Primary care essentials: Managing complications of eczema

Eczema is a frequently presenting condition and generally speaking, management follows a straightforward routine of emollients, with or without the addition of steroid creams or ointments for flare-ups. But occasionally, eczema is more complicated, as our illustrated guide demonstrates

Eczema is one of the commonest skin problems that we encounter in primary care. It has the potential to develop in infancy and may even affect people in later life for the first time. The condition is one that can cause profound itching which may result in complications of scratching. As with all treatments, the benefits of eczema treatments should outweigh the side effects. However, the latter may be significant and so it is essential that the attending practitioner is fully aware of them.

ITCHING

Initially, it can be quite pleasurable to scratch an itchy area of skin. However, after a short time itching becomes an annoyance and results in complications such as excoriated weeping skin, the potential to develop infection and sleep disruption. The latter may have profound effect on children, leaving them tired for the next day

Itching may be worse at night time when it can be caused by a hot environment, so it is important to avoid over-heating, by wearing cotton night clothes and using a low tog duvet. Maintain bedrooms at a comfortable temperature (cool enough to feel comfortable in a tee shirt) and maintain some air moisture by having a window open.

Medication with an antihistamine such as hydroxyzine may be helpful. Some suggest this works as an anti-pruritic but others claim it benefits by sedation. On occasion antihistamines can cause children to become hyperactive and so it is important to warn parents. Non-sedating antihistamines are of no benefit.

BACTERIAL INFECTION

Staphylococcus aureus frequently colonises the skin of people with eczema. It is thought that the organism may act as a superantigen, stimulating activity of T cells and as a result, exacerbating eczema. Topical steroids applied to the skin alone will reduce the number of colonies of S. aureus but the number of colonies will be reduced even more if a steroid/antibiotic preparation is used. More significant infection is suggested when a yellow appearance to the surface of the skin is apparent along with crusts, weeping and yellow pustules. (Aureum is Latin for gold). Short-term treatment should be with a steroid/anti-staphylococcal cream, such as Fucibet. Care should be taken to avoid spread of the staph. infection, and a useful tip is to apply cream with a cottonwool pad (as used in make-up removal) rather than the finger. If there are signs of staph. spread beyond the eczema, a course of oral antibiotics, e.g. flucloxacillin, is recommended. Once the infection appears clear, then the patient can return to using their standard regime of emollients and topical steroid. It is important to keep the duration of antibiotic use to a minimum to avoid the development of resistance.

VIRAL INFECTION

Eczema herpeticum

Herpes simplex infection may become disseminated in the presence of atopic eczema, when it is also known as Kaposi Varicelliform eruption. The condition presents with areas of eczema becoming more painful. Multiple vesicles develop and these evolve to become punched-out erosions. This occurs most commonly on the head and upper body. Where the areas coalesce, larger open areas may develop which will be prone to bacterial infection. If the infection becomes widespread or fever develops then the patient should be referred to hospital for intravenous antiviral therapy as this is a serious condition with a mortality risk.

Molluscum contagiosum

Molluscum contagiosum is a viral infection from the pox family, which may produce multiple small individual lesions usually less than 0.5cm in size. Their surface may appear normal initially, but then develops an indentation described as umbilication. The infection appears to be present more frequently in atopic dermatitis, cause an increase in severity of the condition and may take longer to clear than normal. The lesions can be left and will disappear spontaneously. Sometimes children may pick at them and they will become inflamed and then resolve. Cryotherapy may leave a scar, and so some dermatologists recommend pinching a couple of lesions with forceps for a few days to produce an inflammatory response.

ERYTHRODERMA

Erythroderma, literally translated, means redness of the skin which has a generalised impact on the body. It is not unique to atopic eczema but occurs when there is significant deterioration and instability. It may also be encountered in, for example, drug reactions, psoriasis, or lymphoma. This is a serious condition and requires hospitalisation as it may be complicated by infection, heart failure, dehydration, hypothermia, and even death.

EYE COMPLICATIONS

The impact of eczema is not just on the skin: it may also affect the eye. The conjunctiva may become involved, which may relate to generalised allergy as in hayfever, but may also be due to localised irritation. Patients worry about using hydrocortisone near the eye but I encourage them to treat like any other area of skin to prevent chronicity. However, absorption of steroid in the region of the eye is high, so explain that the ointment should be used to cover the affected area with a thin layer and to only continue for as long as necessary. Long-term application in the region may cause glaucoma. (The author has never encountered this in over 30 years of general practice).

Keratoconus may occasionally occur in eczema sufferers. In this condition, the cornea becomes cone shaped and a distorted image is created. This cannot be adequately corrected with glasses and the patient will require rigid contact lenses.

Cataracts are normally associated with the ageing individual. However, people suffering from severe atopic dermatitis may develop cataracts between the ages of 15 and 25 years, and these are usually bilateral.

Retinal detachment may also rarely be encountered in people with atopic dermatitis.

PSYCHOSOCIAL IMPACT

The psychological impact of skin disease should not be underestimated. This may have been enhanced over recent years with the advent of computer programmes creating

GROWTH IN CHILDREN

Children with severe atopic eczema may suffer growth retardation. While treatment may involve the uses of steroid applications, it is felt that the effect is caused by the impact of the disease rather than the steroids.

TREATMENT

Steroid treatment

Some areas of the skin absorb steroids more readily than others. The face absorbs much more than the sole of the foot. Using 50 grams of clobetasol per week may cause adrenal suppression or at worst Cushing

Calcineurin inhibitors

Application may cause a burning sensation, and there is possibly an increased risk of infection and so application should be avoided to obviously infected areas. There is concern that longer-term use may be associated with cutaneous malignancy and so it is preferable to avoid application on sun-exposed sites long-term and during ultra-violet therapy.