Case Studies: Eczema

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Case 1
A mum presents her four-month-old, bottle-fed baby who clearly has severe atopic eczema. She has attended on a few occasions and been prescribed the standard treatments, but with little success. The child’s mother is beginning to feel frustrated by the lack of progress. ‘Can she have stronger creams, doctor?’ she asks. ‘Or do you think it’s worth me changing her milk?’
What topical treatments are appropriate in this situation? To what strength of topical treatment can GPs reasonably escalate before considering referral?
During a moderate-to-severe flare of eczema, it is important to get the eczema settled down very quickly, otherwise the patient will need much longer spells of topical steroids, and the poor sleep associated with itchy skin may have an adverse impact on the child and parents. To settle a severe flare of eczema quickly, it is recommended that:
• A potent topical steroid such as betamethasone valerate 0.% cream should be used to settle the flare. Treatment on the face and neck should be for not more than five days.
• Consider infection and take a skin swab for culture and specimen. If the swab shows a significant growth of Staphylococcus aureus, and if the eczema is not responding to treatment, a one-week course of a systemic antibiotic should be prescribed – for instance flucloxacillin, or erythromycin if there is penicillin allergy.
Arrange to review the child and parents the following week and organise a long-enough appointment to discuss the long-term management of eczema. This should include:
• More detail on possible triggers such as cow’s milk allergy.
• The provision of patient information leaflets.
• Links to national organisations such as the National Eczema Society.
• Discussion about the long-term management of eczema, which is based around:
• Complete emollient therapy – include online support and video links on how emollients should be used.
• A steroid ladder – use the weakest topical steroid (% hydrocortisone cream/ointment) to control the eczema, and reserve potent topical steroids for flare-ups.
• Provide a written management plan.
In children with frequent flares (two or three per month) of atopic eczema, it is recommended that topical steroids be used for two consecutive days per week as a strategy for flare prevention. This is sometimes referred to as weekend therapy. This strategy can only be started once a flare has been controlled.
Check compliance to make sure that the correct treatment is being used.
Referral to a GPSI in dermatology or dermatologist is recommended for children who continue to flare frequently, despite the measures described above. Referral should also be considered it there is a doubt about the diagnosis.
What is the possible role of cow’s milk allergy in this situation? Is it worth trying another formula and, if so, what should be prescribed, and for how long?
When the child first presents with moderate-to-severe eczema, the initial aim is to get the eczema settled quickly. It is important to acknowledge the mother’s question about changing milk, but also to explain that this will be explored at the follow-up appointment, once the flare is settled and everyone has had more sleep.
A child that responds well to topical steroids, has only occasional flares, and is otherwise well is unlikely to have a milk allergy. However, milk allergy should be considered in the following circumstances:
• An immediate reaction to milk.
• Young children with moderate or severe atopic eczema that has not been controlled by optimum management.
• If there is also gut dysmotility (colic, vomiting, altered bowel habit) or failure to thrive.
If cow’s milk allergy is a possibility, the child should be given a six-to-eight-week trial of eliminating cow’s milk. If the child is breastfed, the mother will need to avoid cow’s milk. If bottle fed, the child should be prescribed an extensively hydrolysed protein formula or amino acid formula in place of cow’s milk.
Goat’s milk should not be offered to bottle-fed babies because it is nutritionally inadequate and shares 9% of cross-reacting allergens with cow’s milk. Soy-based formulas contain phyto-oestrogens and are not recommended in the UK as the primary protein source in infants under 0 months.
If the child improves significantly on a cow’s milk-free diet they should be referred for specialist dietary advice.
What is the prognosis in a case of this sort?
The severity of eczema at presentation will not necessarily dictate the long-term outlook. It is important to explore the parent’s expectations and explain that treatment will be ongoing at least in the short to middle term, but that the majority of children will grow out of eczema.

Case 2
A -year-old man with extensive and longstanding eczema attends with an exacerbation affecting his arms, legs and a good deal of his trunk. ‘I’m not due to see my specialist for four months,’ he says. ‘So I’m wondering if you could prescribe me some steroid tablets. I’ve had them before and they work a treat.’
What is the role of oral prednisolone in patients with severe eczema? How difficult is it to wean these patients off this type of treatment?
The patient first needs a thorough skin assessment to make sure they are not erythrodermic. Erythroderma refers to erythema affecting 90% or more of the skin – patients will often feel quite unwell and complain of feeling hot or cold. In such circumstances contact must be made with the on-call dermatologist as the patient may need to be admitted, or at least have an urgent outpatient assessment.
In less severe cases, patient compliance needs to be checked to make sure they are using topical treatments appropriately.
If the patient has not already tried a potent or super-potent topical steroid, they should do so, and a systemic antibiotic may be needed for one week if the eczema is infected.
If the patient fails to respond to the above measures, a short course of systemic steroids, such as prednisolone 0mg od for seven days, should only be provided if it is part of a management plan provided by the specialist, or if circumstances dictate (for instance the patient is about to go on holiday), or as a very occasional measure.
Patients should not be given systemic steroids by the GP on a regular basis – instead, a timely review should be organised with the patient’s specialist.
If you are going to prescribe steroids, ensure it is a short course to avoid patients reaching a position whereby you have to wean them off.
What are the usual causes of severe exacerbations? Are there any triggers that can realistically be avoided?
There are several possible reasons for severe exacerbations:
• The patient may inherently have severe eczema.
o Compliance with emollients and other topical treatments may be poor. Emollients should be prescribed in large quantities, with the recommended quantities used in generalised eczema being 600g/week for an adult and 0g/week for a child.
• The patient has a skin infection:
o Make sure that, if a patient is using an ointment as a moisturiser, they are not placing their hands directly in the tub of ointment and scooping it out. Instead. advise them to scoop the ointment out with a spoon or ladle onto a clean surface.
• Swab the skin for culture and sensitivity.
• Consider an emollient bath solution or wash with an antiseptic property.
• The patient may have contact allergic dermatitis and should be referred for patch tests – this should be considered in the following circumstances:
o Poorly responsive eczema at certain sites – face, hands, feet and the perianal area.
o Previously well-controlled eczema that becomes difficult to manage – consider allergy to topical treatments.
What other treatment options are available for adults with severe, intractable eczema?
The following treatments are considered for use in secondary care:
• Phototherapy, mainly for younger patients.
• Azathioprine, ciclosporin, methotrexate, mycophenolate mofetil, and, occasionally, low-dose prednisolone for generalised eczema.
• Neotigason or alitretinoin for severe hand/foot eczema

Clinical casebook: eczema

Case 3
A seven-year-old girl attends with her mother. ‘The moisturiser just seems to make her itch more,’ mum explains. ‘And we need something to help her sleep – the itching is driving her mad at night.’ As you sort out the relevant prescriptions, mum adds: ‘Her creams don’t seem to be helping much and a doctor friend has recommended this.’ She reads from a piece of paper she has taken from her pocket: ‘Pimecrolimus’.
Parents often complain that certain emollients make their child’s eczema worse – is this the case? There are so many emollients to choose from. How can the GP make a rational choice?
It needs to be explained that many emollients will cause some itch or irritation when first applied to the skin, especially if the eczema is flaring. If the eczema is not settling despite the use of appropriate amounts of emollients and topical steroids, and if the parents still believe that the moisturiser is a problem, then change emollient.
There is no evidence supporting one emollient over another and, to an extent, the process is trial and error. However, it may be worth contacting your local dermatology department, as it may have established a formula of products that best suit their patients. They won’t have anything evidence based, but some keep a tick-list of which patients prefer.
What is the role of night sedation in childhood eczema? Does this treatment relieve the itch or simply sedate the child? If one is to be prescribed, which should the GP choose?
There is no role for the use of non-sedating antihistamines in atopic eczema. Although the evidence is poor, clinical experience still supports short-term (seven to days’) use of sedating antihistamines at bedtime in children with atopic eczema that causes debilitating sleep disturbance to them or their families or carers. If treatment with sedating antihistamines is successful, it can be repeated during flares if needed.
Sedating antihistamines work by making the child feel tired, which indirectly makes them feel less itchy.
There are several sedating antihistamines to choose from. Only one study has compared treatments, and this showed hydroxyzine to be slightly superior to cyproheptadine.
When is pimecrolimus appropriate? Should it only be initiated by a specialist?
The main advantage of pimecrolimus over topical steroids is that topical calcineurin inhibitors do not cause adverse effects such as skin atrophy (thinning of the skin). This is particularly beneficial when treating delicate sites such as the face, where the skin barrier is very thin and the amount of topical steroid that passes through can be enough to cause atrophy.
Pimecrolimus can be initiated by the GP in patients aged two years and over, mainly for facial eczema. It should be used if the eczema cannot be controlled by emollients and the occasional use of topical steroids for flares.

Case 4
A -year-old woman attends in a state of some distress. ‘I can’t go to work like this,’ she says. She has an obvious flare of eczema on her hands, which look infected. ‘It looks so awful,’ she explains, ‘and I’m sure it must put my clients off.’ It transpires that she is a trainee hairdresser and has noticed a significant deterioration in her eczema since she started this work.
In infected eczema, when should the GP use oral antibiotics as opposed to a topical steroid and antibiotic combination?
Oral antibiotics should be considered for widespread infected eczema, or if localised eczema is severe and not responding to a topical steroid and antibiotic combination.
What are the typical features that would suggest occupational eczema?
Site is the most important clue. If the eczema is confined to, or is considerably worse at, a body site in contact with chemicals, a contact allergic dermatitis should be suspected.
Chronology may be less important. While some allergies develop quite quickly after contacting the offending chemical, others – for instance, chromate allergy from contact with cement – may take years to develop.
If the eczema gets very much better when away from work – for instance on holidays – this could be relevant, though it is worth noting that relaxation in itself can help eczema improve.
How should the GP manage a patient with apparent occupational eczema? Should these patients be referred?
• Give advice and, if the hands are affected, provide a patient information leaflet on hand dermatitis.
• Treat as per atopic eczema with emollients, topical steroids (use potent or super-potent topical steroids initially and for flares) and antibiotic preparations if indicated. Particular notice must be given to the provision of emollient soap substitutes for hand eczema.
• In the vast majority of cases, patients should be referred for patch tests. A referral could be put on hold in certain circumstances – for instance, a planned change in occupation. There is no role for blood RAST tests in contact allergic dermatitis.