In this case study I intend to analyses and evaluate the care that I delivered to a patient who presented with topic eczema, beginning with a actionable for the case study and a description of the presenting complaint. It is then relevant to describe the function of skin and the path-physiology of eczema. I will then go on to describe how I arrived at the diagnosis. Followed by a critical review around the importance of the effect topic eczema has on quality of life. Consideration will be made to the effect of triggers and Irritants on topic eczema before discussing the treatments available and a rationale for the care given.
Finally I will review ongoing research In relation to possible future treatment developments. It Is relevant to study eczema because epidemiological work has shown that “the number of new cases of eczema is rising in most westernizes countries, affecting 10 significant impact upon the quality of life (Orange, 2010). Julie attended the Out-of- Hours GAP with her 5-year-old daughter, Chloe (the names have been changed, for confidentiality). Julie was concerned about School’s skin. Chloe had an itchy red rash and her skin was dry.
Julie was upset and stated that she has already seen her own GAP and was using the aqueous cream that had been prescribed but the condition as not improving. Julie was concerned, as Chloe had been having difficulty sleeping the last two nights because of the rash being itchy. The primary function of the skin is to act as a barrier against the external environment, preventing the entry of pathogens and allergens and minimizing water loss (Cork 1997). In normal skin cornerstone (cells in the outer skin layer), are full of natural moisturizing factor, which attracts water into the cells helping them to swell to produce a smooth skin barrier.
In people with eczema, inherited factors affect the development of the skin barrier White, 2011). The cornerstone shrink allowing penetration of irritants and allergens, leading to exacerbation of eczema and the loss of transcendental water (Vogel 2011). There is no definitive test that can be used to diagnose topic eczema. The diagnosis relies on assessment of the clinical features, together with a detailed history (White, 2011). It is important to ascertain whether the rash is itchy as the diagnosis is unlikely to be topic eczema if there is no itch (NASH CSS, 2011).
Chloe did have an itchy rash, suggestive of eczema. According to NICE (2007) children would also have three or more of the following: Visual flexural dermatitis involving the skin creases. History of flexural dermatitis. History of dry skin in the last 12 months. History of asthma or allergic rhinitis. Onset of signs and symptoms under the age of 2 years. On questioning Julie stated that Chloe has had episodes of rashes and dry skin since being a baby, further suggestive of topic eczema. It is important when diagnosing eczema to examine all areas of affected skin (White, 2011).
On examination Chloe had visible dry, red skin with localized excoriation and thickening, evident on the backs of ere knees, arm flexure and abdomen. There was no evidence of bleeding, oozing, cracking, or alteration of pigmentation, suggesting that the eczema is not infected. Robinson (2011) describes the signs of infected eczema as weeping with pustules, crusts and failing to respond to therapy. The extent and severity of eczema can be classified as follows (NICE, 2007): Mild eczema, dry areas and infrequent itching. Moderate eczema, areas of dry skin, frequent itching and redness.
Severe eczema, widespread dry skin, incessant itching and redness. It can be seen from this guidance that Chloe can be described as having moderate eczema. Assessment of topic eczema needs to include the effect of the condition on the quality of life (Robinson 2011). It is relevant to ask about the effect of eczema on daily activities (school, work, and social life), sleep, and mood. The impairment of quality of life caused by childhood eczema has been shown to be greater than or equal to other common childhood diseases such as asthma and diabetes mellitus (Lewis Jones 2006).
School’s eczema was causing sleep problems suggesting the need for an increase in treatment and a review to assess the effectiveness of the new treatment. And measure the effect of eczema on children and their families. These include the patient-orientated eczema measure (see appendix 1). This was not done at the time of School’s consultation; on reflection this would have been useful to further evaluate the impact of School’s eczema upon the quality of life. However it was recommended that Chloe saw her own practice for review.
I advised to review in 2 weeks in the event of improvement and sooner if no response to treatment or in the event of deterioration. Eczema is an episodic disease of exacerbations and remissions. Exacerbation can be triggered by many factors including irritants for example soaps ND detergents, which reduce the already depleted lipid barrier of the skin and may also, act directly as an allergen (NASH CSS, 2011). Also skin infections, extremes of temperature and allergens (including food and inhaled allergens, house dust mites and animal dander) may act as triggers.
The role of factors such as stress and humidity is not clear but it has been suggested that a combination of factor acting together may be important (Eraser and Van Oneself, 2010). There have been no clinical trials identified that address the effectiveness of avoidance of irritants in the management of topic eczema. However, where an irritant effect is suspected, then it should be suggested to patients that they avoid fragrances products such as soaps and shower gels (Peat, 2011). During the consultation with Chloe and her Mum advice was given on using products for sensitive skin, avoidance and detergents of allergens.
Advice was also given on, avoiding scratching the eczema and keeping the nails short, as suggested by Peat (2011). Antihistamines should not be used routinely, they are recommended for children with severe topic eczema or where there is severe itching or artistic (NICE, 2007). Treatments available for eczema aim to ease or control symptoms. They should be tailored to severity of the eczema and should be delivered in a stepped approach (NICE, 2007). Emollients should form the basis of therapy.
Emollients smooth, soothe, soften and hydrate the skin and reduce inflammation and irritation (Green, 2011). Emollients work by retaining water in the skin and enable repair of damaged cells on the skins surface. They also act as a barrier to the environment, preventing irritants penetrating the epidermis (NICE, 2007). Despite limited evidence on the effectiveness f emollients and how best to apply them, their importance in the management of eczema is widely accepted (Green, 2011). Chloe was already using aqueous cream, a type of emollient, but was not having any improvement of her symptoms.
The British Association of Dermatologists (2009) recommends that emollients might be sufficient for mild eczema but for moderate and severe eczema emollients are used as an adjunct to topical treatment. Green (2011) suggests the emollient of choice should be that which the patient finds most effective and acceptable. The British Association of Dermatologists (2009) recommends complete emollient therapy (different emollient products used in combination) for optimum effect. A prescription was offered to Chloe for Avenue cream, which is well absorbed and easy to spread.
I recommended to Julie that Chloe should discontinue to use the aqueous cream. Recent research has indicated that aqueous cream contains sodium laurel sulfate, an anionic surfactant and irritant, which has been shown to increase water loss from the skin should be used frequently and generously (The British Association of Dermatology, 2009). Topical steroids have an important role in eczema. They inhibit production of and action of inflammatory mediators in the skin and reduce inflammation and itch (Robinson, 2011). Topical steroids should be used when, the eczema is not controlled by emollients (NICE, 2007).
They should be applied only to the area of active topic eczema and should be applied once or twice daily. The NICE guidelines give a stepped approach to treating eczema depending on severity and suggest moderate eczema should be treated with moderate potency topical corticosteroids. Chloe was given a prescription for a moderate potency topical corticosteroid and advised to use wick daily, only on the areas of active eczema and was given reassurance about the safety of corticosteroids and that the benefits out-weight the risks when applied correctly.
A barrier to effective treatment with steroids is parental anxiety about the side effects. Smith et al (2010) found that most parents believe that corticosteroids are dangerous, with skin thinning as the most worrying side effect. However, the study also found that giving parents information relating to the safety of topical steroids, relative to the potency and demonstration of their use, could modify these concerns. Also discussion around how they work, and possible outcomes of failure to use them to treat eczema, is important.
This should include education around the detrimental effect of quality of life. The use of calceolaria inhibitors is also suggested as a second line treatment for moderate to severe eczema (NICE, 2007), they have been shown to have anti-inflammatory properties. This could be considered for Chloe if the improvement is not satisfactory with her new treatment. NICE, 2007 also recommends the use of bandages in moderate eczema. Bandages can help to protect the skin and encourage penetration of topical treatments.
For a wet wrap dressing a damp bandage is applied over the topical treatment and a dry bandage is placed over. Wet wrap dressings help to keep the skin cooled and soothed and reduce further damage from scratching. However wet wrap bandages should not be used as a first-line treatment and are best used in children whose eczema has not responded to standard treatment (Robinson, 2011). This suggests that School’s eczema should be managed initially with emollients and steroids with consideration to calceolaria inhibitors and bandages as a second line treatment.
Recent research has shown that there are individual variations between patients with topic eczema (Novak, 2009). It has been suggested that in the future it may be possible to sub classify patients with topic eczema based on clinical features and trigger factors in order to create individualized and effective treatment. This might amend current symptomatic therapies, which target more on pathways of inflammation and skin barrier function (Novak and Simon, 2011). In conclusion topic eczema is a common chronic condition in children, which is increasing in incidence in westernizes countries.
In people with topic eczema, inherited factors affect the development of the skin barrier allowing irritants and allergens to penetrate the skin, leading to exacerbation of eczema. School’s rash was diagnosed, according to the NICE guidelines, as moderate eczema. Throughout the literature emphasis is given to the importance of assessment of the effect on quality of life. School’s sleep was affected by her condition and the use of an assessment tool would have been beneficial to Emollients are the mainstay of treatment and should be prescribed in large quantities and used frequently.
Topical steroids play an important role and are used when emollients are not controlling the eczema. Chloe was given a combination of both of these treatments, with the aim of gaining control of the symptoms. Second line treatment of eczema involves the use of calceolaria inhibitors and bandages, these methods should only be considered after emollients and topical corticosteroids have been ineffective. Chloe was advised to return to her own practice, where an increase in treatment should be considered if the treatment does not gain control of the symptoms.