Lucy Ronda, BA (Hons) Nursing, RN.
Research Sister/Unit Manager, Skin Therapy Research Unit, St John's Institute of Dermatology, St Thomas's Hospital, London...
Atopy is a partly inherited capacity to make IgE-class antibodies to antigens (substances that cause an immune response) that enter the body (Friedmann, 1998). The causes of AE are still not fully understood, but it is thought that the condition is the result of this genetic hypersensitivity to irritants and allergens, combined with environmental factors. Many people with AE or their close relatives also have allergic rhinitis (hay fever) and asthma. AE, allergic rhinitis and asthma are sometimes described as the 'atopic triad'.
People with AE report an uncontrollable itch and the urge to scratch, and they may do so until the skin bleeds, increasing the chance of in-fection. This vicious 'itch-scratch' cycle is an important factor in causing persistent symptoms (Wahlgren, 1999).
AE is a clinical diagnosis, based on the patient's history, family history and appearance of the skin (Box 2). Additional tests such as a skin biopsy, skin-prick testing or a radioallergosorbant test (RAST) should not be required. However, the nurse should take a bacteriological swab in patients with infected AE who are not responding to antibiotic treatment to identify resistant strains of Staphylococcus aureus or to detect other infections such as Herpes simplex (McHenry et al, 1995).
Education and counselling are an essential part of managing AE. There is usually little time for these in an average consultation with a GP or dermatologist, so nurses in both primary and secondary care are likely to be responsible for giving advice. Nurses should provide patients and families with a clear understanding of the condition to ensure they have realistic expectations of the results of treatment. Patients should be aware that, while a cure is not at present possible, they can learn how to control the symptoms.
Nurses should advise families that AE is not caused by a single factor and suggest that patients may be able to identify and avoid factors that may exacerbate their symptoms. Anyone with AE should avoid using soap and detergent bubble baths and shampoos, since these impair the skin's natural lipid barrier (Hughes and Van Onselen, 2001). Products labelled 'kind', 'gentle' or 'for dry skin' are not necessarily suitable for people with AE, and nurses should suggest substitutes, a list of which can be obtained from the National Eczema Society.
Pharmacy labels often carry vague instructions such as 'use sparingly' or 'use regularly'. Patients need clear advice from the nurse on how and when to use their treatments, and it can be particularly helpful to specify the number of 'fingertips' of product the patient should use. A fingertip unit is defined as a ribbon of cream and ointment about the same length as a person's fingertip: it is estimated that this is the correct quantity to treat an area equalling that of a patients palm. The nurse's advice is more likely to be followed if it is realistic and practical: for example, it may not be possible for an adult to apply topical treatments while at work, so an alternative regimen should be suggested.
Tacrolimus ointment is a topical treatment for AE that is prescribed by a specialist (Drug and Therapeutics Bulletin, 2002). It is indicated for treating moderate to severe AE in patients who do not adequately respond to, or are intolerant of, conventional therapies. It is not licensed for children aged under two, and children under 16 are restricted to the 0.03% dosage.
AE is a common chronic condition that severely affects the quality of life of patients and their families. Recently, new treatments have become available, offering valuable new options for patients and health professionals.
National Eczema Society, Hill House, Highgate Hill, London N19 5NA.
Tel: 020-7281 3553; fax: 020-7281 6395; helpline: 0870-241 3604 (1-4pm Mon-Fri). Website: www.eczema.org/
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