex can lead to multi-organ failure with encephalitis, hepatitis and pneumonitis
  • Dupilimab is a human monoclonal antibody which inhibits signalling of cytokines IL4 + IL13 (these play an important role in maintaining the Th2 immune response)
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12
Q

What do you do if there is antibiotic resistance to bacterial eczema?

A

Take swabs from infected lesions of atopic eczema only if you suspect microorganisms other than staph aureus or if you think there is abx resistance.

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13
Q

What are the bacterial infection medication options?

A
  • Systemic abx active against S. aureus and streptococcus, use for widespread bacterial infections (1-2 weeks)
  • Topical abx, including those combined with topical corticosteroids, use for localised clinical infection (max 2 weeks)
  • Flucloxacillin - 1st line treatment of S. aureus and streptococcal infections
  • Erythromycin - 1st line treatment if allergy/resistance to flucloxacillin
  • Clarithromycin - 1st line treatment of S. aureus and strep infections in the case of allergy to flucloxacillin or resistance and intolerance to erythromycin
  • Antiseptic such as triclosan or chlorhexidine - adjunct therapy for decreasing bacterial load in cases of recurrent infected atopic eczema - avoid long term use
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14
Q

What do skin lesions of the epidermis appear like?

A

Rashes with scale. Scale is ketinocytes without a nucelic shed from the stratum corneum: the top layer of the epidermis. Also desquamation.

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15
Q

What do skin lesions of the dermis appear like?

A

Can have infiltrated plaques peri-orbitally which suggest some deposition or expansion process. Xanthalasma is due to deposition of lipids in the dermis (yellowy).

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16
Q

What do skin lesions of the hypodermis appear like?

A

Subcutaneous fat layer - expect a skin coloured appearance (due to deeper involvement)

17
Q

What do other changes to the skin appear as?

A
  • Purpuric or necrotic (black scabs) lesions suggest pathology within blood vessels. The size of the blood vessels affected (small or medium in the skin) would need to be determined by performing a skin biopsy.
  • Melanocytes: pigementary changes suggestive of melanin deposition
18
Q

What is the pathophysiology of atopic eczema?

A

Loss of function mutations in the filaggrin gene, carried by about 10% of European ethnicity, cause ichthyosis vulgaris and are strong predisposing factors for atopic dermatitis and asthma secondary to atopic dermatitis. Breakdown of skin barrier function > an inflammatory cascade that has predominantly Th2 cells.
*Psoriasis - Th1 cell immune reaction

19
Q

What are the triggers of atopic eczema?

A
  • Allergen - pets, pollen
  • Irritant - soap
  • Environment - sand
  • Occupational
  • Psychological - stress
  • Infection
20
Q

What are the classifications of purpura?

A

Classified clinically by palpability:

  • Macular pupura (non-inflammatory usually)
  • Petechiae - small bruises (<5mm across)
  • Ecchymoses - large bruises (>5 mm across)
  • Palpable purpura are due to inflamed blood vessels usually
21
Q

What do you need to test if someone presents with widespread purpura?

A

Urine dipstick to exclude haematuria/proteinuria, as the purpura may be due to inflamed blood vessels (vasculitis). Vasculitis affects the kidneys to need to rule out renal vasculitis.

22
Q

How are emollients used in eczema?

A
  • Lotions contain the most water, followed by the creams and then the ointments which contain no water
  • Correct use of emollients can reduce the need for topical corticosteroids to maintain control of eczema
  • Emollients improve barrier function in eczema by reducing trans-epidermal water loss
  • Emollient therapy: ointments and creams are applied at least 3x/day to all the skin. Soap substitutes replace soap/shower gels which are very drying to the skin.
23
Q

What is the topical steroids strength ladder?

A
  • Mild: hydrocortisone 1% (ideal for use on face temporarily, 3-5 days)
  • Moderate: Eumovate (Clobetasone butyrate 0.05%)
  • Potent: Betnovate N (betamethasone (as valerate) 0.1%, neomycin sulfate 0.5%); Betnovate C (betamethsone (as valerate) 0.1%, clioquinol 3%)
  • Very potent: Dermovate (clobetasol propionate 0.05%)
24
Q

What is the emollient ladder?

A
  • Light: E45 lotion, Aveeno lotion, derma 500 lotion (antimicrobial)
  • Creamy: Diprobase, Cetrabin, E45 cream, Aveeno cream
  • Rich cream: Doublebase gel
  • Greasy: Hydromol ointment, emulsifying ointment
  • Very greasy: 50% liquid soft paraffin, 50% white soft paraffin
25
Q

What is the treatment ladder for eczema?

A
  1. Topicals (emollients, creams, bath additive, ointments)
  2. Topicals (steroids, immunomodulators)
  3. Phototherapy (UVB, narrow band light therapy (TL01), photochemotherapy (PUVA))
  4. Systemics (systemic steroids, azathioprine, ciclosporin)
  5. Biologics (dupilumab)
26
Q

Describe Dupilumab

A

Human monoclonal antibody that inhibits cytokines IL4 and IL13. Used in moderate/severe eczema if patient resistant/unable to take ciclosporin.

27
Q

What is the step by step treatment for atopic eczema?

A
  • Always use emollients as baseline, even when eczema is clear - management can be stepped up or down according to severity of symptoms
  • Treatment for flare-ups to be started as soon as symptoms appear and continued for 48 hrs after symptoms go
  • Info on how to recognise flares - increased dryness, itching, redness, swelling and general irritability
  • Leave- on emollients should be prescribed in large quantities (250-500g wkly) and easily available to use at nursery/pre-school/school
  • Emollients used in large amounts and more often than other treatments - used on whole body even when clear
  • Use unperfumed emollients +/or emollient wash products
  • Review medication and combination of products once a year in children
28
Q

When are topical steroids used?

A
  • Use max 1-2x/day, only on affected areas, do not use on face and neck
  • If steroids are needed for the face, give 1% Hydrocortisone ointment (mildest topical steroid) - use for max 3-5 days
29
Q

What are the treatment options for topical steroids?

A
  • Potent topical corticosteroids should not be used in children aged <12 months without specialist dermatological supervision
  • Mild potency only for the face and neck, except for short-term (3-5 days) use of moderate potency for severe flares
  • Moderate or potent preparations for short periods (7-14 days) for flares in vulnerable sites such as axillae and groin
  • Only apply topical corticosteroids to areas of active atopic eczema (or eczema that’s been active within the past 48hrs), which may include areas of broken skin
  • Healthcare professionals should exclude secondary bacterial or viral infection if mild or moderately potent topical corticosteroids have not controlled the eczema within 7-14 days.
  • In children >/= 12 months, potent topical corticosteroids should be used for as short a time as possible (no longer than 14 days)
30
Q

When can topical steroids be used as prophylaxis treatment?

A

Can consider treating problem areas of atopic eczema with topical corticosteroids for 2 consecutive days per week to prevent flares, instead of treating flares as they arise. This is in children with frequent flares (2/3 per month) once their eczema has been controlled. This should be reviewed within 3-6 months.

31
Q

When are topical calcineurin inhibitors used in eczema?

A
  • Tacrolimus and Pimecrolimus are used in eczema as they suppress T-lymphocyte responses, thereby suppressing the synthesis of pro-inflammatory cytokines.
  • Used as 2nd line to avoid side effects of chronic topical steroid use e.g. on the face where the skin is most thin.
  • Patients should be warned of the side effect of burning/stinging sensation on initial application and long-term safety data is yet to be established.
  • Shouldn’t be used on mild eczema or as 1st line
  • Recommended (tacrolimus) as 2nd line for adults and children 2yrs and older where eczema has not been controlled by topical corticosteroids, where there is serious risk of adverse effects from further steroids, particularly, irreversible skin atrophy.
32
Q

How is more severe/resistant eczema treated?

A

Phototherapy or systemic medications

33
Q

What are possible causes of severe eczema flare-up?

A
  • Withdrawal of systemic steroids
  • Secondary infection with bacterial (staphylococcus or streptococcus species) or viruses (HSV, varicella)
  • Psychological stress
  • Development of contact dermatitis
34
Q

How are different ages affected in eczema?

A
  • Infants: the face and trunk are often affected
  • Younger children: eczema often occurs on the extensor surfaces
  • Older children: a more typical distribution is seen, with flexor surfaces affected and the creases of the face and neck

Dermatology (9 decks)

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