Symptoms in the Pharmacy : skin disorders 1

Eczema/dermatitis

Eczema is a term used synonymously with dermatitis. The latter is
more commonly used when an external precipitating factor is present
(contact dermatitis). The rashes produced have similar features but the
distribution on the body varies and can be diagnostic. Atopic eczema
affects up to 20% of children, in many of whom it disappears or
greatly improves with age such that 2–10% of adults are affected.
Atopy is a term that has been used to describe a group of diseases, e.g.
eczema, asthma and hay fever, which run in families.
The rash of eczema typically presents as dry flaky skin that may be
inflamed and have small red spots. The skin may be cracked and
weepy and sometimes becomes thickened. The rash is irritating and
can be extremely itchy. Many cases of mild to moderate eczema can be
managed by the patient with support from the pharmacist.

What you need to know

• Age
• Distribution of rash
• Occupation/contact
• Previous history
• History of hay fever/asthma
• Aggravating factors
• Medication

Significance of questions and answers

 
Age/distribution
The distribution of the rash tends to vary with age. In infants, it is
usually present around the nappy area, neck, back of scalp, face, limb
creases and backs of the wrists.
In white children, the rash is most marked in the flexures: behind
the knees, on the inside of the elbow joints, around the wrists, as well
as the hands, ankles, neck and around the eyes. In black and Asian
children, the rash is often on the extensor surface of the joints and may
have a more follicular appearance.

In adults, the neck, the backs of the hands, the groin, around the
anus, the ankles and the feet are the most common sites. The rash of
intertrigo is caused by a fungal infection and is found in skin folds or
occluded areas such as under the breasts in women and in the groin
or armpits.

Occupation/contact
Contact dermatitis may be caused by substances that irritate the
skin or spark off an allergic reaction. Irritant contact dermatitis is
most commonly caused by prolonged exposure to water (wet work).
Typical occupations include cleaning, hairdressing, food processing,
fishing and metal engineering. Substances that can irritate the
skin include alkaline cleansing agents, degreasing agents, solvents
and oils. Such substances either cause direct and rapid damage to
the skin or, in the case of weaker irritants, exert their irritant
effect after continued exposure. Napkin dermatitis is an example
of irritant dermatitis, and can be complicated by infection, e.g.
thrush.

In other cases, the contact dermatitis is caused by an allergic response
to substances which include chromates (present in cement and
rust-preventive paint), nickel (present in costume jewellery and as
plating on scissors), rubber and resins (two-part glues and the resin
colophony in adhesive plasters), dyes, certain plants (e.g. primula),
oxidising and reducing agents (as used by hairdressers when perming
hair), and medications (including topical corticosteroids, lanolin, neomycin,
cetyl stearyl alcohol). Eye make-up can also cause allergic
contact dermatitis.

Clues as to whether or not a contact problem is present can be
gleaned from knowledge of site of rash, details of job and hobbies,
onset of rash and agents handled, and improvement of rash when
away from work or on holiday.

Previous history
Patients may ask the pharmacist to recommend treatment for eczema,
which has been diagnosed by the doctor. In cases of mild to moderate
eczema, it would be reasonable for the pharmacist to recommend the
use of emollients and to advise on skin care. Topical hydrocortisone
and clobetasone preparations can be recommended for the treatment
of mild to moderate eczema. However, where severe or infected
exacerbations of eczema have occurred, the patient is best referred
to the doctor.
Occasionally, pharmacists receive requests for topical hydrocortisone
or clobetasone products from patients on the recommendation of
their doctors. It can be difficult to explain why such a sale cannot
legally be made if the product is for use on the face or anogenital area
or for severe eczema. Pharmacists can minimise such problems by
ensuring that local family doctors (especially those in training) are
aware of the restrictions that apply to the sale of hydrocortisone and
clobetasone OTC.

History of hay fever/asthma
Many eczema sufferers have associated hay fever and/or asthma.
There is often a family history (in about 80% of cases) of eczema,
hay fever or asthma. Eczema occurring in such situations is called
atopic eczema. The pharmacist can enquire about the family history of
these conditions.

Aggravating factors
Atopic eczema may be worsened during the hay fever season and by
house dust or animal danders. Factors that dry the skin such as soaps
or detergents and cold wind can aggravate the condition. Certain
clothing such as woollen material can irritate the skin. In a small
minority of sufferers (less than 5%), cow’s milk, eggs and food
colouring (tartrazine) have been implicated. Emotional factors, stress
and worry can sometimes exacerbate eczema. Antiseptic solutions
applied directly to the skin or added to the bathwater can irritate the
skin.

Medication
Contact dermatitis may be caused or made worse by sensitisation to
topical medicaments. The pharmacist should ask which treatments
have already been used. Topically applied local anaesthetics, antihistamines,
antibiotics and antiseptics can all provoke allergic dermatitis.
Lanolin used to be a common sensitiser. Very highly purified lanolin is
now available, and sensitisation problems appear to have been eradicated.
Some preservatives may cause sensitisation. Information about
different preparations and their formulations can be obtained from the
local pharmacist or from the manufacturer of the product. The BNF is
also a good source of information on this subject, with a list of
additives for each topical product and excipients that may be associated
with sensitization.

If the patient has used a preparation, which the pharmacist considers
appropriate for the condition, correctly but there has been no
improvement or the condition has worsened, the patient should see the
doctor.
When to refer
Evidence of infection (weeping, crusting, spreading)
Severe condition: badly fissured/cracked skin, bleeding
Failed medication
No identifiable cause (unless previously diagnosed as eczema)
Duration of longer than 2 weeks