eczema with details on how to apply wet wraps · •there are many facies of atopic eczema...
TRANSCRIPT
Dr Carol Hlela
Consultant DermatologistHead of Unit, Department of Dermatology, Paediatrics
Red Cross Children’s Hospital, UCT
Atopic Eczema with detail on
how to apply wet wraps
Red Cross War Memorial Children’sHospital
The many “FACIES” of Atopic Eczema
Very dry skin-may be an early manifestation of AE
Prophylactic Moisturisation
• Full body application of moisturisers for 6-8 months beginning in the first month of life for high risk infants showed a cumulative reduced incidence of AD
J Allergy Clin Immunology.2014 Oct; (134(4):818-23
J Allergy Clin Immunology.2014 Oct; (134(4):824-830.e6.
The many “FACIES” of Atopic Eczema
The many “FACIES” of Atopic Eczema
Infant phase(birth to 2 years)
• face, scalp, extensors of limbs
• cheeks, spares perioral and perinasa
• chin, cheilitis
• spares nappy area
AE distribution evolve over months/years
You can objectively confirm AE, using the UK working party criteria
You can objectively confirm AE, by searching for
Signs (stigmata) of cutaneous atopy
The many “FACIES” of Atopic Eczema
The many “FACIES” of Atopic Eczema
Education
Soap substitutes
Optimal topical care (emollients)
Specific therapy:
corticosteroids / calcinuerin inhibitorsAntihistamines systemic therapy –e.g. Azathioprine, Methotrexateultraviolet light therapy
Management principles – AE (to control the disease)
• Work with patients and parents as a team.
– Education
– Written instructions
– Address steroid phobia
Education in AE
Avoiding triggers
• Soaps ( use emollient wash products)
• Bubble baths
• Woolen or rough fabric clothes
• Fragrances
• Aggressive antiseptics
• Shampoos with high content sodium lauryl sulphate
• ?cats
• Sweat (use wet wraps)
• Dry climates (increase frequency of moisturizing)
Atopic Eczema - a chronic skin disease
Bathing Practice
• Bath/ shower once a day in warm (not hot) water
• Avoid soap
• Use a soap substitute such as aqueous cream
– bath oils, liquid paraffin
• Pat dry
Moisturisers
Basis of management
Should be used continuously even when skin is clear
• ?Ideal moisturiser: unperfumed, low pH
• Guided by patients needs and preferences
– Emulsifying ointment or cetomacrogol or Vaseline
– Avoid aqueous cream
• Applied frequently, after bathing and swimming
• Within 3 min of a luke warm bath or shower
• Prescribed in large quantities (250g/wk)
Topical corticosteroids
Mainstay of pharmacological treatment
vast majority respond very rapidly to adequate topical steroid treatment
But:
-need adequate quantities
-need correct potency (mid to high potent)
-steroid phobia
-applied for maximum 2 weeks, before side effects occur
Prescribing topical steroids -Vehicle:
Ointment – dry eczema
Lotion- wet eczema or scalp
Creams – wet eczema or eczema in folds
Gel - scalp and wet eczema
Quantity
Do not under-prescribe!
Prescribing topical steroids
• Once daily as effective as twice daily
• Acute flare:
– Intermittent use 7-14 days with emollient only “steroid holidays”
– Short bursts may be needed for flares
– Start potent , wean down
• Maintenance:
– Least potent that controls disease
– “weekend therapy”
Topical calcineurin inhibitors
• Not cause skin atrophy
• Pimecrolimus 1% (Elidel) is approved for mild AD, less effective than betamethasone
• Tacrolimus (0.03%) is superior
• May be useful for face, periorbital and intertriginous areas
Adjuvant therapy-in AE
NICE UK GUIDELINES
The many “FACIES” of Atopic Eczema
Benefits- Wet wrap therapy
• Ancient practice - in Babylon and Egypt
• To cool skin, anti-inflammatory, itch reduction
• For severe , refractory AD
• Safe and effective
• Biggest barrier: it’s time consuming
Side effects- Wet wrap therapy
• Increased infectious complications- folliculitis, impetigo, herpes
• Skin atrophy, striae, easy bruising, hypopigmentation, telangiectasia, steroid acne, steroid rosacea, hirsutism, contact dermatitis
• Rare: suppression of HPA axis, growth retardation, cataracts, glaucoma, tachyphylaxis, Cushing's
Conclusions• there are many facies of atopic eczema
• intervene appropriately depending on the stage of AE
• the vast majority will respond to optimal topical care
– Emollients
– Topical corticosteroids/TCIs
• moderate-severe AE require WWT -acute intervention
• WWT should be considered as a treatment option ahead of systemic immunosuppressives