The Generalist: Eczema
Vanessa Cardy MD, Adrien Selim MD, and Heidi James MD
- Eczema/atopic dermatitis is a chronic disease
- History
- Ask about impact on patient/family sleep, quality of life, function
- Remember significant psychological/emotional impact of eczema lesions
- Ask about triggers, patterns of flares
- Ask about history and family history of allergies and asthma (atopy)
- Physical
- Rash can vary quite widely and locations vary depending on age group
- Babies: head and face, and trunk and extensors
- School aged kids: flexor surfaces, back of neck
- Teens/adults: most often hands, other areas too
- Treatment
- Non-pharmacological
- Clothing
- Cotton, long sleeves, long legs
- “Mittens” to prevent night-time scratching in babies
- Diet
- Effects is overestimated by parents and underestimated by doctors
- The worse the eczema, the higher the probability of allergy
- Fortunately these allergies are generally outgrown
- Most common allergies
- If a food allergy is suspected, do formal IgE levels and skin prick testing
- Most kids land in the gray zone on these tests and both false positives and false negatives are common
- Baths
- No soap
- Gentle unscented cleansers, oil or plain water
- Ok to take daily baths, not too long and not too hot
- Pat to dry
- Apply moisturizer within thirty minutes of bath to lock in moisture
- Bleach baths?
- Helps with supra-infected eczema
- Recipe is ½ cup per full bath, of regular bleach
- Wet wraps
- Apply lotion to patient then apply dunk clothes/PJs/dressings in warm water and place on the patient
- Then dry layer of clothes/PJs/dressings placed over top of the wet layer
- Moisturizers
- Apply as many times a day as possible
- Use unscented products
- Use petroleum jelly, OTC creams/ointments, sunflower seed oil or coconut oil, but NOT olive oil
- Steroids
- Start steroid treatment with first signs of a flare in established cases
- Ointments sting less, are more potent and provide better moisturization
- Address steroid phobia
- If symptoms note improving, consider allergy to the carrier/inert portion of the cream/ointment.
- Calcineurin inhibitors
- Can be used in steroid sensitive areas
- Can be used for maintenance or flares
- Infections
- Topical antibiotics if small areas of impetigo
- Cellulitis might need oral meds
- Can give cephalexin BID in children
- Always consider eczema herpeticum (can be fatal)
- Referral
- When treatments are not effective
- If questioning the diagnosis
- When need second or third line therapies (phototherapy, methotrexate, cyclosporin, azathioprine)
