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Explaining a new diagnosis to a patient is an important skill that may be tested in an OSCE scenario. Eczema is a common dermatological condition seen in both the paediatric and adult population. This guide provides an overview of the steps involved in explaining the diagnosis and management of eczema to a patient in an examination situation. Check out the explaining a diagnosis of eczema mark scheme here.


Opening the Consultation

  • Introduce yourself
  • Confirm the patient’s (or parent and child’s) details
  • Establish why they have attended, check their understanding and ask what they want to find out during the consultation
  • Take a brief history if required

 


Explanation

Eczema (a.k.a atopic dermatitis) is a chronic inflammatory condition of the skin that can affect people of all ages. It is a relapsing and remitting condition that presents with areas of red, itchy, dry skin on the body, face and/or scalp.

  • The most frequently affected areas are the flexor surfaces of the elbows and the backs of the knees, wrists, neck, and face
    • Infants are predominantly affected on the face and extensor surfaces of limbs
    • Adults with new presentations are often affected on the hands due to exposure to irritants
    • Children and adults with chronic eczema are typically affected on the flexor surfaces
  • Usually presents before the age of 5 (70-90%)
  • Often becomes less severe with age (may fully resolve)
  • Often runs in families (i.e. there is an inherited component)

 

An example of how you might explain eczema to a patient

“The normal function of the skin is to act as a barrier. We can imagine the skin to be layers of bricks stacked on top of each other. In normal skin, the mortar between the bricks prevents irritants from getting in and prevents water from getting out which stops the skin from drying out. In eczema, the bricks become dry and cracked, and the mortar between the bricks can be lost, compromising the waterproofing. This means that the moisture from the skin can escape, causing it to become dry and itchy, and increasing the exposure to irritants which causes it to become red and inflamed.”

“Eczema is a condition that mostly affects children, who may grow out of it, however sometimes it can affect adults. We typically see eczema come and go in what we call flares, in which affected skin becomes more sore, dry, and red than usual, after which it may settle down.”

“We don’t know exactly what causes eczema, but we do know that it can run in families. Family members can have eczema, hay fever or asthma or a combination of these conditions. People who suffer from eczema are more likely to get allergic reactions to food, clothing, dyes etc. but eczema is not an allergy itself. It is caused by a complex immune reaction in the skin.”

 


Investigations

  • Eczema is a clinical diagnosis
  • Investigations including skin biopsies and lab tests are not recommended in the diagnosis of eczema, except for ruling out any differential diagnoses
  • Radioallergosorbent tests (RAST) do not help diagnose eczema as it is not an allergy
  • Assessment of the severity of symptoms and psychological impact should be undertaken (e.g. EASI score)

 

Example of how you might explain the process of diagnosing eczema

“Eczema is normally diagnosed by inspecting the affected skin for signs of the disease. We don’t usually need to do any additional tests for eczema. It is not caused by an allergy, so allergy tests do not help us make the diagnosis.”

 


Management

  • Avoid any exacerbating factors/triggers such as soaps with perfumes, detergents, wool, stress, pets etc
  • The management of eczema follows a stepwise approach, which allows room for increasing the strength and effectiveness of treatments in patients that do not respond to first-line treatments
  • As the effectiveness of treatments increases up the stepwise ladder, so do the side effects associated with them
  • Topical emollients are the first step, followed by topical steroids and immunomodulators, then phototherapy, and finally systemic treatments
  • Antihistamines are only used to reduce itching when this causes problems with sleeping

 

Emollient therapy

  • Use regularly regardless of how well-controlled eczema is (up to 8 times a day)
  • Helps to reduce the number of flares
  • Apply a thin film, gently to the skin
  • Apply in the direction of hair growth to help prevent folliculitis

 

Ointments

  • paraffin based
  • oily/greasy, thick
  • can stain clothing
  • the most effective emollient if used properly

Creams

  • water-based
  • soak in and disappear

 

Lotions

  • water-based
  • replacement for soaps and shampoos
  • not used as an emollient alone

 

Topical corticosteroids

  • The strength of the steroid is dependent on the body site
  • Used only to treat active symptoms, not to prevent flare-ups
    • Continue for 48 hours after the skin has returned to normal, then cease
    • Long-term use of topical steroids can cause the skin to become thin
  • Apply to areas of red, inflamed skin regularly (two to three times a day)
  • Allow 30 minutes after applying emollients before using topical steroids

 

Tacrolimus and Pimecrolimus

  • Topical calcineurin inhibitors
  • Suppress T-lymphocyte response (i.e. reduce the inflammatory response)
  • Second-line treatment for moderate to severe eczema to avoid side-effects of long-term topical steroids
  • Used for maintenance therapy
  • Tacrolimus must be initiated by a dermatologist
  • May burn or sting on initial application, but this disappears with regular use
  • Long-term safety not known

 

Example of how you might explain the management of eczema

“Eczema can really affect people’s confidence, particularly when it is visible, and it can also affect sleep if it becomes severe, so we know that it’s important to get the symptoms under control.”

“The mainstay of management for eczema is what we call emollient therapy. Emollients work by filling the cracks between the dry bricks, which stops irritants getting in and prevents water from escaping, which helps to moisturise the skin. This can also reduce the number of flare-ups of eczema. There are lots of different types of emollients such as creams, ointments, and gels, so we can pick ones that are most effective and work best for you. This can sometimes be a case of trial and error at the beginning.  I can give you some samples of the different types of emollients, and ask a specialist nurse to speak to you about them today if you would like?”

“During a flare, we suggest that you use a topical steroid cream. Steroids work by reducing inflammation, and we know that the best way to do this in eczema is to rub it directly onto the inflamed skin. We recommend that you continue to use this for 48 hours after your skin improves, to help prevent it flaring up again, but we don’t suggest continuing to use it after that. Steroids should not be used on the face as they can cause thinning of the skin and other serious side effects. You should always wash your hands after applying steroid creams.”

“In most people, the treatments we have discussed will control your eczema extremely well. However, we do have other options for treatment if these are not successful and we can discuss those if it becomes appropriate.”

 


Emergency situations and safety net

Infection can be a serious complication of eczema, so it is important to be able to communicate to a patient/parent when to seek medical attention.

Bacterial infection

  • Most commonly caused by Staphylococcus aureus
  • Normally presents with oozing, crusting, redness, and pain

Management

  • Swab the skin
  • For localised infection, prescribe a short course (7 days) of a topical antibiotic
  • Oral antibiotics (e.g. flucloxacillin) are used for extensive areas of infection
  • Refer to dermatology if there is no response to treatment

 

Eczema herpeticum

  • Herpes simplex viral infection in skin affected by eczema
  • Potentially life-threatening
  • Presents with:
    • Rapidly worsening, painful areas of eczema
    • Fever and/or lethargy
    • Blisters in clusters which appear similar to cold sores
    • “Punched-out” erosions which may form areas of erosion with crusting
  • If a patient/parent is worried about any of these features, they should seek medical attention immediately for diagnosis and management.

 

Example of how you might explain the potentially serious complications of eczema

“One of the serious complications of eczema is infection of the skin. The signs to look out for are if your skin starts to ooze, crust, you see clusters of blisters or if you have any of these symptoms with a fever. If at any point you feel like your eczema is infected or is getting worse quickly you should see your doctor the same day and attend A&E if that is not possible.”

 


Plan

Example of how you might outline the ongoing treatment plan

“We have discussed what eczema is, and how it is treated. You are going to meet with a specialist nurse who can talk to you in more detail about the different types of emollients available, as we don’t have time during this appointment. Hopefully, once you have been following this treatment for a few weeks you will have noticed some improvement, but it would be a good idea to see you again in 2-4 weeks.”


Closing the consultation

Example of summarising and ending the consultation

“In summary, eczema is a very common skin condition which often gets better with age. We have lots of treatment options available to manage your eczema, and we usually start with emollient therapy and add in other things if they are needed. If your eczema gets worse quickly or you have any concerns about it being infected, you should see a doctor the same day. You are going to meet the specialist nurse today to talk about the emollients which will suit you best, and then we can meet again in a few weeks to see how things are going.”
 

Final questions?

“Do you have any further questions for me?”

 

Provide an information leaflet if possible


References

1. NICE. Eczema – atopic CKS [Internet]. 2017. Available from: https://cks.nice.org.uk/eczema-atopic#!topicsummary

2. NICE. Atopic eczema in under 12s [Internet]. 2013. Available from: https://www.nice.org.uk/guidance/qs44/chapter/Quality-statement-2-Stepped-approach-to-management

 


 

Editor

Andrew Gowland