What are the key components to document during an eczema rash exam and what are the initial treatment options?

Key Components to Document During an Eczema Rash Exam and Initial Treatment Options

When documenting an eczema rash exam, record the extent, location, and severity of the eczema, along with evidence of clinical infection such as crusting, weeping, or grouped punched-out erosions. 1

Essential Documentation Components

History Elements

• Presence of itching (essential diagnostic criterion) 1
• Location of affected areas, especially skin creases, flexures, cheeks in children under 4 years 1
• History of asthma or hay fever (or family history of atopic disease) 1
• General dry skin in the past year 1
• Age of onset (typically first two years of life) 1
• Aggravating factors and exposure to irritants 1
• Sleep disturbance 1
• Previous treatments and response 1
• Impact on quality of life (school, work, social activities) 1

Physical Examination Findings

• Distribution pattern (flexural in older children/adults; cheeks, forehead, outer limbs in children under 4) 1
• Morphology of lesions 2:
  • Acute: erythema, papules, vesicles, seropapules, crusting 1
  • Chronic: lichenification, hyper/hypopigmentation 2
• Signs of infection 1:
  • Bacterial: crusting, weeping (suspect Staphylococcus aureus) 1
  • Viral: grouped, punched-out erosions or vesiculation (suspect herpes simplex) 1
• Extent and severity of the rash 1
• Condition of nails (should be kept short) 1

Initial Treatment Approach

First-Line Management

• Emollients as foundation therapy 1, 3:

  • Apply liberally and frequently (at least twice daily) 3
  • Most effective when applied immediately after bathing 3

• Bathing recommendations 1, 3:

  • Use lukewarm water 3
  • Replace soaps with gentle, dispersible cream cleansers 1, 3
  • Limit bath time to 5-10 minutes 3

• Topical corticosteroids for active inflammation 1:

  • Use the least potent effective preparation 1, 3
  • For adults and children over 2 years: apply to affected areas no more than 3-4 times daily 4
  • For children under 2 years: consult a doctor before use 4

Avoidance of Triggers

• Avoid soaps and detergents that remove natural skin lipids 1
• Use cotton clothing and avoid wool or synthetic fabrics 1
• Keep nails short to minimize damage from scratching 1
• Avoid extremes of temperature 1

Managing Pruritus

• Consider short-term sedating antihistamines for sleep disturbance caused by itching 3
• Non-sedating antihistamines have limited value in managing atopic eczema 3

Infection Management

• If bacterial infection is suspected, obtain bacteriological swabs 1
• For suspected herpes simplex infection, obtain viral swabs and consider electron microscopy 1

When to Refer to a Specialist

• Diagnostic uncertainty 1
• Failure to respond to first-line treatment with appropriate topical steroids 1, 5
• When second-line treatment or dietary manipulation is being considered 1

Patient Education

• Demonstrate proper application of treatments 1
• Provide written information to reinforce verbal instructions 1
• Explain that deterioration in previously stable eczema may indicate infection or contact dermatitis 1

Common Pitfalls to Avoid

• Undertreatment due to steroid phobia - explain proper use and safety of topical corticosteroids 1
• Overuse of topical corticosteroids - use the least potent effective preparation 1, 3
• Neglecting emollients - these are the foundation of treatment 1, 3
• Missing secondary infections which can cause treatment failure 1, 5
• Implementing dietary restrictions without professional supervision 1, 3