eczema and dermatitis

• Dermatology


  The branch of medicine concerned with the skin and its diseases
• Types of eczema


  • Atopic eczema
  • Asteatotic eczema
  • Pompholyx (dyshidrotic) eczema
  • Gravitational (venous, varicose or stasis) eczema
  • Irritant contact dermatitis
  • Allergic contact dermatitis
  • Seborrhoeic eczema (dermatitis)
• Eczema


  • Inflammatory condition of the epidermis
  • In UK, affects 20% of children and 8% of adults (improves with age)
• Pathology of eczema


  • Genetic component - Filaggrin gene mutation – loss filament protein → less binding of keratin fibres → weakens barrier → loss of moisture and drying → irritants and allergens → hypersensitivity
  • Allergic responses – disease flare
• History taking for eczema

  • FH or MHx of dermatitis, hay fever or asthma
  • DLQI (Dermatology Life Quality Index)
• Examination of eczema


  • Flexures, but widespread. Often hands and face. Erythema, papules, scaling. Secondary excoriation, lichenification and infection
  • EASI (Eczema Area and Severity Index)
• Self-help treatments for atopic eczema

  • Emollients
  • Topical corticosteroids
  • Topical immunomodulators
  • Oral systemic
  • Biological
• Non-pharmacological self-help for atopic eczema

  • Bathing
  • Environment
  • Clothing
• Emollients


  • Cornerstone of management
  • Apply all the time (not just flare ups)
  • Apply liberally and often; after bathing/washing hands, when itchy. Avoid perfumed products
  • How to apply: 250-500g per week – child, Think layer, leave 10 minutes, Stroking in direction of hairs (rather than rubbing), Dispenser or tubs, Fridge (creams)
  • Complete Emollient Therapy
  • Give patients choice
• Emollients can make fabrics flammable and bath slippery
• Topical corticosteroids


  • 1st line – Atopic eczema
  • Acute/flares – not for long term (tachyphylaxis and side effects)
  • 'maintenance' – if experiencing flares 2-3 times a month
  • Potency (see Table in BNF)
  • build up OR 'hit hard'
  • body area (palms/soles/scalp versus face/flexures/genital areas; age; occlusion)
  • Application: Use max. twice or once (very potent) a day; shortest time (7-14 days, wean), Evidence – once day only, 30 minutes after emollient, Finger-tip units, Formulation - creams, ointment and lotions
• Topical steroid side-effects are rare with short term use, but can include skin atrophy and thinning, striae, perioral dermatitis, telangiectiasia, Cushing's syndrome (oral) with long term or on and off use
• Other topical treatments for eczema

  • Bandages – ichthammol and zinc oxide
  • Dry-wrap or wet-wrap dressings
  • Astringent – potassium permanganate
  • Pimecrolimus
  • Tacrolimus
  • Phototherapy
• Systemic treatments for severe refractory eczema (specialist only)

  • Antibiotics
  • Sedating antihistamines
  • Systemic steroids – short course
  • Licensed - ciclosporin
  • Unlicensed - methotrexate, azathioprine, mycophenolate
  • Biological - Dupilumab – monoclonal antibody, blocks signalling from IL-4 and IL-13
  • Baricitinib - selectively and reversibly inhibits the Janus-associated tyrosine kinases JAK1 and JAK2
• Treatments for hand eczema

  • Emollients
  • Topical steroids
  • Alitretinoin
  • PUVA
  • Systemic immuno-suppressants
• Irritant contact dermatitis (ICD)


  • More common than ACD
  • Irritant penetrates stratum corneum to invoke a response
  • Develops quickly after exposure (< 24 hours)
• Allergic contact dermatitis (ACD)


  • Requires sensitisation to occur
  • Once sensitised to allergen, re-exposure triggers T cells to initiate inflammatory response 48-72 hours later
  • Reaction not limited to site of exposure
• OTC management of exogenous eczema


  • Avoid irritant or allergen
  • Emollients
  • Topical corticosteroid - Mild potency – Hydrocortisone 1%, Moderate potency – Clobetasone 0.05% (Eumovate)
  • Sale restrictions: Hydrocortisone > 10 years, Clobetasone > 12 years of age, Cannot sell any for use on the face, anogenital region or on broken / infected skin, Only 15g, Duration limited to one week
• Resources

  • NICE and CKS; SIGN (adult eczema)
  • British Association of Dermatologists (BAD)
  • Primary Care Dermatology Society
  • DermNet New Zealand
  • National Eczema Society (patients)
  • Textbooks - Community Pharmacy: Symptoms, Diagnosis and Treatment, Minor Illness or Major Disease?