Atopic dermatitis (mild)
Consultation guide for UK community pharmacy: clinical features, referral criteria, time frame to resolution and management strategy.
Clinical features
- Mild means that there are areas of dry skin, and infrequent itching (with or without small areas of redness). Validated tools may help assess severity such as visual analogue scales of the person's assessment of severity, itch, and sleep loss or using the Patient-Orientated Eczema Measure
- Infants: face, scalp and extensor (outer) surfaces of joints are usually affected. Children and adults: flexure (inside) surfaces of limbs are most commonly affected. Children of Asian, black Caribbean, and black African ethnic groups, my be affected on the extensor surfaces rather than the flexures
- NICE states that atopic eczema is likely if the following criteria are fulfilled, although alternative diagnoses may need to be excluded:
An itchy skin condition (parents may report the child is scratching) plus three or more of the following:
- Visible flexural eczema involving the skin creases, such as the bends of the elbows or behind the knees (or visible eczema on the cheeks and/or extensor areas in children aged 18 months or younger)
- Personal history of flexural eczema (or eczema on the cheeks and/or extensor areas in children aged 18 months or younger)
- Personal history of dry skin in the last 12 months
- Personal history of asthma or allergic rhinitis (or history of atopic disease in a first-degree relative of a child aged under 4 years)
- Onset of signs and symptoms before the age of 2 years (this criterion should not be used in children younger than 4 years of age)
Atopic dermatitis
Referral criteria
- Moderate or severe forms (symptoms of frequent itching, more widespread symptoms and greater disruption to daily life)
- Signs of secondary bacterial infection (bacterial skin infections may present with clinical features such as weeping, oozing, crusting, pustules, erythema in tandem with systemic symptoms such as fever and malaise)
- Rapidly worsening or painful atopic dermatitis
- Patients in need of corticosteroids that are outside OTC product licence such as children under 10 for hydrocortisone products or needing to use steroids on the face
Time frame to resolution
- Usually appears before age 5, with a high incidence of onset in first 12 months of life
- It is a chronic condition with periodic flare-ups. This condition frequently resolves in children as they get older, but some will have life-long symptoms
Management strategy
Non-pharmacological advice
- Avoid scratching affected areas; rub the area gently to alleviate itch
- Avoid triggers that make the condition worse such as animals, heat, soaps and detergents (use emollient substitutes instead)
- Wear clothes with natural fibres like cotton
Pharmacological advice
- Frequent, liberal application of emollients should be recommended, even when skin is unaffected. Emollients are appropriate for regular (long-term) use in order to keep the condition under control. BNF has guidance on emollient quantities and how to apply them to the skin
- Best to apply to moist skin (such as after bathing) and may want to do a patch test first
- There is no evidence for one emollient being better than another - usually a trial and error approach is needed to find most suitable one. Oily emollients may be better than water-based ones
- See MHRA Drug Safety Alert for guidance on emollients and risk of severe and fatal burns with paraffin-containing and paraffin-free emollients. Note that aqueous cream (with sodium lauryl sulfate) is less suitable to use as a leave-on emollient. Hydrogenated lanolin may cause hypersensitivity reactions but some manufacturers will use a pharmaceutical/medical grade of lanolin to minimise the likelihood of such adverse effects
- When recommending emollients for use on the face or around the eyes, advise the patient to check the individual product's suitability for facial application. The MHRA has received reports of ocular surface toxicity and chemical injury associated with certain emollients (e.g. Epimax Ointment) being used on or near the eyes
- Care needed with using emollients/additives in the bath as they make the surface very slippy
- Pregnancy: not likely to be managing atopic dermatitis in pregnancy (as many people grow out of it) and particularly not in an OTC setting. May be able to provide emollients but double check the specific product prior to recommendation/sale