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New topical treatments in the management of atopic eczema

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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

...

Over the past 30 years, atopic eczema (AE) or atopic dermatitis has become increasing common, possibly because of environmental and lifestyle factors (Charman, 1999). The condition usually begins in childhood, and in the UK about 15% of schoolchildren are affected (National Institute for Clinical Excellence, 2003). It will clear in about 60% of children by the time they enter their teens (NICE, 2003); in others the condition may persist or recur in later life, with an estimated 2-10% of adults affected (McHenry et al, 1995).


Not surprisingly, AE has important implications for nurses' workload in both primary and secondary care since it is responsible for 30% of dermatological consultations in general practice and 10-20% of all referrals to dermatologists (McHenry et al, 1995). Because the condition affects many people, it is important for all nurses to be familiar with its diagnosis and treatment (Box 1) although they can, of course, draw on the knowledge of their specialist colleagues. A recent report identified the increasingly important role of nurse-led eczema clinics for both patients and staff (Action on Dermatology, 2003).


This paper will discuss the nurse's role in managing AE and will look at new therapeutic developments, in particular new topical treatments.


The physiology of AE
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'.


The outermost layer of the skin (the stratum corneum) is formed from overlapping skin cells surrounded by lipids, and it acts as a barrier against water loss and penetration by irritants and allergens. Loss of the skin's barrier function, possibly as a result of frequent washing with soap products, exposure to irritants, bacteria or house-dust mites and dry environments allows antigens to enter the body (Holden et al, 2002).


These antigens are recognised by Langerhans' cells, which react by causing an influx of T cells from the blood to the skin. The T cells produce chemical messengers called inflammatory cytokines, which in turn cause the swelling, redness and itching associated with eczema.


Quality of life issues
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).


Unlike a spontaneous itch, which is easily relieved by scratching, with AE it is intense, and is often described as impossible to relieve (Buchanan, 2001). It is the most distressing symptom reported by patients with AE and is one of the reasons why even 'mild' AE can cause severe morbidity (McHenry et al, 1995).


AE has been shown to have a great impact on a patient's quality of life. A survey of members of the National Eczema Society (Long et al, 1993) found that the condition adversely affected work for 54% of respondents and the choice of career for 20%. Reasons included the time required during the day to apply treatments or colleagues' perceptions of someone with severe eczema. The condition reduced the ability to perform domestic tasks in 83% of women and 71% of men, while social and leisure activities were impaired in 64% of adults. The survey found that 14% had been less able to form personal relationships, while 19% said that their sex lives had been affected.


Sleep was the most commonly affected activity in children with AE, with 60% having problems (Long et al, 1993). Lack of sleep can seriously impair the whole family's quality of life, especially that of the main carer, with parents in one study reporting emotional distress, increased costs, lack of sleep, adverse effects on family leisure activities and on the ability to perform housework (Ben-Gashir et al, 2002). The severity of the child's AE has a major bearing on family life, and nurses are in a key position to improve the quality of life not only of the child, but the whole family, by helping parents to better manage their child's AE.


Differential diagnosis
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).


In some patients, AE may manifest as the occasional dry red scaly patch, while in others much of the body will be affected, with lichenification and bleeding, encrusted lesions, both of which are caused by incessant scratching. In infants, AE is typically found on the cheeks, wrists, legs, arms and neck. All skin areas may be involved in older children and adults, with lichenification especially seen on areas of the body the patient can reach to scratch. Lesions are particularly common on flexural surfaces such as the eyelids, neck or forehead.


Although eczema is usually easy to diagnose, the nurse should not presume a diagnosis of AE. The patient's symptoms may be the result of an irritant or allergic contact dermatitis. This condition generally affects the hands, but can affect other parts of the body. For example, a nickel allergy may affect the ears or waist area, following contact with earrings, and trouser buttons or belt buckles. Other types of eczema, such as drug-induced eczema, photodermatitis, discoid eczema, aseatotic eczema or contact dermatitis also need to be ruled out, as do other skin conditions that cause inflammation, scaling and itch (Table 1).


Approach to the patient
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.


Careful adherence to treatment will help to break the itch-scratch cycle, and can be combined with psychological approaches in motivated patients. Behaviour modification or habit reversal techniques can be used to reduce or eradicate the destructive scratching behaviour associated with AE. Patients are taught alternative behaviours such as pressing or patting the skin, squeezing balls or clenching fists. The technique can be taught to parents of affected children, as well as directly to adults and older children with AE (Buchanan, 2001).


Effective treatment will also help to reduce the risk of exacerbations or flare-ups of AE, but the nurse should make sure the patient is able to rapidly obtain the necessary prescription should these occur. Patients should be encouraged to contact the nurse if they have any questions or problems between follow-up visits, and they should be able to arrange an urgent appointment if necessary. Nurses should advise patients to get in touch with the National Eczema Society, which is an invaluable source of advice and support.


Prevention strategies
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.


People with AE should also protect their skin from the extremes of temperature and should avoid wearing clothing made of potentially irritant materials (such as wool) next to the skin. Cotton clothing is recommended and patients should also be advised to keep their fingernails short as this can minimise damage from scratching.


People with AE may be particularly sensitive to house-dust mites, but it not always possible to eradicate them (Barnetson and Rogers, 2002). Advice to do so may put an intolerable burden on already stressed families. Clinical trials of mite control have used a combination of measures but it has proved difficult to distinguish which had the beneficial results (Charman 1999). However, microporous or polyurethane mattresses, pillows and duvet covers appear to be effective in reducing mite levels, while washing bedding at 55°C will kill mites (Charman, 1999).


Families are often keen to try dietary manipulation. There is controversy over whether there is any benefit from excluding single foods such as eggs or cow's milk, although many trials have used soya milk, which is also potentially allergenic (Charman, 1999). It is reasonable for patients to avoid foods that upset them, but when they want to avoid whole food groups the nurse should consult a dietitian, since there is a risk of malnutrition.


Treatment approaches
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.


Nurses should take time to demonstrate carefully how to apply treatments, and check at subsequent appointments that patients are using this procedure. It can also be helpful to involve partners or relatives, where appropriate. This advice can be reinforced if the nurse and patient write a simple list of instructions during the consultation. This is particularly important when applying treatments such as topical steroids, as these can cause adverse effects if used incorrectly (Hughes and Van Onselen, 2001).


AE receives a great deal of coverage in the media and on the internet. One result of this is that even patients with long-standing AE can be reluctant to use certain conventional treatments. This is particularly true of topical corticosteroids: in one study three-quarters of patients were worried about using them and nearly half admitted to non-adherence (Charman et al, 2000). Although it may be time consuming, a concordant approach, in which the nurse and patient negotiate a long-term treatment plan with realistic goals, is more likely to win the patient's and family's trust.


While people with AE can be reluctant to use conventional treatments, they may be more enthusiastic about complementary medicine, which they may believe to be free of adverse effects. However, there is little compelling evidence for its effectiveness, and there is some evidence of its dangers with AE (Ernst et al, 2002). Many complementary therapies are harmless placebos. Some topical treatments, however, may contain substances that irritate skin (Barnetson and Rogers, 2002), while systemic treatments may be toxic (Ferguson et al, 1997). Analysis of some treatments labelled and sold as complementary therapies have been found to contain potent steroids (Keane et al, 1999).


People with AE are very likely to try complementary therapies (Ernst et al, 2002), and it is important for the nurse to be non-judgemental and help patients to use them appropriately in the context of their prescribed treatments. As Box 3 shows, some patients will need referral to secondary care. All nurses should be aware of the approaches listed in Table 2, since some may be continued in the community under shared-care arrangements. Most patients are treated in primary care with emollients, skin-selective cytokine inhibitors and topical corticosteroids.


Emollients Daily emollients (creams, ointments, soap substitutes, bath oils) are recommended to improve the barrier function of the skin and to relieve dryness and itching. These are most effective when applied after bathing - when the water content of the skin is high - and should ideally be reapplied regularly throughout the day. However, emollients are often used incorrectly (Holden et al, 2002) and not as frequently as they should be.


Nurses should offer patients the opportunity to try a range of products until they find the emollients that suit them and that they are likely to use. Patients should receive a thorough demonstration on using them, and nurses should make sure patients are prescribed adequate supplies to encourage them to use the products when they bath. At least 500g of cream is needed each week, together with 150ml of bath oil (based on 15-30 ml per bath for daily use) (Holden et al, 2002).


Pimecrolimus Even if patients follow instructions on using emollients, this therapy alone will not control inflammation, so some people will require treatment for AE flare-ups. Until recently, topical corticosteroids were the mainstay, but the skin-selective cytokine inhibitor pimecrolimus (Elidel) was licensed in the UK this year, the first new treatment for AE to be launched in the community for more than 50 years.


Pimecrolimus is a steroid-free, anti-inflammatory cream developed specifically for use on skin. It is licensed in the UK for the treatment of mild to moderate AE in patients aged two years and older, both as a short-term treatment for the signs and symptoms and as a long-term intermittent treatment to prevent progression to flare-ups. It acts by targeting T cells to prevent them releasing inflammatory cytokines in response to allergens.


The cream should be applied in a thin layer to affected skin twice daily and rubbed in gently and completely. Emollients can be applied immediately after application of pimecrolimus, once this has been absorbed into the skin and, unlike topical corticosteroids, there is no restriction on the total daily dose, extent of body surface area treated or duration of treatment. Pimecrolimus, therefore, promises to be particularly useful in treating children and delicate skin areas such as that on the face, neck and flexures.


Clinical studies found that this therapy prevented AE flare-ups in adults and children in cases where it was used at the first signs of redness and itch - that is, when emollients alone were no longer able to control symptoms and when it was applied before treatment with topical corticosteroids (Meurer et al, 2002; Wahn et al, 2002). Patients needed less treatment with topical corticosteroids (Wahn et al, 2002), reported rapid relief of itch (Meurer et al, 2002) and an improved quality of life (Whalley et al, 2002).


Unlike topical corticosteroids, pimecrolimus does not cause skin atrophy (thinning). However, nurses should be aware that some patients may experience a mild and transient sensation of warmth or burning after applying the cream, although in most the sensation lessens with repeated application. It should not be used at the same time as topical corticosteroids, and patients should be advised to avoid excessive exposure to sun and other sources of ultraviolet light.


Coal tar and wet wrapping Both these methods can be useful in healing lichenified AE. The former includes the use of ichthammol or coal tar, but coal-tar wrapping is messy and odourous and thus unpopular with patients. After careful demonstration by the nurse, wet wrapping can also be used as a short-term treatment in the community, but not if the patient has an infection. Although it is time-consuming, it can be a very effective treatment.


Antibiotics Antibiotics should be used to treat bacterial secondary infection. Oral treatment should generally be used. Topical antibiotics should be restricted to limited areas, so they are usually not ideal for patients with AE, who often have widespread secondary infection (McHenry et al 1995).


Topical corticosteroids It is hoped that pimecrolimus will promote greater control over AE by providing early disease management, by filling the existing management gap between emollients and short courses of topical corticosteroids. This is not to say that topical corticosteroids are ineffective - short courses are undoubtedly effective in controlling AE flare-ups when used appropriately (Drug and Therapeutics Bulletin, 2003) - but many patients have concerns about potential side-effects (Charman et al, 2000).


Patients worry about skin atrophy due to the use of topical corticosteroids (Charman et al, 2000) and their concerns should be taken seriously - the risk is high with prolonged use of potent formulations (Drug and Therapeutics Bulletin, 2003). Consequently, when topical corticosteroids are necessary, nurses should advise patients that it is essential to discontinue treatment once the flare-up has settled and never to use these drugs as emollients. Nurses should also ask the patient about any non-prescription treatments they may be using. This will reduce the risk of unwanted effects from the combination of a moderately potent prescribed corticosteroid with a weak topical corticosteroid bought over the counter.


Parents of young children may be concerned about systemic side-effects such as growth retardation. However, where topical corticosteroid treatment is standard, prescribed and closely monitored this is highly unlikely (Charman et al, 2000). Nevertheless, nurses should ensure that children who require frequent or prolonged courses of topical corticosteroid are referred to secondary care for consideration of other treatments (Table 2), including the recently launched topical immunomodulatory drug tacrolimus (Protopic).


Topical tacrolimus
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.


Like pimecrolimus, topical tacrolimus specifically targets the action of T cells. (When used systemically, tacrolimus prevents organ rejection in liver and kidney transplant patients.)


Several clinical studies show that topical tacrolimus is effective in patients with moderate to severe AE, but none has investigated its use in patients unresponsive to, or intolerant of, conventional therapy (Drug and Therapeutics Bulletin, 2002).


Conclusion
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.


However, successful control of AE symptoms will continue to depend on careful self-care by the patient, with nurses in both primary and secondary care helping patients and families to manage their symptoms.


Useful contact
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/

Action on Dermatology. (2003) Good Practice Guide. London: NHS Modernisation Agency.

Barnetson, R.S., Rogers, M. (2002) Childhood atopic eczema. British Medical Journal 324: 1376-1379.

Ben-Gashir, M.A., Seed, P.T., Hay, R.J. (2002) Are quality of family life and disease severity related in childhood atopic dermatitis? Journal of the European Academy of Dermatology and Venerealogy 16: 455-462.

Buchanan, P.I. (2001) Behavior modification: a nursing approach for young children with atopic eczema. Dermatological Nursing 13: 1: 15-23.

Charman, C. (on behalf of Clinical Evidence) (1999) Atopic eczema. British Medical Journal 318: 1600-1664.

Charman, C.R., Morris, A.D, Williams, H.C. (2000) Topical corticosteroid phobia in patients with atopic eczema. British Journal of Dermatology 142: 931-936.

Drug and Therapeutics Bulletin. (2002)Topical tacrolimus - a role in atopic dermatitis? Drug and Therapeutics Bulletin 40: 10, 73-75.

Drug and Therapeutics Bulletin. (2003) Topical steroids for atopic dermatitis in primary care. Drug and Therapeutics Bulletin 14: 1, 5-8.

Ernst, E., Pittler, M.H., Stevinson, C (2002) Complementary/alternative medicine in dermatology: evidence-assessed efficacy of two diseases and two treatments. American Journal of Clinical Dermatology 3: 5, 341-348.

Ferguson, J.E., Chalmers, R.J., Rowlands, D.J. (1997) Reversible dilated cardiomyopathy following treatment of atopic eczema with Chinese herbal medicine. British Journal of Dermatology 136: 592-593.

Friedmann, P.S. (1998) Allergy and the skin II - contact and atopic eczema. British Medical Journal 316: 1226-1229.

Holden, C., English, J., Hoare, C. et al. (2002) Advised best practice for the use of emollients in eczema and other dry skin conditions. Journal of Dermatological Treatment 13: 103-106.

Hughes, E., Van Onselen, J.V. (eds). (2001) I. Dermatological Nursing: A practical guide. Edinburgh: Churchill Livingstone.

Keane, F.M., Munn, S.E., du Vivier, A.W. et al. (1999) Analysis of Chinese herbal creams prescribed for dermatological conditions. British Medical Journal 318: 563-564.

Long, C.C., Funnell, C.M., Collard, R., Finlay, A.Y. (1993) What do members of the National Eczema Society really want? Clinical and Experimental Dermatology 18: 6, 516-522.

McHenry, P.M., Williams, H.C., Bingham, E.A. (1995) Fortnightly review: management of atopic eczema. British Medical Journal 310: 843-847.

Meurer, M., Folster-Holst, R., Wozel, G. et al. (2002)Pimecrolimus cream in the long-term management of atopic dermatitis in adults: a six-month study. Dermatology 205: 271-277.

National Institute for Clinical Excellence. (2003) Atopic eczema in children: referral practice. Version under pilot. www.nice.org.uk/article.asp?a=10562 (Accessed April 25, 2003).

Wahlgren, C.F. (1999) Itch and atopic dermatitis: an overview. Journal of Dermatology 26: 11, 770-779.

Wahn, U., Bos, J.D., Goodfield, M. et al. (2002) Efficacy and safety of pimecrolimus cream in the long-term management of atopic dermatitis in children. Pediatrics 110: 1, e2. Available at: www.pediatrics.org/cgi/content/full/110/1/e2

Whalley, D., Huels, J., McKenna, S.P. et al. (2002) The benefit of pimecrolimus (Elidel, SDZ ASM 981) on parent's quality of life in the treatment of paediatric atopic dermatitis. Paediatrics 110: 6, 1133-1136.
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