Atopic Eczema with detail on how to apply wet wraps

Transcription

1 Atopic Eczema with detail on how to apply wet wraps Dr Carol Hlela Consultant Dermatologist Head of Unit, Department of Dermatology, Paediatrics Red Cross Children s Hospital, UCT

2 Red Cross War Memorial Children s Hospital

3 The many FACIES of Atopic Eczema

4 Very dry skin-may be an early manifestation of AE

5 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): J Allergy Clin Immunology.2014 Oct; (134(4): e6.

6 The many FACIES of Atopic Eczema

7 The many FACIES of Atopic Eczema

8 Infant phase(birth to 2 years) face, scalp, extensors of limbs cheeks, spares perioral and perinasa chin, cheilitis spares nappy area

9 AE distribution evolve over months/years

10 You can objectively confirm AE, using the UK working party criteria

11 You can objectively confirm AE, by searching for Signs (stigmata) of cutaneous atopy

12 The many FACIES of Atopic Eczema

13 The many FACIES of Atopic Eczema

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15 Education Soap substitutes Optimal topical care (emollients) Specific therapy: Management principles AE (to control the disease) corticosteroids / calcinuerin inhibitors Antihistamines systemic therapy e.g. Azathioprine, Methotrexate ultraviolet light therapy

16 Education in AE Work with patients and parents as a team. Education Written instructions Address steroid phobia

17 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)

18 Atopic Eczema - a chronic skin disease

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20 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

21 Basis of management Moisturisers 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)

22 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

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24 Prescribing topical steroids -Vehicle: Ointment dry eczema Lotion- wet eczema or scalp Creams wet eczema or eczema in folds Gel - scalp and wet eczema

25 Quantity Do not under-prescribe!

26 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

27 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

28 Adjuvant therapy-in AE

29 NICE UK GUIDELINES

30 The many FACIES of Atopic Eczema

31 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

32 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

33 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