Managing Mild Eczema Symptoms

A resource for Healthcare professionals

What is eczema?

Atopic eczema or Atopic dermatitis is a very common inflammatory skin condition that affects approx. 1 in 5 children and 1 in 10 adults in the UK It is characterised by disruption of the skin barrier leading to xerosis and intense pruritus. Erythema may be present due to Inflammation. This tends to present as redness on lighter skin tones and may appear as purply, grey or darker brown on skin of colour. In addition, Lichenficiation (thickening of the skin) can also occur.

In the UK eczema affects…1 in 5 children and 1 in 10 adults.

Mild eczema

Mild atopic eczema is characterised as areas of dry skin, with infrequent itching (with or without inflammation) and in most cases has little or no impact on everyday activities, sleep, and psychosocial well-being.

Management of mild atopic eczema

Often mild atopic eczema can be successfully managed with regular use of emollients, avoidance of trigger allergens and irritants and occasional use of mild topical corticosteroid (TCS) treatment.

Using Emollients

Emollients (or moisturisers) are very useful in the management of atopic eczema. They help soften the skin and relieve the itch caused by excessive dryness.

Leave on emollients are designed to be left on the skin and used frequently on the whole body, they should be prescribed in large enough quantities that encourage regular liberal application.

Using Corticosteroids

Intermittent use of mild corticosteroids may be required in the management of mild eczema. These include hydrocortisone 0.5%, 1% and 2% and fluocinolone acetonide 0.0025%.

Education on how to use treatments effectively and ongoing supportive management are key to maintaining adherence with therapy. This must include awareness of the importance of avoiding or reducing contact with known irritants and trigger allergens, including perfumed or scented emollients, bathing products and cosmetics. More detailed information on managing atopic eczema using corticosteroids is detailed in the Managing Moderate to Severe Eczema Symptoms leaflet from Allergy UK.

Which emollient is best?

Informed choice is crucial in the choice of emollient. The best emollient is the one the patient prefers and will use regularly. The University of Bristol has developed a moisturiser decision aid to help guide the choice of emollient.

Ointment	Cream
Thick and greasy preparation Oil based Good for people with lots of allergies as they don’t contain any perfume or preservatives/ parabens that can irritate the skin Ointments leave a protective layer on the skin to seal in moisture so are very good for dry cracked skin.	Contains more water than oil Feels lighter on the skin than oil based May need to be applied more frequently if skin is very dry Many find it a more cosmetically acceptable solution for day time use Can be combined with ointment treatment at night.
Gel	Lotion
Thicker and last longer on the skin than cream- based emollients Water based Suitable for people who are looking for a more cosmetically acceptable solution for daytime use Can be combined with ointment treatment at night.	Light emollients that are absorbed quickly by the skin Water based Has a cooling effect Good for dry skin in areas of the body where hair grows including the scalp, chest, arms and legs.
Soap substitutes and shower emollients
These cleanse the skin without the drying effect of soap. Many leave on emollients can often be used as a soap substitute as well.

Important Considerations

When first applied to broken or very dry skin some patients may report a localised skin reaction. This sensation is transient and will often occur with any emollient and is not a sign of allergy. However, this may also be a result of undertreatment, especially with topical corticosteroids, or skin infection so a skin assessment may be required.

Antimicrobials – some emollient preparations contain antimicrobials which may have a limited, short-term role for some patients with infected eczema. Be aware that for some, these preparations can irritate the skin.

Caution – advise avoidance of products containing perfume or fragrance, as well as anionic surfactants eg sodium lauryl sulphate (SLS), e.g. Aqueous Cream. These ingredients are known to irritate the skin, producing an immune response, weakening the epidermal barrier function and increasing Trans epidermal water loss (TEWL).

Advice to share with patients on how to use emollients

Always wash hands before applying any creams or ointments.
When applying emollients, use a gentle downward stroke in the direction of the hair growth.
Avoid rubbing the emollient in to the skin as this can irritate the skin and trigger or worsen the itch sensation.
Apply emollients liberally and frequently throughout the day as required and continue to use emollients, even when the skin is clear, to maintain skin integrity.
If the emollient is in a pot, the required amount should be removed with a clean spoon or spatula. and not fingers. This is to prevent contamination with bacteria. Similarly, pots should not be shared with others.

Trigger irritants and allergens

Individual trigger irritants and allergens vary hugely from person to person. While some trigger factors may be easy to identify, others may be harder to identify due to the delayed immune response of atopic eczema.

Common triggers include, skin infection, sudden changes in temp, stress, detergents, fragrance, fabrics including animal wools and man-made fibres, house dust mite, pets, pollen, mould spores and foods.

Additional Eczema Symptoms – The quality-of-life burden of eczema

It is vital to not underestimate the impact of skin disease, even in what may be perceived as a mild case of eczema. This can still cause an individual and their family distress. This may include

sleep deprivation caused by itch
anxiety around avoidance of triggers, the treatments and diagnosis of eczema
feelings of depression, and anxiety related to the visual aspect of skin disease impact on self-esteem and confidence
additional financial cost of living with eczema.

The burden of living with eczema can be very great and overwhelming for both the sufferer and their family and it is important to recognise this as part of the treatment extended to those living with the condition.

When to consider onward referral

If the skin is not responding to recommended prescribed medications, is worsening and the individual is experiencing repeated skin infections despite using antimicrobial therapy and/or the condition is causing the individual psychological distress then consider referring onto a dermatology specialist, even if the skin condition is perceived as mild.