Signs and symptoms. They vary widely from person to person, but we will usually see dry skin.
Patients will have itching or pruritus and this is usually worse at night. This is when histamine
levels rise. You'll see red to brownish gray patches on the skin and there are some common
locations. These include the hands, the feet, the ankles, the wrists, the neck, the upper chest,
the eyelids, and then behind the knees and in the antecubital regions. In infants, we also see
this on the face and the scalp. This can also look like a small bump that can start to crust
over, and this might be a secondary impetigo. There can be a thickened, cracked, scaly skin
and the patient's skin may be raw or excoriated from scratching. On exam, you want to collect
a full health history and review your patient's vital signs. This should be normal. Next, you'll
do a physical exam including a thorough inspection of the skin. You'll see lesions that are
ill-defined, erythematous, scaly, and crusted. And with eczema, the lesion borders are not as
well defined as with fungal lesions like ringworm. This can help distinguish between the
2 disorders. You're also going to look for evidence of thickening of the skin or lichenification
and that's from frequent scratching. The patients get into a chronic itch-scratch cycle. So the
diagnosis, this can be challenging because each patient presents differently. You want to
review the health history and use the information from your exam. Rarely, patients will need
a skin biopsy. This is not common and there's no definitive diagnostic test available. This is a
clinical diagnosis and you want to assess your patient for triggers. How do we manage eczema?
Well first we use topical steroids. There is a 5-day maximum, if at all, and you want to use
with extreme caution on the face because these topical steroids thin and discolor the skin.
You can use anti-inflammatory topical medications. Antihistamines can be used either topically
or orally and this helps with the histamine release and the itch control. Your patient might
need oral or topical antibiotics and that's not to treat the eczema, but if they have a
secondary bacterial infection due to the break in the skin, that's why we use antibiotics. If
the patient has a large flare or they're just not responding to topicals, they may need a
course of oral steroids. Ultraviolet light done at a dermatologist clinic or immunosuppressant
medications are also used. There are also non-medicated treatments for eczema. We want the
patient to moisturize their skin at least twice per day and we want them to avoid scratching.
This is going to release more histamine and can introduce bacteria. You're going to have the
patient apply occlusive wet dressings at night and you want them to take a 10 to 15-minute
warm bath everyday. The patient should wash with a mild soap without dyes or perfumes and
they may not need a soap at all. Here you can see the process for wet wrap therapy. You're
going to soak the wraps in water then the parent will bathe their child in warm water for
about 10-15 minutes using a gentle soap or no soap. After that bath, they will lightly pat their
child dry and we don't want them to completely dry the skin. While the child is still wet,
they're going to apply an ointment or a cream over the entire body within 3 minutes and this
seals in the moisture. Next, they'll get the wraps out and wring them out and immediately
dress the child in this damp wrap and put a dry layer on top. Now you can see this is a messy
and intricate process and it can affect the child's ability to travel, sleepover at a different
house, or even attend activities such as summer camp. So what are complications for eczema?
Well, asthma and hay fever are present in more than half of children with eczema; however,
eczema doesn't cause these conditions. They typically co-exist. There is a correlation, not
causation. Patients will have chronic itching and scaly skin. Remember that's lichenification
and that's from the itch-scratch cycle. Patients can develop secondary bacterial infections,
and this is from the break in the skin barrier and that normal flora will go in deeper. Patients
can have irritant hand dermatitis. Due to the itching at night, they may have sleep problems.
And then they'll have side effects of medications including the side effects of steroids and
immunosuppressants. The patient may have to restrict their activity including swimming.