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13.5.1
Eczema
Refer to the Eczema: Hand and Foot Dermatology Referral and Management Pathway or the Atopic Eczema Dermatology Referral and Management Pathway.
Eczema (dermatitis) has several causes, which may influence treatment. The main types of eczema are irritant, allergic contact, atopic, venous and discoid; different types may co-exist. Lichenification, due to scratching and rubbing, may complicate any chronic eczema. Atopic eczema is the most common type and it usually involves dry skin as well as infection and lichenification.
Management involves the removal or treatment of contributory factors including occupational and domestic irritants. Known or suspected contact allergens should be avoided. Rarely, ingredients (active ingredients or excipients) in topical medicinal products may sensitise the skin.
Skin dryness and the consequent irritant eczema require emollients applied regularly and liberally to the affected area. The use of emollients should continue even if the eczema improves or if other treatment is being used. See section 13.2 – Emollients and barrier preparations.
Topical corticosteroids are also required in the management of eczema; the potency of the corticosteroid should be appropriate to the severity and site of the condition. See section 13.4 – Topical corticosteroids.
Tacrolimus ointment is used
for atopic dermatitis in patients who are not adequately responsive to or are
intolerant of conventional therapies such as topical corticosteroids. See
section 13.5.3 – Drugs affecting the immune response
and
Tacrolimus Ointment Shared Care Agreement (Staffnet intranet link only).
Alitretinoin
capsules are licensed for
adults over 18 years, for the treatment of severe chronic hand eczema refractory
to potent topical corticosteroids. In general it is only used in cases
refractory also to allergen avoidance (when appropriate) measures and to PUVA.
See
BNF for dose and monitoring requirements.
Alitretinoin is a retinoid and, like other systemic retinoids, should
only be prescribed by a consultant dermatologist or the Dermatology clinic.
Alitretinoin is teratogenic and must not be given to women of child bearing
potential unless they practise effective contraception
1 month before, during, and 1 month after treatment
and, after detailed
continual assessment and explanation by the prescribing physician.
Alitretinoin is to be dispensed by a hospital pharmacy only. Monitoring is
undertaken by the Dermatology clinic. The suggested monitoring requirements for
alitretinoin include:
Monthly pregnancy prevention programme will be followed,
Baseline and 6 week Full Blood Count checked then monitored every 3 months,
Lipids, LFTs, TSH and fasting blood glucose monitored before treatment, 1 month after starting and then 3 monthly.
Other treatments for
severe refractory eczema (or severe refractory atopic dermatitis) include:
azathioprine
[unlicensed use ‘off-label’],
ciclosporin
[licensed for short-term treatment of severe atopic dermatitis where
conventional therapy ineffective or inappropriate],
lymecycline
[unlicensed use ‘off-label’],
oral
methotrexate or
parenteral
methotrexate [unlicensed use ‘off-label’], and
mycophenolate
mofetil [unlicensed use ‘off-label’]. See also section
13.5.3.
Acitretin
[unlicensed use ‘off-label’] (typical
dose range 20-60mg daily), may be considered by specialists for severe
refractory eczema, prescribed by a consultant dermatologist or the Dermatology
clinic. Acitretin is a retinoid and like alitretinoin is teratogenic and
requires monitoring which is undertaken by the Dermatology clinic. See also
section 13.5.2.
© 2010 NHS Tayside
