Type 4 delayed hypersensitivity seen to a range of things including:

• Nickel (for example in jewellery, belt buckles, fastenings)
• Limonene, found in many cleaning products and cosmetics
• Sodium lauryl sulfate, found in cleaning products and cosmetics
• Lanolin and other wool products

Mechanism is complicated as metals are clearly not proteins so not identified by HLA class 2 as happens in type 1 allergy. Presumably happens through toll like receptors.

Testing is by patch testing, done by dermatology.

Remember house temperature, clothing.  14-16 degrees in bedrooms, max 18 in house. 

Stepwise approach, with early recognition of eczema flares. Use lots of emollient frequently, even if skin clear. Management can then be stepped up or down, according to the severity of symptoms, with the addition of the other treatments as listed below.

Mild atopic eczema	Moderate atopic eczema	Severe atopic eczema
Emollients	Emollients	Emollients
Mild potency topical corticosteroids	Moderate potency topical corticosteroids	Potent topical corticosteroids
	Topical calcineurin inhibitors	Topical calcineurin inhibitors
	Bandages	Bandages
		Phototherapy
		Systemic therapy

Emollients

Mostly underused.  Should always be used, even when the skin is clear (see immunology of eczema).  250-500g per week for most! 1FTU (finger tip unit) covers palm sized area.   Apply in downwards motion, in direction of hair rather than rubbing (which might increase irritation).  Allow to soak in as much as possible.

Should be easily available to use at nursery, pre-school or school.  

Aqueous cream not recommended as “leave on” (ok as soap substitute) says NICE – higher risk of skin reactions. Not much evidence to say one better than another, so whichever suits family best, be it a combination of products or one product for all purposes!  Only risk is is flammability, and slipping when washing!

Offer a choice of unperfumed emollients to use every day for moisturising, washing and bathing.  Offer an alternative if a particular emollient causes irritation. Spray on emollients are also available, if skin is really sore.  Ideally allow several minutes between different creams where practical.  Pump dispensers preferred (and don’t share!) as bacterial contamination possible, which may make skin worse. Folliculitis another risk with emollients.  

Quickest is steroid first, ideal is emollient first, steroid 20 mins later!  But family preference.

Ointments are greasier, so messy, and leaves you looking shiny.  Tend to only come in tubs, not pump dispensers. Relatively free from additives so perhaps less likely to lead to irritation, but can occlude, leading to heat rash.  Good for fissured skin.  50:50 white/soft paraffin good for lichenification. Emulsifying ointment is difficult to use. Cream applies better to moist, weeping areas.  Lotion good for scalp (most soluble). Epaderm and Doublebase are cream/ointment mixes.

Stinging may just be under treated eczema, which will only improve with regular topical steroids. [BMJ 2019]

Combined antibacterial products available, good for flexures eg Dermol 500 lotion, Dermol 600 bath emollient, Fucidin H (hydrocortisone), Trimovate (clobetasone), Fucibet (betamethasone).

Bathing

Baths should be short (max 20 minutes), not too hot, towel dry by patting not rubbing. Oats in muslin bag or sock can be squeezed under tap and as sponge. Use a bath additive eg Oilatum NOT bubble bath (beware how slippery the bath gets) and a soap substitute – or just apply your usual emollient before hand, rinse off, and re-apply. Cleans just as well as soap!

For scalp eczema, if inflamed then use your usual topical steroid, applied directly to scalp rather than hair.  For scale, you can just use emollients and/or emollient wash products instead of shampoo, usually all you need for babies. Shampoo for older children should be unperfumed and ideally labelled as being suitable for eczema; washing the hair in bath water should be avoided.  Coal tar shampoo eg Capasal available.  Otherwise, apply emollient at night (use old pillowcase), wash out in morning [itchybaby.co.uk].

• Soap substitutes – cetraben wash, doublebase wash, e45 wash, oilatum soap bar, ultrabase etc
• Shower additives – doublebase shower, E45 shower, oilatum shower etc

Topical Steroids

It is important to remember that undertreatment can be just as damaging as overtreatment. Strengths of steroid:

• Mild eg hydrocortisone (any strength, incl 2.5%), Synalar 1 in 10. Mild combinations include Fucidin H, Daktacort, Timodine
• Moderate eg Eumovate, Betnovate RD, Synalar 1 in 4. Moderate combinations include Trimovate, Hydromol HC intensive (hydrocortisone, but additional urea)
• Potent eg Betnovate (incl Fucibet), Elocon, Hydrocortisone butyrate (Locoid)
• Very potent eg Dermovate

Note that Fucibet is potent steroid, don’t confuse with Fucidin H (mild)!

• Use mild potency only for the face and neck, except for short-term (3–5 days) use of moderate potency for severe flares.
• Use moderate or potent preparations for short periods only (7–14 days) for flares in vulnerable sites such as axillae and groin.
• Do not use very potent preparations in children without specialist dermatological advice, or potent topical corticosteroids in children aged under 12 months .[ie you can/should prescribe everything else!]
• Only apply topical corticosteroids to areas of active atopic eczema (or eczema that has been active within the past 48 hours), which may include areas of broken skin.
• Exclude secondary bacterial or viral infection if a mild or moderately potent topical corticosteroid has not controlled the atopic eczema within 7–14 days.
• In children aged 12 months or over, potent topical corticosteroids should then be used for as short a time as possible and in any case for no longer than 14 days. They should not be used on the face or neck. If this treatment does not control the atopic eczema, the diagnosis should be reviewed and the child referred for specialist dermatological advice.
• Consider pulse treatment of problem areas of atopic eczema with topical corticosteroids for two consecutive days per week to prevent flares, instead of treating flares as they arise, in children with frequent flares (two or three per month), once the eczema has been controlled. This strategy should be reviewed within 3 to 6 months to assess effectiveness.

Lichenification reduces penetration so needs more intense and longer treatment (but lower risk of toxicity too!). 

Flares

Teach how to recognise flares: increased dryness, itching, redness, swelling and general irritability. Give clear instructions on how to manage flares according to the stepped-care plan

Treat flares as soon as signs and symptoms appear and continue for approximately 48 hours after symptoms subside.

Eczematous skin is predisposed to staph aureus infection, and this may result in acute flares. Topical steroid is not contra-indicated in infection, but consider a steroid-antibiotic combination e.g. Fucibet, tailing down to steroid only over a week as things improve. If severe, topical corticosteroids with oral flucloxacillin would be a good option.

Eczema herpeticum can spread rapidly, forming extensive sheets of monomorphic eroded or umbilicated vesicles. Risk factors include early onset, clinical severity, high total serum Ige. Clinically, lymphopenia and fever are hallmarks of disease.  Treatment is with aciclovir 200mg 5x a day for 5 days. Parents of children with eczema who have cold sores should be warned not to kiss their children until the sore has healed.

IgE antibodies to Malassezia furfur (a fungus) are found more commonly in eczema patients. Use of antifungals is under investigation.

Bandages and Garments

Cotton gloves help hand eczema eg pompholyx, but also reduce scratching.  Nail care similarly important.  Tubular bandages (Comfi-easy) keep cream in place, less scratch (but too hot?).  Protects clothes too.  Garments available, tubular or silk, which are looser, look less medical.

Wet wrap technique is 2 layers: wet 1^st layer and wring out, 2nd layer dry.  Should only be recommended by experts as higher absorption of steroids.

Ichthammol bandages soothing but messy – pleat, don’t wrap round.  Or Zinc.

Duoderm hydrocolloid wound dressing good for putting on top of steroid in poorly healing areas (1-2/7) eg discoid.

Haelan topical steroid tape – for cracks, sticky, can be cut into shape eg T for wrapping around finger.  Apply for 12 hrs.  See youtube videos.

Cavilon spray or foam applicator is a no-sting barrier film esp hands.  Lasts up to 72 hours.

Other treatment options

Tacrolimus 0.03% ointment (Protopic) has been licensed for use in children with moderate to severe atopic dermatitis unresponsive to conventional therapies. Application is twice a day at first for up to 3 weeks, reducing to once daily after three weeks until the atopic dermatitis is clear. Tacrolimus needs time to work, don’t stop too soon after flares (2-4 weeks!).  Can also be used 3x a week regularly.

More effective than mild topical steroid but not more than potent. No skin atrophy was observed when patients used it daily for up to 2 years. Should only be prescribed by doctors with adequate experience of treating with immunomodulatory agents; consider for patients vulnerable to steroid side effects. For unresponsive patients, referral to a dermatologist for wet-wrap bandaging, a short course of cyclosporin or ultra-violet treatment, in-patient care.

Pimecrolimus has been tested only in mild to moderate disease and has not been compared to mild topical steroids. It is not as effective as potent steroids. Tacrolimus and pimecrolimus have not been compared with each other. Tacrolimus and pimecrolimus are approximately 10 times more expensive than topical steroid preparations. (Arch 2004; 89)

Acupuncture reduces itch in placebo controlled cross over study vs cetirizine – flare size less too!

= excessive sweating.

Primary usually develops in adolescence, usually focal esp palms, soles, axillae.  Often family history.

Secondary tends to be generalized but can be focal.  Long list of causes – endocrine, neurological, chronic infection, catecholamines etc.

Treatment in kids is limited to anti-perspirants and iontophoresis (devices available, administered via trays for feet and hands, via pads for body – do 3x per week).

For axillae – aluminium hydrochloride like Driclor. It causes irritation due to hydrochloride, so dry armpit carefully before use (blow dryer if required), and consider intermittent topical steroid to alleviate discomfort.

GPs can also prescribe 1% glycopyrrolate in cetomacrogol cream for topical use 2-4/d – this is obtainable from the Western Infirmary Production Unit (Pharmacy).

For generalised disease – probanthine or oxybutinin – dose titrated up slowly to point of efficacy and minimal side effects – works well.

Surgery – botox, or sympathectomy, eg if disabling i.e. constantly dripping hands,

Patient Support

sweathelp.org

Young person site although it is aimed at US families, http://www.sweatometer.org/