Atopic eczema and infected eczema

eczema · atopic dermatitis · atopic eczema · infected eczema · eczema flare

The commonest childhood skin disease - in the ED the job is to spot the infected flare and to fix the treatment that is not working.

GPBand B

Red flags

Monomorphic punched-out erosions, or a painful rather than itchy flare - eczema herpeticum, needing aciclovir without waiting for swabs
Fever, systemic upset, or rapidly spreading infection
Periocular involvement in a suspected herpetic flare - same-day ophthalmology and dermatology
Failure to thrive, or severe eczema in an infant not responding to appropriate treatment
Erythroderma - near-total skin involvement is a medical emergency in its own right

Recognise

On light skin

Ill-defined red scaly itchy patches, weeping and crusted when acute, lichenified and thickened when chronic, in a flexural distribution.

On brown and black skin

Erythema is the standard description of eczema and it is frequently absent in brown and black skin, where active inflammation appears violaceous, grey, dark brown or simply as an ashen change - which is why eczema severity is systematically under-scored in darker skin and children are under-treated as a result. Two pattern differences also matter: follicular or papular eczema, with prominent goosepimple-like papules around hair follicles, and a more extensor than flexural distribution. Sarkar and Verma's review of atopic dermatitis in skin of colour describes atypical papular and follicular morphology with more pronounced lichenification, reported particularly in patients of Asian ethnicity; the extensor distribution is widely taught but is not stated in that review. Either way these patterns are often not recognised as eczema at all. Judge severity on lichenification, excoriation, warmth and the child's sleep and scratching rather than on redness. Post-inflammatory hypopigmentation and hyperpigmentation are prominent and, in that review, persist long after the active inflammation subsides, causing significant psychosocial distress. NICE CG57 makes the same point in its own words - atopic eczema may temporarily cause the skin to become lighter or darker. They persist for months and are a major source of distress - explain that they are not scars and not steroid damage.

In any skin tone

Itch is essential to the diagnosis - eczema that does not itch is probably not eczema
Personal or family history of atopy
Lichenification and excoriation mark chronicity and severity
Infected eczema: weeping, golden crusting, pustules, rapid worsening, or a flare that stops responding
Eczema herpeticum: monomorphic punched-out erosions, pain rather than itch, and systemic upset - a different emergency

Distribution

In infants, the face and the extensor surfaces. In older children and adults, the flexures - antecubital and popliteal fossae, wrists, ankles and neck. In brown and black skin, extensor and follicular patterns are common at any age.

Photographs

Severe infantile atopic eczema. The skin is dry, scaling and thickened rather than red - on skin this dark the erythema that scoring systems — Severe infantile atopic eczema. **The skin is dry, scaling and thickened rather than red** - on skin this dark the erythema that scoring systems lean on is simply not visible, and severity has to be judged from scale, lichenification, excoriation and the child's sleep. Note the **sparing of the central face**, which is typical and helps separate this from seborrhoeic dermatitis.
Fitzpatrick IV-VI (Fitzpatrick type estimated from the photograph, not stated by the source) · Oladokun RE, Lehloenya RJ, Hlela C, Ubesie AC, Katibi SO, Malande OO, Eley BS · Atlas of Paediatric HIV Infection, UCT Libraries Press 2018 - Chapter 5: Inflammatory Skin Conditions, p96 · CC BY 4.0

Provenance for every photograph in this library: image licences. How much of the corpus still has no darker-skin photograph: skin tone coverage.

Mimics

Eczema herpeticum — The complication that must never be missed - it is treated as an emergency, not as a flare
Impetigo — Bacterial infection of eczema is common and the two frequently coexist
Nappy rash, candida, and patterns that should worry you — In infants, irritant and candidal nappy dermatitis is distinguished by involvement or sparing of the skin folds
Erythroderma — Eczema is a leading cause of erythroderma when it becomes near-total
Acute urticaria — Acute urticaria is itchy but the weals move within hours and leave no scale
Pompholyx — Pompholyx is a vesicular pattern of eczema on the palms and soles, and many patients have atopic eczema elsewhere

What to do in the ED

Establish first whether this is a plain flare, a bacterially infected flare, or eczema herpeticum - the three have different urgencies
Emollients generously and frequently, and a topical corticosteroid of potency matched to severity and site, per NICE CG57's stepped approach
Check what they are actually using and how much. Under-use of emollient and fear of topical steroid are the usual reasons a flare reaches the ED, and correcting that is often the whole intervention
Treat bacterial infection with antibiotics where there is crusting, weeping or pustulation with systemic features
Start aciclovir if eczema herpeticum is suspected - do not wait for confirmation
Assess sleep, school attendance and the family's coping; severe eczema is a substantial burden and warrants dermatology referral rather than repeat ED attendance
Explain pigment change explicitly in patients with brown and black skin - this is a common reason for lost confidence in treatment

Disposition

Optimise treatment and discharge with GP follow-up; dermatology referral for severe or poorly controlled disease. Admit for eczema herpeticum with systemic upset, severe infection, or erythroderma.

Safety-netting

Use the emollient far more often and in far greater quantity than feels necessary, and use the steroid as prescribed - used properly it is safe and under-using it is what keeps the eczema going. Return urgently if the skin becomes painful rather than itchy, if clusters of small identical punched-out sores appear, if there is fever or the child is unwell, or if the rash spreads rapidly. Darker marks or pale patches left behind afterwards are not scars and will fade slowly.

Local variation

NICE CG57 covers children under 12 only. Its stepped approach is applied here to older children and adults by extension, not by guideline - there is no equivalent NICE guideline for adult atopic eczema, and CKS is the practical reference above that age.

Sources

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