Pauline BrownClinical Nurse Specialist Eczema/Allergies

Northland DHBChild Health Centre

Debbie RickardChild Health Nurse Practitioner Candidate

Capital coast DHB

This sessionWhat is eczema?Who it affects and prevalenceNon-allergic triggersEczema and Atopy (allergy)The skin barrierGene-environment interactionsReasons for treatmentsCosts and stresses on familiesPathophysiology of skin and eczemaComplications of eczema – bacteria, fungus, virusNurse led clinics DebbieBasic Skin treatments/management concepts DebbieManagement infant/pre-school PaulineManagement in the school age/adolescent/adult – Debbie

What is eczemaEczema is a chronic, inflammatory skin

condition that is characterised by DrynessDeep-seated itchRedness and inflammationSometimes areas can be weepy or oozing

IncidenceThe incidence of eczema has increased

steadily in westernised countries, over the past 40 years (Cork et al 2006, p3 ISAAC study, lancet, 2006)

It is believed that up to 1 in 4 children may be affected and there is no cure. (Gold & Kemp, 2005)

It affects around 30% of preschool-age children, 15% of school-age children and 9% of adolescents

60 % of the children will have onset before the age of 1 year (Krakowski, Pediatrics, 2008)

Historically it is poorly understood and frequently under treated.

Name Confusion?Eczema has been historically thought of as an

allergic disease hence the name Atopic Dermatitis (inflammation of the skin due to allergies) (Cork et al, Exchange, NES 2006)

However, more recently it has been suggested that we should be dividing the condition of ‘eczema’ into 2 terms

(Darsow etal European Task Force on Atopic Dermatitis, JEADV, 2010, Ricci etal, Am J Clin Derm, 2009, Cork et al, Exchange, NES 2006)

Atopic - having allergic tendencies (extrinsic)

Non atopic – not having allergic tendencies (intrinsic)

Eczema - AtopicAtopy, or the tendency to be sensitised or allergic

approximately 1/3rd of all individuals with eczema has either;

IgE (immediate hypersensitivity) (example hayfever, asthma, food allergies)

or Cell-mediated (delayed type hypersensitivity). (example

contact dermatitis to nickel, dyes etc.)

Cell mediated allergy does not show on skin prick testing or RAST

(Cork et al 2006)

Eczema – Non Atopic2/3rds have non allergic eczemaTrigger (things that irritate) factors include:

Soap based products, body wash chemicalsHeat, dry air or heatingStress and anxietyWoolly/rough clothes/fabricsCertain food chemicals or

colourings/preservatives (intolerances and not allergy)

Some infections/bacterial, viral, fungalteething

However................

Regardless of the classification, it is thought that the primary problem is the skin barrier

Functions of the skinSkin cells (keratinocytes) divide at the bottom of the epidermis to make a new supply of skin cells

The new cells mature as they move up through the skin

At the top of the skin, the skin barrier (stratum corneum) is formed

The barrier protects the body from the environment and prevents the penetration of irritants and allergens

The skin cells in the stratum corneum are locked together by structures call corneodesmosomes and the skin cells are surrounded by lipid bi-layers.(Cork et al, Exchange, NES 2006)

The skin barrier

The stratum corneum can be viewed as a brick wall

Comparing skin cells to the bricks and lipid lamellae to the cement

The wall is stabilised by passing iron rods though the bricks which are compared to the corneodesmosomes

The iron rods keeps the skin together

In order to maintain a constant thick barrier skin cells shed from the surface of the skin

Malfunctioning skin barrier

The skin cells in the stratum corneum are locked together by structures call corneodesmosomes and the skin cells are surrounded by lipid bi-layers.

?Faulty genes break down the skin barrier's binders or iron rods much faster than normal.

People with eczema have gaps in their lipids or mortar.

This results in cracks all the way through the skin barrier.

Irritants such as soap cause more break down and the "brick wall" starts to fall apart.A broken barrier lets allergens enter the skin easily.

Germs and more irritants then lead to an eczema flare

Why has the prevalence increased?The genes that predispose us to eczema has

not changed, but our environment has

One theory - we are exposing our skin to more soaps and surfactants such as bubble baths to wash babies

Soap and surfactants shown to decrease the stratum corneum by 40% (Cork et al Dermatol in Practice, 2002)

The rising prevalence of atopic eczema and environmental trauma to the skin.

Cork et al. Dermat Pract 2002, 10, 22.

UK data 1960 - 1981 1995 - 2001Personal use of soap -

detergent76 million £ 453 million £

Water for personal washing 11 L /day 51 L/day

Increased skin barrier dysfunctions

Genes associated with strength of skin barrier

Chemicals called proteases break down the corneodesmosomes (iron rods)

Normal skin has low levels of proteases so skin barrier is thick

Non-allergic eczema has a change in the gene which produces higher levels of protease

Leads to premature break down of the iron rods.

The lipid lamellae (cement) is also incomplete

Normal pH of the skin is 5.5Exposure to soap and surfactants ↑ 7.5 or

higherThe protease SCCE is pH sensitive50% increase in protease activityEquals greater breakdown of the skin

barrierIncrease penetration of irritants and

allergens.

Aqueous CreamContains surfactantsSurfactants break down the skin barrierAqueous cream was designed as a soap

substitute for eczemaWidely used as a ‘leave on’ moisturiserAudit of children attending dermatology

clinic showed aqueous cream caused irritant reactions in > 50%

(Cork et al, Pharmaceutical J, 2003)

Genetic link

If a child has one parent with atopic eczema – 20%

If both parents have (or had) atopic eczema – 50%

Which leads us to the treatments

Our increasing knowledge and understanding of how the skin barrier breaks down, reinforces

the importance of skin-barrier maintenance and repair

This is the first-line treatment →Complete emollient (moisturiser) regimes

2nd line of treatment

↓

Identification and avoidance of irritants and allergens

3rd line of treatment

↓Treatment of flares

The more attention paid to the first two steps, the less often flares will

occur

Loss of skinbarrier

Moisturise

Bathe

Cleanse

SteroidsAntibiotics

Primary/secondary infection occurs

Immune system responds toBacterial invasion

Desire to scratch

Excoriation occurs

Creates allergic response

Produces moreItch and inflammation

It is far more…… yet it is a disease that is often minimized by health professionals

Consider The Impact Of Eczema

Overall it is the commonest specific skin disorder encountered – yet very poorly managed

Second commonest skin disorder seen in dermatologist office – yet very poorly managed

Major issuesPhysical symptoms

Pruritus, skin discomfort, sleep disruptionEmotional problems

Stigma associated with the visibility of the disease

Social dysfunctionLoss of work, school, social activities

Financial Burden in AustraliaApprox. A$1142/year/per person for mild eczema

Approx. A$6099/yr/person for severe eczema

A$157Million/year per mild eczema population

A$316.7 Million/year per severe eczema population

These figures do not include national expenditure on subsidised medications

Annotation/Atopic eczema: Its social and financial costs; AS Kemp, Department of Immunology, Royal Children’s Hospital, Parkville, Victoria, Australia - 1998

Major negative impact on the quality of life (QoL)Since 1987 impact measured in a repeatable

standardised way;Dermatology Life Quality IndexChildren’s Dermatology Life Quality IndexSkinex

the impairment of the QoL and the psychological wellbeing has been well documented

Br J Dermatol 2006; 155: 145-151

Recent study on monitoring ‘course of life’ (CoL) impact on children with ADCoL refers to fulfilling age specific developmental

tasks and milestonesHampered CoL has been found in adults who

have had; Childhood cancerEnd-stage renal failureAnorectal malformationsHirschsprung diseaseEsophageal atresia...but this is 1st study on eczemaPaediatric Dermatology, Vol. 26 No. 1, 114-22, 2009

Study results117 patients, median age of 23.4 years 508 control patients, median age 24.2 years

Need for support was identified87% needed more information about treatment

regimes85% wanted improvement of personal guidance and

advice of the physician during their treatments52% desired contact with fellow-sufferers68% felt they needed psychological support

CoL ResultsCompared mod eczema to severe eczema

Less friends in primary and secondary school Spent less leisure time with friends Fewer belonged to a group of friends Less went to school dances

Comparing severe eczema with healthy peers Less were members of sports clubs during primary and

secondary years 70% felt shame around their peers 49% avoided intimacy 25% reason for missing school 24% did things on their own

Physical aspects90.7% experienced pain and itch69% sleeplessness60% fatique74% had increase in eczema when stressed

International Study Of Life with ATopic Eczema (ISOLATE)

Largest and most comprehensive study conducted into the impact of eczema on patients' lives and relationships

Revealed the extent of the emotional suffering caused by eczema. (2004)

 

Results55% either always or sometimes worried

about the next eczema flare51% always or sometimes unhappy/depressed86% avoid at least one type of everyday

activity during a flare-up43% fairly or very concerned about being seen

in public during a flare74% of patients and caregivers state that their

physicians have never discussed the emotional impact that eczema has had on their lives

Australian StudyIndicated that the family stress related to the care of a child with

moderate or severe atopic dermatitis is significantly greater than that of care of children with

insulin-dependent diabetes mellitus. (Kemp, 1999)

 

Never underestimate the emotional cost of eczema

Single young mother 1 year old Moderate – severe eczema and

receiving multiple and conflicting advice

Multiple food allergies – conflicting advice

Multiple environmental allergies

No family living in same town Mother studying Minimal income Sleepless nights Irritable child during day Difficult finding childcare due

to eczema