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Referral and warning signs
When to refer
Refer to Dermatologist/Specialist if: Diagnosis uncertain. Severe or widespread eczema. Poor control despite appropriate topical therapy. Recurrent skin infections. Significant impact on quality of life. Consideration for patch testing or systemic therapy.
Red flags
- Sudden worsening with widespread vesicles/pustules/erosions and fever (suspect Eczema Herpeticum - EMERGENCY).
- Signs of severe secondary bacterial infection / cellulitis / sepsis.
- Failure to thrive in infants with severe eczema.
- Erythroderma (whole body redness).
Signs and symptoms
- General: Itching (pruritus) is hallmark. Erythema (redness). Dry skin (xerosis). Scaling. Vesicles/Blistering (acute). Oozing/Weeping (acute). Crusting. Lichenification (thickened skin with prominent markings - chronic scratching).
- Atopic Eczema: Onset usually childhood. Dry, itchy skin. Typical distribution varies with age: Infants (face, scalp, extensors), Children/Adults (flexures - elbows, knees, neck, wrists, ankles). Associated with personal/family history of asthma, allergic rhinitis (atopic triad).
- Allergic Contact Dermatitis: Itchy, erythematous, often vesicular rash at site of contact with an allergen (e.g., nickel jewelry, poison ivy, fragrance, preservative). Well-demarcated initially.
- Irritant Contact Dermatitis: Redness, dryness, stinging/burning from direct skin damage by irritant (e.g., soaps, detergents, solvents, excessive water exposure). Less vesicular, less well-demarcated than allergic.
- Seborrhoeic Dermatitis: Greasy, yellowish scales on erythematous base in areas rich in sebaceous glands (scalp - 'dandruff', face - eyebrows, nasolabial folds, central chest, skin folds).
- Discoid (Nummular) Eczema: Coin-shaped, itchy, red, often weeping/crusted plaques, typically on limbs.
- Stasis Dermatitis: Occurs on lower legs due to chronic venous insufficiency. Erythema, scaling, itching, pigmentation (haemosiderin), may lead to ulceration.
Risk factors
- Atopic Eczema: Genetic predisposition (filaggrin mutations), Family history of atopy.
- Contact Dermatitis: Exposure to specific allergens or irritants.
- Seborrhoeic Dermatitis: Malassezia yeast, neurological conditions, HIV.
- Stasis Dermatitis: Venous insufficiency, varicose veins, obesity, immobility.
Diagnosis
Clinical assessment
Diagnosis based on history (onset, duration, triggers, personal/family history of atopy) and clinical examination (morphology and distribution of lesions).
Differential diagnosis
- Psoriasis (well-demarcated silvery plaques, extensor surfaces, nail changes).
- Fungal infections (Tinea - annular lesions, KOH positive).
- Scabies (burrows, intense nocturnal itch, typical distribution).
- Impetigo (honey-coloured crusts).
- Drug eruptions.
- Lichen simplex chronicus (lichenified plaques from chronic scratching).
Investigations
- Usually clinical diagnosis.
- Patch Testing: To identify specific allergens in suspected Allergic Contact Dermatitis (specialist).
- Skin scraping for KOH: Rule out fungal infection.
- Skin biopsy: If diagnosis uncertain or unresponsive to treatment.
Diagnostic criteria
Clinical pattern recognition based on morphology, distribution, and history.
Management
Non-pharmacological management
- General Measures (Especially Atopic/Dry Skin):
- - Emollients/Moisturizers: Apply liberally and frequently (several times daily), especially after bathing. Ointments preferred for very dry skin. (e.g., Petroleum jelly, aqueous cream - UCG). (LOC: HC2)
- - Bathing: Short, lukewarm baths/showers. Use mild, non-soap cleansers or emollient wash.
- - Pat skin dry gently, apply emollient immediately.
- - Avoid Triggers: Identify and avoid known irritants (soaps, detergents, harsh fabrics) or allergens.
- - Wear soft, breathable fabrics (cotton).
- - Keep fingernails short (reduce scratching damage).
- Contact Dermatitis: Strict avoidance of identified allergen/irritant.
- Stasis Dermatitis: Leg elevation, compression therapy (bandages/stockings).
Pharmacological treatment
- Topical Corticosteroids: Mainstay for controlling inflammation/itching. Choose potency based on severity, site, age. Apply OD/BID thinly to affected areas ONLY during flares.
- - Mild (e.g., Hydrocortisone 1%): Face, eyelids, groin, infants. (LOC: HC2)
- - Moderate (e.g., Betamethasone valerate 0.1%, Triamcinolone): Body, limbs. (LOC: HC2 - Betamethasone)
- - Potent/Very Potent (e.g., Clobetasol propionate): Thickened/lichenified skin, severe flares (short-term use, specialist guidance often needed).
- - Caution: Skin thinning, striae, telangiectasias with prolonged/potent use, especially on face/folds.
- Topical Calcineurin Inhibitors (Tacrolimus, Pimecrolimus): Steroid-sparing alternative for sensitive areas (face, folds) or long-term use. Specialist initiation.
- Antihistamines: Oral antihistamines (e.g., Chlorphenamine, Promethazine, Cetirizine) primarily for itch relief, especially sedating ones at night. (LOC: HC2)
- Antimicrobials:
- - Treat secondary bacterial infection (impetiginization) with topical (Mupirocin) or systemic antibiotics (Cloxacillin/Erythromycin - see Impetigo). (LOC: HC2/4)
- - Treat fungal infection if present (e.g., Ketoconazole shampoo/cream for Seborrhoeic Dermatitis).
- Systemic Therapy (Severe/Refractory Eczema):
- - Systemic Corticosteroids (short course for severe flares).
- - Phototherapy (UVB).
- - Systemic Immunosuppressants (Ciclosporin, Azathioprine, Methotrexate).
- - Biologics (Dupilumab).
- - (Requires Specialist Management).
Monitoring
Monitor symptom control (itch, redness, dryness). Assess adherence to emollients/topical steroids. Monitor for side effects of treatment (esp. steroids).
Complications
- Secondary bacterial or viral (eczema herpeticum) infections.
- Lichenification, scarring.
- Pigmentary changes (hypo/hyper).
- Sleep disturbance due to itching.
- Psychosocial impact (appearance, QoL).
- Side effects of treatments.
Prevention
- Regular emollient use to maintain skin barrier (atopic).
- Avoidance of known triggers/allergens.
- Appropriate management of flares to prevent chronicity.
Patient education
- Understanding eczema as a chronic inflammatory condition (flares and remissions).
- Role of skin barrier dysfunction and triggers.
- Crucial importance of liberal and frequent emollient use.
- Correct use of topical steroids (appropriate amount, duration, potency for site).
- Strategies to manage itching (cool compresses, antihistamines, distraction).
- Identifying and avoiding triggers.
- Recognizing signs of infection.
- When to seek medical review.
Uganda-specific notes
Eczema is common, especially atopic in children. Access to varied emollient formulations and potent topical steroids/calcineurin inhibitors limited. Secondary infections common. Vaseline widely used as emollient. Betamethasone cream commonly available.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 22, Section 22.5.3