Evidence based management of atopic eczema

A topic eczema (AE, synonymous with atopic dermatitis), together with asthma and hay fever, has been on the increase for at least three decades.At present, around 15-20% of children in industrialised countries suffer from AE, leading to a significant reduction in quality of life and a burden on health care resources.1 2 Paediatricians encounter patients with AE both ''on call'' and in outpatient clinics and are therefore often directly involved in AE management and patient education.Paediatricians who run asthma clinics encounter AE frequently.In addition, a few paediatricians have a special interest in AE, and some even run dedicated paediatric dermatology outpatient clinics.This review focuses on the practical management of AE from a paediatric perspective, with an emphasis on relating treatment decisions to the currently available evidence.Sufficient evidence from clinical trials is now available to inform many areas of AE management, although some ''grey areas'' and some areas of relative ignorance remain.We will illustrate common AE management issues in case scenarios and use these to discuss the place of emollients, topical steroids, the new topical immunomodulators (tacrolimus and pimecrolimus), ''wet wrap'' bandages, as well as systemic treatment options, phototherapy, and advice on allergen avoidance and complementary therapies.Much of the evidence in this article is based on a Health Technology Assessment report that was commissioned by the National Health Service in 2000, supplemented by other studies that have been published since.3 We also refer to our practical experience in running a multi- professional eczema clinic at the Queen's Medical Centre, Nottingham. EMOLLIENTS AND TOPICAL CORTICOSTEROIDSCase history A Marc, age 2 years, attends your asthma clinic.On his third visit, Marc's father tells you that he has developed an itchy widespread rash (fig 1).Examination reveals widespread, ill defined erythematous patches, with more pronounced involvement in the skin folds.You are satisfied that he fulfils the UK diagnostic criteria for AE 4 (table 1).Marc is currently using both a moisturiser and 1% hydrocortisone ointment twice a day.Emollient treatment probably has an important role in AE management, although its use is supported by relatively few good studies.5 Emollients can often be sufficient to provide relief in children with very mild eczema, especially when using greasier preparations such as white soft paraffin/liquid paraffin in a 50:50 mixture.The best emollient is the one that the child will actually use, and a tray of different emollients set up in the clinic area can be a good way to empower the older child to select his/her own emollient.If applied two or three times daily to the whole body, an 8 year old child will require at least 250 g per week.Emollients alone are not so useful during acute inflammatory flares when additional topical steroids will be needed.The basic principle is to use the least potent steroid required to control the AE on a daily basis, until the skin has cleared.Current evidence suggests that short bursts of a potent topical steroid (once or twice daily), followed by ''holiday periods'' of just emollient use, are as effective and safe as long term treatment with low dose topical steroid.3 Steroid dilutions and topical steroid-antibiotic combinations should be avoided, as there is little evidence that they have superior treatment efficacy in comparison to topical steroids alone.Bacterial resistance development may be a problem in antibiotic containing preparations.A recent National Institute for Clinical Excellence (NICE) appraisal evaluated the clinical trial evidence for different frequencies of application for topical corticosteroids and commented, ''Overall, studies found little difference in response to treatment between once-daily and twicedaily application of potent topical corticosteroids'' and that ''Some statistically significant differences favouring twice-daily treatment were identified, but these were inconsistent between outcome assessors (physicians versus patients) and outcomes selected for analysis''.6 We now routinely use all our topical steroids once daily.This has simplified treatment plans for busy