ECZEMA MANAGEMENT, Eczema is a chronic inflammatory skin disease that affects 20-30% of children and 2-10% of adults. Eczema is a multifactorial disease with genetic and environmental aetiology.
Atopic eczema is a common skin condition that causes patches of skin that are itchy, cracked and sore.
The main symptom of atopic eczema is patches of skin that are itchy, dry, cracked and sore.Treatments for atopic eczema include emollients (moisturising treatments) and steroid creams.You’re more likely to get atopic eczema if you have allergies or other family members with conditions like atopic eczema, asthma or hay fever.
In secondary care, eczema severity is increasingly measured using the Eczema Area and Severity Index (EASI). EASI is a clinical tool scored by assessing the erythema, excoriations, induration and lichenification of the skin.
The NICE guideline for dupilumab requires that patient outcomes are measured according to EASI, which has influenced its uptake as a clinical disease severity tool for eczema in the UK.
Optimal treatment of eczema is important because poorly managed disease has a significant impact on mood, sleep, relationships, school and work life. In a large US study, one third of patients with eczema reported mood and sleep disorders at more than twice the rate of matched controls without eczema.
NICE guidance suggests that flares of eczema could be reduced with optimised topical therapy and there is often undue concern about overuse of topical steroids.
A 2020 synthesis of qualitative studies performed to explore the views and experiences of people with eczema demonstrated that:
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When dermatologists review people with eczema in secondary care, assessment of topical therapy is always taken into account, this may include:
If there is a need for daily topical corticosteroids to keep eczema controlled, and especially if there is facial eczema with eyelid involvement, the next step is often to introduce a topical calcineurin inhibitor (TCI).
The steroid-sparing TCIs pimecrolimus (Elidel®) and tacrolimus (Protopic®), have been available since 2000. Protopic 0.03% ointment and Elidel cream are licensed for ages 2 years and above. Protopic 0.1% ointment is licensed for ages 16 years and above.
It is worth reminding patients that side effects with immunomodulators, including burning and stinging, tend to improve over time.
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Most patients with eczema have mild-to-moderate disease and can be managed with optimisation of the topicals already discussed.
If topical therapy fails to control disease, and patients can attend hospital for the required appointments, phototherapy remains a useful second-line treatment for children and adults.
An expert panel for the International Eczema Council has devised a pathway to demonstrate when it is appropriate to consider starting a systemic therapy for eczema.6
The advice includes starting a systemic if:
|Drug||Approved for atopic dermatitis?||Reported efficacy in moderate-to-severe disease||Side effects|
|Azathioprine||No||30-40%||Hematologic abnormalities, skin and other malignancies, hepatosplenic lymphoma, and central nervous system infections|
|Ciclosporin||Yes, in Europe||50-90%||Renal insufficiency, hypertension, and drug interactions|
|Methotrexate||No||40%||Hepatotoxicity, hematologic abnormalities, teratogenicity, gastrointestinal intolerance, nausea, and fatigue|
|Dupilumab||Yes||70%||Injection site reactions and conjunctivitis|
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