The Generalist: Eczema

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
• Egg
• Wheat 
• Milk
• 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)