1.  Eczema The basics

2. Objectives  At the end of this lecture you should  Be more familiar with the presentation of eczema  Have better understanding of the stages of eczema  Be able to formulate a plan of care for a patient with eczema  Have some new strategies for helping your patients manage their eczema.

3. Eczema  This is a skin barrier dysfunction  Can be aggravated by stress  Is worsened in very dry climates  Is generally a lifelong condition which means…  We have to teach our patients how to best live with the skin they are in.  Proper care helps lessen the need for prescription medications: Topical calcineurin inhibitors, steroids, antihistamines

4. Eczema Typical locations, typical appearance Affects young to old Can be infected or not (these are not) Images – typical atopic eczema, eczema craquele, ichthyosis, Infant eczema

5. lichenification

6. Stages of severity http://www.coolhealthtips.com/category/diseases-and-conditions/skin-diseases/page/2

7. Superinfection http://derm-imaging.org/wp-content/uploads/DSCN9420-e1297246010546.jpg

8. Eczema – preventing rash  Cleansers not soaps – soaps have detergents  You scrub a greasy skillet with detergent, eczema patients need to conserve their body oils !  Warm, not hot, showers or baths  PAT dry with a wadded up towel, don’t rub !  Apply emollient while still slightly damp  Cotton is your friend – towels, clothing, bed-sheets, etc. Is least irritating to the skin

9. Topicals  Humectants hold water on the skin  Emollients fill the crevices between the corneocytes and help restore barrier function  Occlusives applied correctly are a great way to lock in moisture. They’re especially helpful because they don’t contain preservatives which some patients are sensitive to.

10. Humectants  Ammonium Lactate  Butylene glycol  Gylcerin  Propylene glycol  Urea  Others  These products should be applied immediately after a bath or shower while the skin is still damp.

11. Occlusives  Petrolatum  Lanolin  Beeswax  Paraffin  Mineral oil  These tend to be hot and sticky but when applied correctly are and are very helpful in keeping the skin healthier

12. Ok, so when is a prescription necessary ?  When the non-medicated topical treatments fail  When the patient cannot be consistent in the application of the OTC products  When a flare of eczema breaks thru despite good skin care  When eczema has become inflamed and weepy  When eczema has become infected

13. Topical non-steroidals  Elidel cream(pimecrolimus)  Protopic ointment ( tacrolimus )  Expensive but effective  Low side effect profile (*Black box warning in the US)  Variable dosing depending on whether using for a flare or for long term suppression / maintenance  Cannot use in patients less than 2 years old

14. Topical steroids  Generally class II, III, IV for the body (never, ever, ever for face, intertriginous areas, or for genitals)  If eyelids are involved – may use OTC hydrocortisone cream twice a day for THREE DAYS ONLY ! (most eyelid dermatitis is irritation from or allergy to nail polish, hair spray, or eye make-up)  Used correctly they are very safe, the problem is convincing the patient to use them correctly. THAT is why there are so many sizes to choose from when dispensing.

16. Topical antibiotics  Polysporin (otc)  Triple antibiotic (otc)  Altabax (retapamulin)  Bactroban (mupirocin)  DO NOT recommend Neosporin as topical neomycin is a well known sensitizer.

17. Systemic Antibiotics  Amoxicillin  Cephalexin  Others as necessitated due to individual patient (allergies, chronic medications, etc)  A 7 – 10 day course is usually prescribed when extensive areas of skin are involved

18. The bleach bath  ¼ cup (250ml) bleach in a bathtub of water. Bathe in this twice a week for two weeks after skin is mostly healed.  Eczema infection is usually caused by the patients own skin flora.  Dilute bleach helps to eradicate skin flora and reduce incidence of infection.  Rinse under the shower after bathing, pat dry, apply topical medications.

19. The bleach bath  Cautions  Bleach etches fiberglass tubs. Ask what they have.  If your patient has a fiberglass bathtub, have them mix 1 tsp (5ml) bleach in a litre of water. Use a spray bottle or a washcloth to apply to the skin. Wait a few minutes and then bathe as normal.  Caution patients to NOT overdo on this therapy. It CAN cause harm but not if directions are followed.

20. Tricks of the trade  When applying an ointment - wet hands, place small amount of ointment in palm and scrub hands together. Place hands on area to be treated and apply the thin film of ointment. This application method helps with compliance.  For the itch, especially with children, lightly patting or pinching the itchy area can override the itch sensation and bring relief without the scratching that can tear skin  Trim fingernails short  EDUCATE that this is likely a lifelong process but that you will help the patient learn to live with the skin they’re in.

21. Review  It is my hope that you all now  Are more familiar with the presentation of eczema  Have better understanding of the stages of eczema  Feel more confident in formulating a plan of care for a patient with eczema  Have some new strategies for helping your patients manage their eczema.

23. References  Most photographs are on the Dermnetnz.org site. Those that are not, are credited with the website from which they were taken.  Dermetnz.org also has an excellent tutorial on the dermatoses: http://dermnetnz.org/doctors/dermatitis/http://dermnetnz.org/doctors/dermatitis/