Eczema

This edition of check considers the diagnosis and management of eczema in general practice.

Eczema (atopic dermatitis) is a life-long inflammatory condition characterised by itchy, painful and infection-prone skin. Despite being a common patient presentation, the exact cause remains elusive, with genetic, environmental and immunological factors all contributing. There is a strong link with other atopic conditions such as asthma, allergic rhinitis and food allergies.

The onset of eczema is often in infancy, typically before a child is aged 12 months, and it may persist into adolescence and adulthood. Diagnosis can be a challenge and is usually determined through a process of exclusion. Patients present with itching, typical rash distribution and morphology and a chronic, or chronic–relapsing, history. Obtaining a thorough personal and familial history is crucial to identifying related comorbidities. Several approaches are available to practitioners for defining eczema severity, although these may underestimate severity when being used for patients with darker skin tones. Determination of severity informs treatment decision making and potential access to Pharmaceutical Benefits Scheme–subsidised medicines.

Irrespective of severity, the impact of eczema on individuals and their families can be substantial. Beyond the physical symptoms, eczema also brings psychosocial burdens that negatively affect day-to-day functioning, wellbeing and quality of life. For many, the constant itching and pain disturbs sleep. Poor sleep has been associated with mood disturbances, inattention and learning difficulties at school for children with eczema and an increased risk of mental health disorders for adults with eczema. Financial burdens relating to the disease can also be significant. Prescription medications, over-the-counter treatments and specialised skincare products are all common out-of-pocket expenses. These costs can be exacerbated in more severe cases where specialist consultations and systemic therapies may be required, or where geography impacts access to timely care.

Eczema management involves a stepwise approach, starting with foundational skincare, including regular use of a moisturiser and avoidance of known triggers, irritants and allergens, if possible. Australian and international guidelines recommend prescription medicines, predominantly topical corticosteroids, to reduce the skin inflammation of active lesions (flares).

The goal of these first-line strategies is to reach a balance where symptoms are under control, the impact of treatment on daily life is minimal and side effects are absent or minimal. This can take time and be hindered by misconceptions and inconsistent information – particularly regarding topical corticosteroids – which reduces patient adherence to recommended regimens and can result in suboptimal outcomes.

Misconceptions and inconsistencies are further compounded by poor eczema health literacy. For example, the 2018 PEEK Study highlighted significant gaps in patient knowledge, with 75% relying on the internet over health professionals as the main source of information about their condition.

Primary care providers play a critical role in understanding a patient’s needs and the many factors that might influence treatment choice and the ability to maintain self-care successfully.

Learning outcomes

• outline a management plan to address the psychosocial impact and burden of eczema on patients and families
• identify eczema and its symptoms, particularly in patients with skin of colour
• discuss with patients and carers the common triggers of eczema and the importance of moisturisers in its management
• prescribe topical corticosteroids as first-line therapy to treat active eczema and address safety concerns associated with their use
• implement a person-centred approach to eczema management.

Case studies