Practice Nurse

Eczema

Eczema is a frequently presenting condition in primary care, and generally speaking management follows a straightforward routine of emollients, with or without steroid creams or ointments for flare-ups. However, there are many variations in eczema, and many presentations may be easily confused with other conditions with similar manifestations.

This resource, consisting of five assessment questions at intermediate level aims to illustrate some of the common – and less common – presentations of eczema, and to assess your knowledge of management based on current guidelines. Complete the resource, including the recommended reading and some or all of the suggested activities, to obtain a certificate for one hour of continuing professional development to include in your annual portfolio.

On completion of this module you should have an understanding of:

Common and less common presentations of eczema

The role of emollients in the management of eczema and how they are correctly used

The differences between allergic contact eczema and contact /irritant dermatitis

Reliable sources of information for patients with eczema

NICE CG57. Atopic eczema in under 12s: diagnosis and management; updated 2023. 

Primary Care Dermatology Society and British Association of Dermatologists. SKIN. Guidelines for the management of atopic eczema 

http://www.nice.org.uk/guidance/ta81/resources/primary-care-dermatology-society2

 provides authoritative information about skin diseases, conditions and treatment for health professionals and patients.

A case of atopic eczema: a guideline-based approach

See also our Practice in Pictures series, practicenurse.co.uk/Essentials/Practice in Pictures

A young man comes into the surgery with pronounced blisters on the palms of his hands. He says they are intensely itchy, and have been worse since a recent period of hot weather. He also has similar lesions on the soles of his feet.

Which of the following conditions would you suspect?

Pompholyx (from the Greek for bubble) eczema, also known as dyshidrotic eczema, affects the palms of the hands and soles of the feet, and may manifest as vesicles (raised, fluid-filled lesions that are less than 0.5cm) and bullae (fluid-filled lesions greater than 1cm). The cause of the condition is generally unknown. About 50% of sufferers have atopic eczema or a family history of atopic eczema. It is often aggravated by sweating and heat, so is often worse in hot weather. It usually affects young adults and can feel very itchy. Assessment should include a full history to rule out the possibility of contact dermatitis, as a result of a reaction to an irritant (e.g. soap, detergent, solvents) or allergen (e.g. latex or nickel).

Bullae may need to be drained and wet dressings soaked in potassium permanganate or aluminium acetate applied, or the affect parts soaked in a potassium permanganate solution. Once the acute phase is over, treatment with a topical steroid preparation can be applied. Alitretinoin, a retinoid drug derived from vitamin A, may be used for adults with chronic hand eczema, including pompholyx, that doesn’t respond to steroid creams or is persistently recurrent, but should only be prescribed by a specialist.

Look up the description of causes of blisters at 

http://www.nhs.uk/Conditions/Blisters/Pages/Causes.aspx.

Question 1

A 64-year-old woman comes into surgery to ask advice about a roughly circular lesion that has appeared on her forearm. She has a history of mild atopic eczema but is concerned that this lesion may be something more sinister. What do you think the most likely explanation for the lesion might be?

Discoid eczema has a typically coin-shaped appearance with a clearly defined border. It predominantly affects the limbs, and is often an extension of atopic eczema. If this lesion was isolated and there was no history or other clinical signs of atopic eczema, it would be appropriate to seek a second opinion to rule out basal cell carcinoma. Discoid eczema may be seen in young adults, but is more common in middle aged or elderly patients. Discoid eczema may be wet – where it consists of plaques made up of numerous vesicles, which break to produce exudate and crust on the surface – or dry. The dry type is similar, but has scale as well as crust on the surface. People with discoid eczema often have dry skin that should be treated to improve the existing eczema and prevent further flares, but the treatment of the lesion itself is usually with a potent steroid cream or ointment, used for 2-4 weeks. If infection is present, a combination antibiotic and steroid cream may be used, but if infection is widespread oral antibiotics will be required.

http://www.dermnetnz.org/dermatitis/nummular-dermatitis.html

Look up the treatment of discoid eczema at 

Question 2

A 51-year-old man comes into your clinical for travel immunisations. As he rolls up his sleeve, you notice a reddened area of flaky skin, with some blistering, around his wrist. What do you suspect?

Allergic contact dermatitis is an allergic reaction at the site of contact with an allergen, such as latex, PTBP formaldehyde resin in leather, e.g. a watch strap, or as in this case, nickel in the chain bracelet. It should not be confused with contact/irritant dermatitis, which is caused by direct contact with an irritant such as detergent and which is far more common. Allergic contact dermatitis requires initial exposure to an agent and the development of sensitivity, which take place over a period of weeks, months or even years. When the individual is re-exposed, a reaction occurs within 2-3 days. Usually the reaction occurs where the agent has been applied, but occasionally the reaction may be at a distant site – for example, a reaction to nail varnish may manifest as an eruption around the eyes. Treatment involves avoiding the allergen (testing may be required if this is in doubt), and the application of a mild steroid ointment or cream applied once or twice a day.

DermNet NZ. Allergic contact dermatitis, 2014. 

http://www.dermnetnz.org/dermatitis/contact-allergy.html

National Eczema Society. Allergic Contact Dermatitis. 

Look around your practice and identify potential sources of allergic or irritant contact dermatitis. What steps could you take if you developed sensitivity to any of these agents?

Question 3

This young man presents with an erythematous rash on his face, which is more pronounced around his nose and mouth. He also has additional pimples on his cheeks, but no evidence of comedones. What condition may be causing these signs?

Seborrhoeic eczema (also called seborrhoeic dermatitis) affects areas of the body where the skin contains high level of sebum, such as the face, scalp and trunk. On the face it will affect the eyebrows, eyelids, ears and sides of the nose. The skin around the sternum and flexural areas such as the axillae, under the breasts and groin may also be involved. The skin looks red and there may be some scale. The scalp may have dandruff. Seborrhoeic eczema is most common in young adults but people with Parkinson’s disease may also be prone to this condition. The lipophilic yeast, Malassezia ovale (formerly known as Pityrosporum ovale), an opportunistic pathogen found in the normal human cutaneous flora, may also be implicated in the development of the condition. Treatment includes shampoos containing ketoconazole, coal tar or selenium. Flexural areas can be treated with a combination steroid-antifungal preparation (2% ketoconazole).

http://www.pcds.org.uk/clinical-guidance/seborrhoeic-eczema

National Eczema Society. Adult seborrhoeic [eczema]. 

National Eczema Society. Adult seborrhoeic dermatitis 

http://www.eczema.org/adult-seborrhoeic-eczema

Search for and download the patient information leaflet on seborrhoeic eczema from the British Association of Dermatologists website, 

http://www.bad.org.uk/for-the-public/patient-information-leaflets

Question 4

A mother brings her 3-month old daughter into the surgery because she is worried about an extensive rash that has appeared in the past few days, and is not sure what it might be. After taking a detailed history and examining the child, what do you think the problem may be?

Atopic eczema develops after three months of age. In the older person, it will affect the back of the knees and the front of the elbows, whereas in the infant, it commonly commences on the face. The flexures are frequently involved e.g. neck, elbows and wrists. The itch can be intense and can disturb the sleep of the individual. Infection is a risk and is usually caused by Staph. aureus and may manifest as golden crusting or a pustular eruption. Application of emollients helps to improve the dryness of the skin and use of steroid preparations (ointment for dry skin, cream for wet skin) will help to improve the condition.

British Association of Dermatologists. Atopic eczema (comprehensive patient information). 

http://www.bad.org.uk/shared/get-file.ashx?id=69&itemtype=document

Knott L. Atopic dermatitis and eczema. Professional reference, 2015. 

http://patient.info/doctor/atopic-dermatitis-and-eczema

Visit DermNet NZ and look up the Eczema Area and Severity Index (EASI) 

http://www.dermnetnz.org/dermatitis/easi.html.

Emollients need to be applied frequently and in sufficient quantity. Emollients can also become contaminated with bacteria and the SIGN guideline recommends that they are prescribed in pump dispensers to reduce this risk. Look at Annex 2 of the SIGN guideline: 

 and compare its recommendations with the practice formulary. Does your formulary correspond with the guidance?

Eczema

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