Topics to be covered in the Certificate Course
Psoriasis,
Atopic eczema ,
Tinea,
Acne,
Rosacea
Seborrhoeic Dermatitis
Below is a sample of how we present material in the Certificate course for Nurses. It looks at Atopic Eczema.
Atopic Eczema
Atopic dermatitis is the commonest form of endogenous dermatitis that you will see. Note that I said endogenous meaning coming from within. An exogenous dermatitis coming from outside would be perhaps an irritant dermatitis or an allergic contact dermatitis from something that you have handled or a plant contact dermatitis. You are born with a genetic tendency to atopic dermatitis.
The essential morphological feature of atopic dermatitis is a red scaly rash with breaks in the surface often with weeping. It is an extremely itchy disorder. In fact most of the rash is caused by scratching the skin. If you scratch skin excessively it will thicken, this is known as lichenification. Children with atopic eczema have an increased incidence of asthma and hayfever. The genes that cause these conditions are all on the same chromosome.
Atopic dermatitis is probably a disorder of barrier function rather than an immune disease. They can be irritated by soaps and detergents but also by wool, grass and sand. Atopics have skin that is much dryer than normal and hyperirritable. People who have the condition do not make good doctors or nurses because they cannot handle the hand washing and detergent exposure. Similarly they are not good hairdressers either.
Q 1: What is atopy?
A 1: Clinically it is the combination of eczema, asthma and hay fever in an individual or their family |
Q 2: What is the main superficial feature of eczema?
A 2: Small breaks or fissures in the red scaly skin.They may or may not weep. |
Q 3: What is the scratching pattern in atopic eczema called?
A 3: The Itch Scratch cycle.
History: Question What is the distribution of the rash in atopic dermatitis?
Answer Distribution is really quite classic. In young children before the age of one it is often on the face particularly on the cheeks. If it is found mainly circumoral then consider a food allergen. Past the age of one it is more typically seen on the fronts of the elbows and behind the knees. In severe cases of atopic dermatitis the entire body can be affected. Occasionally though the eczema can only affect a particular area for example above the lip, eyelids, behind the ears, perhaps just the face itself or present as a hand dermatitis.
Question What other factors are involved in the aetiology of atopic dermatitis?
Answer Allergy is always raised as an issue. Skin prick tests where a dissolved drop of the allergen is placed in the skin and a small scratch or prick is made into the skin tend to correlate with acute skin reactions such as urticaria and generalised erythema.When scratch tests are done for atopic dermatitis dust mite sensitivity is commonly found. In fact it is found in 80% of cases. The most common foods that cause problems in children are eggs, peanuts, milk, fish, soy and wheat. These are usually included in a battery of RAST tests where allergy tests can be done on a sample of blood. It indicates specific IgE immunity. This food worsening of atopic eczema is seen in individuals with severe disease rather than mild disease. It is thought that prolonged breastfeeding can delay the onset of atopic eczema and pro biotic therapy with lactobacillus is also useful but it does not prevent the development of the disorder. Secondary staphylococcal infection is commonly seen. In fact virtually all weeping atopics will have significant secondary staph, which should be treated with either oral antibiotics or with Mupirocin or Bactroban cream topically. Passive exposure to cigarette smoking can aggravate atopic dermatitis in a child.Sweat retention is important in some areas such as the back. Exposure to drying environments also contributes.Stress is certainly a factor in adults. Sweating is common in both children and adults especially in a very humid summer. Clothing and airborne allergens and irritants have already been mentioned.
Q 1: In what three conditions do patients scratch to the point of excoriation?
A 1: Atopic eczema, scabies and dermatitis herpetiformis. |
Q 2: What percentage of the population have an atopic diathesis?
A 2: Around 20% but only around 5% will exhibit eczema.
History: Pityriasis alba is a mild form of atopic eczema presenting in darker skinned individuals where the eczematous process interferes with normal pigmentation. Hence they present with a pale, slightly scaly area, particularly on the face or the upper trunk. This is easily managed with moisturising and some 1% Hydrocortisone cream.
Differential diagnosis. When you see a neonate with a rash on the face and chest wall and they are itchy, it may well be atopic dermatitis but you also have to consider seborrhoeic dermatitis, in which case the child may have extensive cradle cap as well. There is usually extensive flexural involvement under the armpits and in the groin, particularly under the neck fold. Atopic eczema usually spares the folds. This is best seen with the typically normal skin in the area covered by a nappy in a child with atopic eczema. Irritant dermatitis can also be a cause of eczema on the buttock skin and flexures as well as seborrhoeic eczema. In infants seborrhoeic dermatitis is also a significant differential but scabies is another important diagnosis to consider in an itchy child.
Q 1: Which rash is more likely to involve the flexures, atopic or seborrhoeic eczema?
A 1: Seborrhoeic eczema.
History: Question How do you manage a child with atopic dermatitis?
Answer You look at general measures such as avoiding irritants coming in contact with the skin namely wool, grass and excess soaps and detergents particularly bubble baths. You moisturise the skin either with an oatmeal based product such as Dermaveen or some Glycerine and Sorbolene cream or even Lanolin. You then try to suppress the dermatitis. 1% Hydrocortisone is usually quite safe in young children and can be used over extensive body areas. Creams are better than ointments for slightly weepy eczema. If there is significant weeping then there is likely to be secondary staph infection and an oral antibiotic such as Dicloxacillin has to be given or Bactroban cream can be applied.
Children with extensive atopic eczema are very irritable and often do not sleep. This may mean the whole family does not sleep. In these circumstances a sedative may be given such as Phenergan or Valergan. With Phenergan it is generally 5mg to 10mg at night. Sometimes these children should be admitted to hospital for wet dressings. These are done using blue backed incontinence sheets which are wetted on the paper side, a moisturising cream and a bit of Hydrocortisone is then applied to the skin and the damp area is applied to the creamed skin and bandaged on. Oral steroids are not a good idea in children and stronger topical steroids should be avoided. Methylprednisolone or Advantan 1% is a useful alternative if the initial Hydrocortone has not been successful.
Question How do you treat severe atopic eczema in an adult?
Answer All the general measures indicated for children come into play but drugs such as Azathioprine, Cyclosporine and PUVA using oral psoralens and UVA light or narrow band UVB have also been effective. Cyclosporine orally can be used in children as a dose of 5mg per kilogram per day but this is tapered after a few weeks. Any relevant food allergens should be sought and avoided. Desensitisation to dust mite can be attempted but it has to be done over a two to three year period and it is really only of value if you have proven dust mite exposure is a significant factor and that does not just mean a positive RAST test
Q 1: What features would suggest an eczema is infected?
A 1: Weeping and yellow crusts or pustules. Skin tenderness.
History: Question What advice do I give to someone with atopic dermatitis?
Answer First of all I tell them not to scratch. Scratching induces a lot of the lesions that you see in atopic dermatitis. This is very difficult for small children to obey and even adults. The child should rest in a cool room. They should avoid being overheated with blankets or doonas. The room should have tiled or wooden floors to avoid any accumulation of dust mite. The surface of the mattress should be wiped clean once a week or have a dust mite protector put on it. The child should wear cotton or silk clothing and avoid any woollen blankets. Baths should be kept to a minimum. Oil can be put in the bath such as Oilatum or Alpha Keri. The water should not be too warm. The skin should be patted dry and moisturiser should be added to the skin straight away. This is usually in the form of an oatmeal moisturiser such as Aveeno or Dermaveen.
A topical steroid will help reduce inflammation. On the body I use Methylprednisolone or Advantan cream. On the face 1% Hydrocortisone with Hycor 1% eye ointment around the eyes. If the skin is weeping then secondary infection is presumed present and Bactroban cream or some Dicloxacillin or Flucloxacillin orally is given. When topical steroids are used they should be used intensively two to three times a day for three to four days and then there should be a break during which only moisturiser is applied. The moisturiser is applied first and the steroid cream is applied to the areas of eczema.
Recently topical immunomodulators such as Pimecrolimus and Tacrolimus have been used. Pimecrolimus and 0.03% Tacrolimus are equivalent to 1% hydrocortisone. 0.1% Tacrolimus is equivalent to a moderate potency steroid. They are particularly useful for the face, head and neck. They will not work in the presence of infection. They are mainly a preventative rather than a treatment modality. They are there to prevent flares. Occasionally they will cause burning and stinging particularly Tacrolimus. Wet dressings have already been described for severely affected children admitted to hospital. Antihistamines orally primarily act as a sedative but have been used for years. Valergan and Phenergan are usually used.
Q 1: Are immune modulating drugs used to treat acute flares of atopic eczema?
A 1: No topical steroids are used to treat acute flares. Immune modulating drugs such as Pimecrolimus are used to prevent flares.
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History: Question What do you think about if a child’s eczema suddenly flares?
Answer You consider secondary infection. You consider a contact allergen and you also consider a herpes virus involving the eczema areas. This is known as eczema herpeticum. There are crusted papules or vesicles with erosions. They are often described as being monomorphic and punched out. If there are just crusts present it is impossible to differentiate between bacteria and viruses and swabs for both have to be taken. If eczema herpeticum is diagnosed Acyclovir should be given intravenously. In some cases of early eczema herpeticum you may be able to see the classic umbilicated vesicles of the herpes virus infection.
Q 1: How do you treat eczema herpeticum?
A 1: Admission to hospital and intravenous acyclovir. Avoid topical steroids |
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Diagnosis of Skin Diseases
Heroes of Dermatology
High Probability Dermatoses
Atopic Dermatitis
The video below covers the topics listed above in that order. You can download the video and then move the cursor at the base along to any subsection that you wish to view again.
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