Recommended management of eczema in older patients

Transcription

1 Recommended management of eczema in older patients Victoria Sherman MA, MRCP and Daniel Creamer BSc, MD, FRCP Our series Prescribing in older people gives practical advice for successful management of the special problems faced by this age group. Here, the authors describe the management of eczema in older people. Figure 1. Venous eczema is treated with support stockings or compression bandages, emollients and moderately potent steroids Eczema is common in the older population. Age-related changes predispose to an increased burden of dermatitis, which is thought to be due to impaired barrier function. 1 There is an increased prevalence of asteatotic and venous eczema, although atopic eczema is less common. When assessing the patient it is important to establish the time of onset of the eczema, its pattern, severity, response to previous treatments, possible trigger factors, including medications, and the impact on quality of life. Eczema in older people may be linked to systemic disease. Treatments Treatment regimens should be kept simple. Emollients Emollients are essential to restore the waterproofing lipid barrier and their correct use will reduce the need for topical steroids. Patients should be advised to apply the emollient liberally and as frequently as possible (every four hours). An emollient bath additive and emollient soap substitute should also be used: not only does excessive washing exacerbate eczema but many soaps and cosmetic detergents have a detrimental effect on eczema. 16 Prescriber 5 September

2 Patient preference should guide the choice of emollient prescribed and treatment should continue even when the eczema has cleared. Always prescribe emollients in large quantities. A surfactant, eg lauromacrogols, added to the emollient may help reduce the itch, and emollients with antimicrobials added to the bath may reduce bacterial colonisation. Topical steroids Topical steroids are highly effective at clearing eczema. They are safe for short-term use, although they should be prescribed with caution in older patients and rotated to prevent tachyphylaxis. Older patients are at a greater risk of side-effects including skin thinning, striae, telangiectasia and bruising, therefore the potency and quantity should be regularly reviewed, the patient should be monitored for local and systemic side-effects and care should be taken to review patients if steroids are added to repeat prescriptions. The British Association of Dermatologists (BAD) generally recommends that topical steroids should be used for up to a week for acute eczema and up to six weeks to gain remission in chronic eczema. The severity and site should, however, guide the prescription and the weakest steroid that controls disease should be used (see Figure 2). Weaker corticosteroids should be used on the face and the flexures. The BNF provides guidance on the amount of steroid needed per week; fingertip units are useful to help patients use the correct amount (see Table 1). Ointments have better penetration and fewer preservatives, so the potential for irritant and allergic reactions is lower. Topical immunomodulators These have a potent anti-inflammatory effect in both atopic and other forms of eczema. Topical tacrolimus (Protopic) or pimecrolimus (Elidel) can be used if the patient is intolerant of or has not responded to topical steroids; however, they should not be used in patients with a history of recurrent herpes simplex. In contrast to steroids they do not cause skin atrophy, but patients should be warned that they may cause a transient sensation of warmth or burning. Photoprotection should be used due to concerns about a reduced threshold for UV-induced skin cancer with long-term use of topical immunomodulators. Pimecrolimus is licensed for mild to moderate atopic eczema for short-term use; tacrolimus is licensed for topical use in moderate to severe atopic eczema. In the authors opinion, however, both agents can be used for all severities once infection has been excluded. It is recommended that treatment should be initiated by a physician with a special interest and experience in dermatology. The potential risks and benefits should be discussed with the patient. Antibiotic therapy Older patients are at risk of secondary bacterial infection (crusting, weeping, pustulation, rapid deterioration of eczema, fever, malaise). Antibiotics are often needed in moderate to severe bacterial infection and a seven-day course should be given (flucloxacillin for Staphylococcus aureus infection or erythromycin if penicillin allergic). If a beta-haemolytic streptococcal infection is suspected or isolated, phenoxymethylpenicillin should also be given. Mild emollients mild potency topical steroids Moderate emollients moderate potency topical steroids topical immunomodulators day treatment unit Severe emollients potent topical steroids topical immunomodulators day treatment unit second-line treatment Figure 2. Recommended stepped approach to the treatment of eczema Swabs should be taken so that an alternative antibiotic can be prescribed if the infection is not sensitive to first-line antibiotics. Local policies should be followed if the swab is positive for MRSA (methicillin-resistant Staph. aureus). In patients with recurrent infections, Staphylococcus carrier sites should be swabbed. Steroidantibiotic combinations can be used for limited areas but should be prescribed for short periods of time due to the risk of resistance. Eczema herpeticum is secondary infection with herpes simplex virus and, although most often associated with atopic eczema, can be seen in all forms. It is indicated by worsening, painful eczema, clustered blisters, punched-out erosions, fever and malaise. Viral swabs should be taken by bursting an intact vesicle or from the base of a vesicle. There should be a low threshold for referral, and if the patient is unwell they Prescriber 5 September

3 may need to be admitted for intravenous therapy. Second-line therapy BAD guidelines suggest that if the eczema is severe and has not responded to appropriate therapy, particularly if excessive amounts of topical corticosteroids are being prescribed, then patients should be referred to secondary care (see Table 2). These patients may need systemic therapy such as ciclosporin, azathioprine or phototherapy. Although second-line therapies are often employed in the older population, the side-effects may limit their use. Ciclosporin can cause a deterioration in renal function and hypertension, and azathioprine can result in bone marrow suppression. In order to receive phototherapy patients need to attend the department regularly and need to be able to stand in a cabinet. Polypharmacy increases in this population and therefore clinicians need to be aware of potential interactions when using oral medications, and patients should be monitored for side-effects using the BAD guidelines. Antihistamines do not help the symptoms of eczema but sedating antihistamines may improve sleep. Dermatology day treatment With the loss of inpatient beds dedicated to dermatology, there has been an expansion of day treatment units. Specialist day treatment nurses are able to apply topical therapies for patients who find it difficult to treat themselves. The effects of topical therapy can also be enhanced by the use of body suits and medicated bandages. Nurses can give advice to the patient and family regarding the use of occlusive therapy and the effective application of treatments. Education Adequate education and support are essential. A combination of verbal and written information, including patient information leaflets with practical demonstrations, improves compliance. It is important to ensure that instructions are accurately followed and that ongoing compliance with the regimen prescribed is achieved. A district nurse, family member, carer or day treatment unit may be needed if the application of treatments is difficult due to poor manual dexterity or reduced vision. It is important to warn the patient that emollients 20 Prescriber 5 September

4 make the bath or shower slippery and to be cautious. Emollient bath additives or soap substitutes are not, therefore, appropriate for patients at risk of falling. Patients should be advised about recognising aggravating factors such as central heating, woollen garments next to the skin and excessive washing; soaps and detergents should be replaced by emollient substitutes. Types of eczema The most common types of eczema to affect older people are asteatotic eczema and venous eczema; however, any of the clinical types of eczema can occur. Asteatotic eczema (see Figure 3) This is thought to be due to minor abnormalities in epidermal maturation. The water content of the epidermis is reduced and this appears to lead to cracking and inflammation. It often initially presents in the winter, probably due to central heating, in air-conditioned environments or co-existing with another illness. Frequent washing is a causative factor. Examination of the skin reveals dry, scaly skin predominantly affecting the lateral aspect of the shins, but may spread to the thighs, back, arms and hands. The aim of treatment is to minimise water loss, which can be achieved with greasy emollients. These should be applied regularly with an emollient soap substitute. Weak corticosteroids may be used if necessary. Patients should be educated about the importance of avoiding abrupt temperature changes and reducing the frequency or length of bathing. 2 Venous eczema (see Figure 1) Approximately 20 per cent of people over 70 have venous eczema caused by incompetence of the veins in the leg. Risk factors include a previous or family history of deep venous thrombosis, a family history of varicose veins and a high body mass index. Examination reveals red, scaly areas that are itchy, predominantly affecting the medial lower leg. Rarely there is systematisation and it spreads to the fronts and sides of the thighs and upper arms. Other signs of venous hypertension include ulceration, superficial varices, ankle oedema, lipodermatosclerosis and pigmentation. The aim of treatment is to reduce the venous hypertension, which can be achieved with support stockings or compression bandages. These should be worn all day and only removed for showering. At night legs should be raised above the hip. Alternative treatments include surgical procedures. If applicable, patients should be encouraged to lose weight. Emollients should be used and moderately potent steroid ointments may be required. The condition is usually persistent and often relapses after treatment. Patients may also have arterial insufficiency and the arterial supply should be assessed before using compression therapy. Clinicians should be aware that patients with venous eczema are at a higher risk of developing contact dermatitis to topical treatments and bandages. 3 Applications of allergens such as lanolin, neomycin and gentamicin should be avoided. Area of the body 1 hand and fingers (front and back) 1 face and neck arm and hand 4 1 leg and foot 8 trunk (front or back) 7 Table 1. Chart of fingertip units (FTUs) needed for areas of the body in adults; one FTU is the amount of topical steroid from a standard tube along an adult s fingertip (end of finger to the first crease): two FTUs are approximately equivalent to 1g of topical steroid Contact dermatitis Allergic contact dermatitis is caused by a delayed hypersensitivity reaction to an agent, and irritant contact dermatitis is due to the toxic chemical or mechanical effects of an agent. The appearance depends on the site affected and may initially be itchy, swollen and erythematous with vesicles and exudate, becoming thickened with time. Common causative factors of allergic contact dermatitis in older people include topical treatments and bandages. Allergens such as hair dye can cause a reaction around the hair line, ears and Fingertip units the diagnosis is or has become uncertain severe infection with herpes simplex is suspected the eczema is severe and has not responded to appropriate therapy, particularly if excessive amounts of topical corticosteroids are being prescribed the eczema has become infected with bacteria and treatment with an oral antibiotic plus a topical corticosteroid has failed the eczema is giving rise to severe social or psychological problems management in primary care has not controlled the eczema satisfactorily the patient or family might benefit from additional advice on application of treatments, eg bandaging techniques contact dermatitis is suspected and confirmation requires patch-testing dietary factors are suspected and dietary control is a possibility (rare) secondary-care treatment may include dressings by specialist nurses or escalation to systemic treatment such as phototherapy or systemic immunosuppression with ciclosporin or azathioprine Table 2. Primary Care Dermatology Society/British Association of Dermatologists guidelines for referral of patients with eczema to secondary care Prescriber 5 September

5 neck. Medicaments can be allergens, such as aminoglycoside ear drops. Other allergens include rubber in bandages, gloves and shoes, and plastics in hearing aids and spectacle frames. Patients should be patch tested; 4 however, the intensity of positive reactions may be reduced and delayed in older patients. 5 Irritant dermatitis may be caused by excessive washing, for example, resulting in hand dermatitis or may be due to incontinence. Faeces and urine needs to be removed by ensuring frequent pad changes, correct sizes and regular toileting. Treatment involves removing the causative agent. This may, however, be difficult to elucidate in older patients. Topical corticosteroids, soap substitutes and emollients can be used. Discoid eczema Examination reveals coin-shaped areas of eczema on the limbs. These vary from inflamed and weeping to dry, lichenified lesions. It is commonly secondarily infected with Staph. aureus. Potent topical steroid ointments are usually needed with emollients. Discoid eczema is resistant to treatment and usually recurs within months of withdrawing therapy. Seborrhoeic dermatitis Seborrhoeic dermatitis is more prevalent in older people, especially in those confined to bed. It typically affects the scalp, facial flexures, central part of the upper chest and back, and body flexures. Examination reveals red, flaky skin. Men are more frequently affected. Management of the scalp includes an antifungal shampoo. Management of the skin includes emollients used twice a day with an emollient soap substitute and emollient bath additive. Mild steroids with an antifungal agent, eg miconazole, can be used on the face. Eczematous drug eruptions The risk of developing an adverse reaction increases with age, and the prevalence of polypharmacy in this population increases the risk further. It is important to ask about over-the-counter treatments and herbal remedies. The culprit should be withdrawn and the symptoms treated. Medications that are known to cause eczematous drug eruptions include antihistamines, aminophylline, procaine/ 24 Prescriber 5 September

6 SPL dermatitis to topical preparations. There should be a low threshold for referring patients to secondary care. Further reading BAD guidelines for the management of atopic eczema. Portals/_Bad/Guidelines/Clinical% 20Guidelines/PCDSBAD- Eczema.pdf. BAD guidelines for the management of contact dermatitis. www. bad.org.uk/portals/_bad/ Guidelines/Clinical%20Guidelines/ Contact%20Dermatitis%20BJD %20Guidelines%20May% pdf. Eczema atopic. Clinical Knowledge Summaries uk/eczema_atopic. Frequency of application of topical corticosteroids for atopic eczema. NICE Technology Appraisal Looking after elderly skin a simple guide. British Association of Dermatologists, Portals/_Bad/images/default/elderly _skin_care.pdf. Patient advice leaflets on atopic eczema: British Association of Dermatologists. Patient support group: National Eczema Society, Tacrolimus and pimecrolimus for atopic eczema. NICE Technology Appraisal Figure 3. Dry and cracked skin on the legs of an older patient with asteatotic eczema. Treatment is with regular greasy emollients with mild corticosteroids if necessary benzocaine, iodides, radiographic contrast, streptomycin and gentamicin. Atopic eczema Atopic eczema is uncommon in older people. Risk factors include previous atopy, family history of atopy and a tendency towards dry skin. Treatment is similar to regimens used in young patients, and patients should be advised to avoid the trigger factors. Conclusion Treatment should be kept simple using a stepped approach. Patients should be educated and adequate support given. Reasons for deterioration include poor compliance, bacterial or viral infection or occasionally contact References 1. Hara M, et al. J Geriatr Dermatol 1993;1, Looking after elderly skin a simple guide. British Association of Dermatologists, Tavadia S, et al. Contact Dermatitis 2003;48(5): Bourke J, et al. BJD 2001;145 (6): Piaserico S, et al. Aging Clin Exp Res 2004;16 (3): Guidelines for the management of atopic eczema. British Association of Dermatologists, Dr Sherman is a registrar and Dr Creamer is consultant dermatologist at King s College Hospital, London 26 Prescriber 5 September