Clinical Guidelines (Nursing)

Eczema management

  •  RCH: Consider  Criteria Led Discharge


    Introduction

    Aim

    Definition of Terms

    Assessment

    Management

    Referrals 

    Follow up Recommendations

    Parent information

    Resources

    Evidence Table 


    Introduction

    Atopic eczema (AE) or atopic dermatitis (AD) is a dry, itchy, inflammatory, chronic skin disease that typically begins in early childhood, affecting around 30% of children.  
    This condition can worsen and cause intractable pruritus, soreness, infection and sleep disturbance. The onset of eczema is usually before 12 months and it follows a remitting and relapsing course. Most children will "grow out of" eczema before five years of age. There is no cure of AE, however if treated and managed well the disease has less impact on daily living and is less likely to have a negative effect on quality of life for the patient and family.

    Aim

    Provide evidence based strategies for the management of AE in order to improve eczema and reduce impacts on patient and family quality of life. 

    Definition of Terms

    • Atopic eczema (AE) or atopic dermatitis (AD)
    • Flares: a worsening of the eczema
    • Triggers: factors that flare the eczema
    • Wet dressings: dressings used in the treatment of eczema 

    Assessment

    The UK Diagnostic Criteria for atopic eczema are:

    • Must have itch
    • Plus 3 or more of the following:
      • History of involvement in skin creases
      • Personal history of asthma or hayfever (or history of atopic disease in 1st degree relative if child is under 4 years of age)
      • A history of dry skin in the last year
      • Onset under the age of 2 years (not used if child is under 4 years)
      • Visible flexural eczema
    Erythema: redness of the skin
    eczema - erythema 2
    Discoid eczema: disc shaped, clearly demarcated eczematous patches to limbs and trunk.
    eczema - discoid 1
    eczema - discoid 2

    Assessment tools

    Patient assessment should be undertaken by either a medical officer or an eczema nurse consultant/ practitioner  to grade the degree of eczema severity (mild, moderate or severe) and the presence or absence of infection.  Use  SCORAD (scoring atopic dermatitis) index calculator to calculate the severity score.

     Eczema Grading Mild Moderate Severe
    Subjective SCORAD   <25  25-50   >50
    Objective SCORAD   <15 15-40 >40

    Management

    Eczema Treatments fall into two categories

    1. Every day treatments and avoidance of triggers (these treatments are ongoing regardless of the presence or absence of eczema)

    • Avoiding environmental aggravators
      • Heat, (clothes, heaters, hot cars, classrooms, hot baths, blankets)
      • Prickly/rough material (wool, sandpits, tags)
      • Dryness of the skin
      • Regular moisturiser, which should be applied from top to toe at least twice a day even if the skin is clear of eczema. Do not double dip into the tub of lotion.
    • Daily cool bath; adding bath oil (1 capful), salt (1/3 cup per 10 litres water), bleach 4% (12mls per 10 litres water)(sodium hypochlorite 4%) for moderate or severe and chronic, infected eczema (or as recommended by a health professional) and bath oil. Face and head should also be wet and the skin should NOT be rinsed with fresh water after the bath.
    • Consider Vitamin D oral daily supplementation for moderate to severe eczema or if the baby is breast fed
    • Apply a moisturising cream top to toe 2-3 times a day even when the eczema is clear. Moisturisers should be applied over the topical steroids. Examples of trade marked moisturisers; QV cream, Cetaphil cream, Kenkay cream, Atoderm crème. These are available over the counter in pharmacies. Creams should be removed from the tubs onto clean paper and then taken from the paper to the skin to avoid bacterial contamination of the tub. 

    2. Flaring treatments these treatments should be used as soon as there is a flare (an acute deterioration), such as increasing erythema and itch, and stopped when the symptoms are controlled and then again re started if flaring again.

    Topical steroids and anti-inflammatory creams 

        • for moderate facial eczema use of a generally weaker cream for the face such as hydrocortisone 1% for mild facial eczema, 
        • pimecrolimus (Elidel cream) 
        • stronger steroid for the body e.g. Advantan or Elocon

        Tar creams for lichenification (thickening of the skin). Tar creams should not be applied to the face, groin and flexures. 

        Medication such as antibiotics or antivirals for treating organisms causing secondary infected eczema. Usually orally however intravenous may be needed for severely infected eczema and when septic.

        Intranasal bactroban ointment twice daily for five days if nasal swabs are positive for Staphylococcus aureus.

        Wet dressings are to be applied as soon as possible for severe eczema. For moderate eczema apply immediately or within 1 day of starting the topical steroids (if the eczema has NOT cleared) 

        Wet dressings to re-hydrate and calm the skin using Tubifast tm .  

        • The Wet dressing regime is as follows:
          • Severe eczema
              • Four times a day for 3 days only (Admission or HITH may be referred to assist during this acute phase)
              • Then twice daily for one week
              • Then nightly until the eczema is clear and then recommence nightly if flaring.
            • Moderate eczema
              • Twice daily for 3 days
              • Nightly until the eczema is clear and then recommence nightly if flaring
            • Mild eczema
              • Not required
          • Cool compressing - hydration - for immediate relief of itch 
            • Use a wet (water and plain bath oil) towel (e.g. chux or rediwipe)
            • Apply to wet cloth to itchy areas for 5 -10 minutes, then apply a moisturiser post compressing
            • These are also the wet dressing for the face, and are best applied while awake and when feeding

          Eczema Treatment Plan

          All patients should have an Eczema Treatment Plan completed before they go home. To complete an Eczema Treatment Plan.

          Wet dressings
          eczema - wet dresssing 2
          Cool compresses
          eczema - cold compress

          Infected eczema

          Secondary bacterial infection of eczema is a common complication as the skin is not intact and thus more vulnerable to infection. A common bacteria Staphylococcus aureus is normal flora found on the skin. Infection can make eczema worse and more difficult to treat. 
          Infection should be suspected if there is crusting, weeping, erythema, cracks, frank pus or multiple excoriations and increased soreness and itching which may suggest bacterial infection. A common causative organism is Staphylococcus aureus.
          Secondary viral infection caused by herpes simplex virus (HSV) is characterized by a sudden onset of grouped, small white or clear fluid filled vesicles, satellite or "punch out" lesions, pustules, and erosions. It is often tender, painful and itchy. Other viruses that may cause the eczema to flare are molluscum contagiosum and coxsackie A6 virus (hand foot and mouth disease).

          Secondary bacterial infection
          eczema - infected
          Secondary herpes simplex 1 infection
          eczema - infected foot

          Management of infected eczema

          The principles of managing infected eczema are:

          • Removing the crusts – with wiping and cool compressing whilst soaking in the bath
          • Cortisone can be applied over open skin and presence of infection, however FIRST remove the crusts and weeping.
          • For bacterial infections:
            • Oral antibiotics (e.g. cephalexin or flucloxacillin) for 7 to 10 days
            • IV antibiotics for children that are unwell due to the skin infection
            • Add White King tm bleach (4%) to the cool bath water (29 – 32 degrees). The dilution should be 12 mLs per 10 Litres of water. The scalp and face should also be washed whilst bathing. Bleach can be added to the bath every day
            • Pool or table salt can be added to decrease stinging and to help settle inflammation and itch. The dilution is 100 grams per 10 Litres of water. This can be added daily and used ongoing
            • Swabs can be taken if the treating doctor/nurse practitioner is unsure of the organism causing the infection or suspecting a multi resitant organism
          • For viral infections likely caused by HSV when moderate to severe or on the face
            • For best response start oral aciclovir as soon as possible and within 48 hours of onset of symptoms; little benefit will be realised if treatment is delayed beyond onset of symptoms of 72 hours (unless patient is immunocompromised or has progressive clinical state)
            • IV aciclovir may be used for severe infections, those who are systemically unwell and febrile patients and those patient’s with threatened eye involvement (refer to Ophthalmology urgently for eye involvement)
            • Urgent Ophthalmology review if the infection is near the eye/s

            NOTE: most patients with viral infected eczema, invariably also have a bacterial skin infection as well. Assess using appropriate skin swabs to identify a bacterial infection and begin antibiotics as instructed above.

            Possible investigations

            Skin swabs:

            • Bacterial infections:
              • Bacterial skin swabs should be taken from every inpatient admitted to the medical wards for problems of atopic or discoid eczema. This swab should be collected from an open, excoriated or crusted eczema lesion to determine bacteria and assist with identifying organism resistances to assist with antimicrobial prescribing
              • If patients attending the RCH Outpatient Department, a skin swab should be taken from an infected eczema lesion if multi resistant Staphylococcus aureus is suspected or to verify a bacterial infection
              • Patients and parents nasal swabs are only required for patients who are experiencing recurrent infections and boils or suspected nasal carriage.
            • Viral swabs may be needed to confirm causative organism, this should be collected from the base of a fresh blister.  
            • Refer to RCH policy on specimen collection

            Allergy Testing (SPT/ ImmunoCAP IgE test) is indicated if:

            • Child has history of flushing, itch, urticaria or general flare of the eczema after ingestion of food
            • Extremely itchy child (under 12 months) with moderate to severe eczema and not improving with treatment
            • Child compliant with adequate treatment regime for greater than 6 weeks with no improvement in eczema
            • Eczema lesions are in the periorbital and exposed areas such as arms and legs, may indicate environmental allergy (e.g. pollen or house dust mite)

            Refer to immunologist, allergist or dermatologist for Skin Prick Test (SPT) and a dietician if food allergies are proven on SPT or ImmunoCAP IgE test.

            Referrals

            A medical referral is required:

            Eczema Workshop appointments Eczema Workshop Clerk 9345-4691 (Mon-Fri)
            Allergy testing and advice Immunology or Allergy Department 9345-6180
            Family is unable to apply treatment at home

            Home and community care (HACC)- RCH only

            Royal District Nursing Service


            9345-5695

            1300 334 455
            Outpatient enquiries   Specialist Clinics 9345-6180 (Mon-Fri)

            Follow up appointment recommendations

            Inpatient Outpatient Clinic 2 weeks post discharge
            Mild eczema General Practitioner  
            Moderate eczema Outpatient Clinic two to four weeks, if improved to mild then discharge to General Practitioner
            Severe eczema Outpatient Clinic one to two weeks, then as per mild and moderate
            Eczema Workshop Outpatient Clinic 2- 4 weeks post discharge, then as per mild to severe

            For further assistance the Dermatology Registrars and Dermatology Nurse Practitioners/Consultants can be paged via switchboard 9345 5522.

            Parent information

            Summary points for parents:

            • Discuss how to avoid environmental aggravators - overheating, rough prickly materials, and ensure regular and ongoing use of moisturisers and eczema baths
            • Give guidance on how to follow and institute the treatment plan for excellent management and eczema improvement
            • Give guidance that daily baths are a treatment for eczema and help to clean and remove the bacterial load from the skin, add moisture and decrease inflammation and itch.  Bleach can be added to baths for moderate or severe and infected eczema
            • Make sure they understand when to begin flaring treatment (as soon as the flare begins and cease flaring treatment when symptoms decrease).
            • Wet dressings are essential in controlling a flare and promoting sleep and should be applied if the other treatments have not cleared the eczema within 24 hours

            See  parent resources below

            Eczema resources

            For clinical staff:

            Eczema girl green logo 100px

            For parents:

                 Kids Health Information   

            Evidence table

            Eczema Management Evidence Table

             

            Please remember to read the disclaimer.


            The development of this nursing guideline was coordinated by Emma King, Nurse Practitioner, Dermatology Department, and approved by the Nursing Clinical Effectiveness Committee. Updated March 2018.