Atopic eczema (AE), also known as atopic dermatitis, is a chronic, inflammatory skin condition characterised by intense itch and recurring eczematous lesions. This common inflammatory skin disorder affects people of all ages and ethnicities, approximately affecting up to 20% of children and 10% of adults.
Written by Michelle Greenwood, Health Promotion Manager, Irish Skin Foundation
Presentation
Clinical presentation varies from mild to severe and depending on severity, symptoms can include severe dryness caused by a dysfunctional epidermal barrier, intense itching, cutaneous inflammation and vesicle formation. Atopic eczema symptoms have a chronic, or relapsing disease course.
Itch is a major symptom of AE, and scratching only provides temporary relief, and leads to more itching and scratching, which is often referred to as the ‘itch-scratch-cycle’. The clinical appearance of AE may be modified by scratching, which in time may produce lichenification, broken skin surface resulting in excoriations, exudate and secondary infection. Appearance and location of eczematous lesions of AE may vary with age, and three stages have been recognised, infancy, childhood and adolescent/adult.
Cause and risk factors
The causes of this common inflammatory skin disease are complex, and comprises an interplay of genetics, immunologic and environmental triggers, that contribute to a skin barrier disruption and abnormal immune system response.
A strong risk factor for AE is a positive family history. The strongest known genetic risk factor in AE is associated with null mutations in filaggrin gene (FLG), which encodes a key epidermal structural protein filaggrin, which is necessary for skin barrier function.
The epidermis acts as a barrier, preventing water loss, as well as entry of foreign substances such as irritants, microbes and allergens. The epidermal barrier is made up of structural proteins including filaggrin (FLG). FLG deficiencies or mutations in the epidermis result in a weakened skin barrier, as it is less able to retain water, and the lipids that surround and support the cells break down more quickly. The impaired skin barrier allows loss of moisture and irritants or allergens to pass through the skin more easily. This can ultimately prompt an inflammatory cascade.
Triggers of AE may include, allergen exposure such as house dust mite, whereas, non-allergic factors such as Staphylococcus aureus infection, abrasive garments, temperature changes, stress, and exposure to irritants such as detergents, harsh soaps and fragrances and habitual scratching can disrupt the skin barrier function.
Assessment and management of atopic eczema
According to the UK Working Party diagnostic criteria, a diagnosis for AE requires: patients must have a history of itchy skin plus a minimum of 3 of the following;
• Flexural involvement, involving skin creases such as behind the knees, bends of elbows, wrists, front of ankles, or neck
• History of generally dry skin in the last 12 months
• Visible flexural eczema
• Personal history of asthma or hay fever (or history of atopic disease in a first degree relative, if patient is under 4 years)
• Onset of signs and symptoms in the first two years of life
Validated measures of severity in AE, include SCORing Atopic Dermatitis (SCORAD), Eczema Area and Severity Index (EASI) and Patient Orientated Eczema Measure (POEM). Measurement techniques can be helpful in assessment, monitoring and guidance on effective management.
A really useful health-related quality of life measurement tool used in clinical practice is the Dermatology Life Quality Index (DLQI). This tool is not AE specific, however it helps clinicians to assess the impact of AE on the person’s life and assists the clinician to measure effectiveness of treatments. DLQI scores range from 0 (no impairment of quality of life) to 30 (maximum impairment). For children, there is the Children’s Dermatology Life Quality Index (CDLQI) which is also available with added cartoons. The aim of the questionnaire is to measure how much did the child’s skin condition affect them in the last week.
Once a diagnosis of AE is established, treatment decisions are based on disease activity and impact of the disease on the patient’s quality of life.
Management
AE is a life-long skin condition, so the main aim of treatment is to improve symptoms and achieve long-term control. Typically a multistep treatment approach may be considered, according to severity of the disease, patients age, its extent and distribution.
Key principals in AE management are: restoring the skin barrier with emollient therapy, baseline trigger avoidance, anti-inflammatory treatment with topical steroids or topical calcineurin inhibitors. In moderate to severe AE, phototherapy or systemic agents may be considered.
Trigger avoidance and Topical treatments
Trigger avoidance: Taking a careful history to help identify any relationship between suspected triggers and AE skin symptoms is important. Identification, elimination and/or control of exacerbating triggers maybe helpful in preventing recurrent symptoms and disease deterioration. Irritants in the environment, such as physical (fabrics such as wool) household chemicals (bleaches or solvents) can aggravate affected skin in people living with AE. Consideration for non-allergic triggers, may include, psychological stress, temperature extremes, and dry wintery or conditioned air.
Emollients: Ongoing, practical application of over-the-counter emollients is the cornerstone of treatment for the condition, as dry skin is one of the predominant manifestations of AE. The purpose of emollients is to improve the skin barrier by restoring and maintaining skin hydration, therefore soothing the skin and reducing pruritus. Emollients are also a crucial element of maintenance treatment and also in the prevention of flares. Adults require at least 500g/ per week and children at least 250g/per week. Pump dispensers are preferable, in order to prevent contamination. The use of emollient wash products instead of ordinary soaps and bubble baths are also recommended. Bathing should be limited to short periods of time (e.g. 5-10 minutes) with warm water, and when finished, followed by application of emollients. When choosing an emollient, individual preference, skin type, skin dryness, inflammation and body area may be considered to help promote adherence.
In July 2020 the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK, in partnership with the National Fire Chiefs Council, launched a campaign to raise awareness around the potential fire risks of emollients (moisturisers) often used in the management of skin disease.
The British Association of Dermatologists (BAD) released a statement on their website in July 2020 on fire risk associated with emollient use. According to the BAD “emollients represent a safe treatment option, for most patients. That said, it is important that patients, carers, and healthcare professionals are aware of the potential fire risks associated with these products, and how to minimise them. It is important to stress that emollients are not flammable in themselves, nor when they are on the skin. The risk comes when emollient residue dries onto fabrics such as clothing or bedding and then comes into contact with a naked flame or lit cigarette causing them to catch fire.
To reduce the fire risk, patients using these products are advised to avoid naked flames completely, including smoking cigarettes and being near people who are smoking or using naked flames. It is also advisable to wash clothing and bed linen regularly.”
Wet-wrap therapy: This is a technique used in people with moderate to severe eczema by using two layers of open-weave tubular bandage applied over emollients. The bottom layer is soaked in warm water, squeezed out and then put onto the skin over the emollient wet and then followed by the top layer which is dry. This treatment is reported to introduce moisture, soothe and protect irritated skin from damage caused by scratching and is applied for short periods of time. Caution should be taken when wet wrapping using topical steroids, as absorption is increased. Occlusive medicated dressings or dry bandages should not be used in infected AE.
Topical corticosteroids: Recognised as first-line anti-inflammatory prescribed treatments in acute exacerbations. Selection of agent varies depending on potency, the location and severity of skin affected by AE, patient age and formulation. Topical corticosteroids are grouped into classes depending on their potency, ranging from mild, moderate, potent and very potent. A fingertip unit (FTU) is a useful method for individuals to apply topical corticosteroid in safe quantities. A FTU refers to the amount of ointment or cream applied from the end of an adult index fingertip, to the distal crease (first joint) in the finger, and is equivalent to approximately 0.5grams. The recommended FTU of topical corticosteroid will depend on the part of the body being treated and whether the patient is an adult or child. The Irish Skin Foundation has a useful guide describing the number of FTU’s required for different parts of the body in adults and children in the eczema booklet on https://irishskin.ie/eczema/.
Topical calcineurin inhibitors (TCI): Considered as a second-line option for short-term and intermittent treatment of AE. These prescribed non steroidal, anti-inflammatory agents do not cause skin atrophy, and are beneficial in treating sensitive skin areas such as the face and groin. Stinging on application is the most common side-effect, but this usually settles within a few days, also sun protection is advised, in patients treated with TCI.
Phototherapy
Phototherapy is a form of artificial ultraviolet light treatment, comprised of either ultraviolet A (UVA) or ultraviolet B (UVB) wavelengths of light, delivered in hospital dermatology day care centres. Phototherapy may be given in combination with topical steroids and emollients to prevent flare-up.
Systemic agents
In circumstances where AE is moderate to severe or widespread, and has not responded to topical or phototherapy treatments or when quality of life is significantly impacted, systemic immunosuppressive treatments may be prescribed. Current options include, methotrexate, ciclosporin, mycophenolate mofetil, and azathioprine. The individual patient profile, lifestyle factors, associated comorbidities, side effect profile along with patient preference all influence choice of drug. These medications have different toxicity profiles, therefore patients are reviewed and monitored regularly to avoid any potential side effects.
Newer systemic agents which can be prescribed in secondary care for patients with moderate to severe AE, through the HSE managed access programme include; abrocitinib (Cibinqo ® ), dupilumab (Dupixent ® ), tralokinumab (Adtralza ® ) and upadacitinib (RINVOQ ® ). These agents are available to patients that meet a certain criteria set out by the Managed Access Protocol and prescribing is confined to consultant dermatologists.
AE associated infections
AE is often complicated by bacterial, viral and fungal infections, due to a weakened skin barrier, trauma from scratching and impaired cellular immunity. Staphylococcus aureus, is the most common organism, to cause bacterial infection in AE. Distinctive signs may include honey-coloured crusts, weeping and pustules, and folliculitis in hair-bearing areas. Topical or oral antimicrobials may be prescribed. Common viral Infections seen in individuals with AE include molluscum contagiosum, cutaneous warts and herpes simplex virus.
Itch
AE is often referred to as the “itch that rashes” due to the pruritus that patients with AE often experience. The urge to scratch can be overwhelming but only provides temporary relief, leading to more itching and scratching (the itch-scratch cycle) which may lead to excoriation and skin barrier damage. Itch interferes with sleep and negatively impacts on an individual’s quality of life, as well as that of the wider family, with sleep deprivation contributing to difficulties concentrating at school, and/or work. Sufficient sleep is crucial for health and well-being. In children, both acute and chronic sleep disruption has been associated with a range of ‘cognitive, mood and behavioural impairments’, as well as poor performance in school. In a ISF ‘Living with Atopic Eczema Survey’ in 2019, respondents reported interrupted/ loss of sleep in 86% of children and 84% of adults. Additionally, 26% of carers of children with AE, reported that their child missed 1-2 days of school per month due to their skin condition.
Quality of life
For some, the burden of AE often extends beyond the immediate dermatological effects of this disease. AE can place a serious mental health burden on patients, particularly those living with moderate-to-severe disease, with research indicating that the more severe the AE, the more quality of life is impacted. It has been associated with anxiety, depression and attention deficit hyperactivity disorder. Research has indicated that the health related quality of life in children with AE is comparable to that of other chronic childhood diseases such as diabetes or asthma.
Conclusion
AE is often associated as a disease of childhood, but it is important not to forget that AE can be a very distressing condition for adults as well. While severity of AE varies greatly, most are affected by mild disease. Due to a variety of treatments for AE and different individual symptoms, it is important to educate patients and their families about the disease, and self-care to ensure compliance and effective management. These include, basic skin care routines that fits in with the individual’s lifestyle, management of future flares and trigger avoidance. Also consideration around any potential fears with regards to side-effects of medications such as topical steroids should be addressed, as this may impede sufficient treatment. Education for self-managing AE, are reported to improve the severity of the disease and also improve the quality of life for these individuals and their carers.
The Irish Skin Foundation operates a Ask-a-Nurse Helpline that provides free, direct, accessible and specialist guidance about skin conditions, delivered by dermatology clinical nurse specialists on an appointment model.
For information on eczema or other skin conditions log onto www.irishskin.ie
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