CPG UPDATE

Management of Atopic Eczema in primary care

Azizan NZ, Ambrose D, Sabeera BKI, Mohsin SS, PF Wong, Mohd Affandi A, CC Ch’ng,
Gopinathan LP, T Taib, WC Tan, Khor YH, Heah SS, WL Leow, Zainuri Z, Ainol Haniza KH,
Yusof MAM, Tukimin SMT
Azizan NZ, Ambrose D, Sabeera BKI, et al. Clinical Practice Guidelines Management of Atopic Eczema in primary care. Management of Atopic
Eczema in primary care. Malays Fam Physician. 2020;15(1);39–43 .

Abstract
Keywords:
atopic eczema, diagnosis, Introduction: Atopic eczema (AE) is a common inflammatory skin dermatosis that is increasing
assessment, treatment, in prevalence. However, it can present in various clinical presentations, which leads to challenges
education in the diagnosis and treatment of the condition, especially in a primary care setting. The Clinical
Practice Guidelines on the Management of Atopic Eczema was developed by a multidisciplinary
development group and approved by the Ministry of Health Malaysia in 2018. It covers the aspects
Authors: of diagnosis, severity assessment, treatment, and referral.

Ainol Haniza Kherul Anuwar Introduction

(Corresponding author) The U.K. Working Party’s Diagnostic
DDS (UGM) Atopic eczema (AE) or atopic dermatitis Criteria for Atopic Dermatitis:
Cawangan Penilaian Teknologi is a complex, chronic, and recurrent
Kesihatan, Kementerian Kesihatan inflammatory itchy skin disorder. In the Patient must have an itchy skin condition
Malaysia, Putrajaya majority of cases, it starts to develop in early (or parental report of scratching or
Malaysia childhood and may persist into adulthood. rubbing in a child) plus 3 or more of the
Email: [email protected] The prevalence is as high as 20% in some following:
countries. In Malaysia, the prevalence has
increased from 9.5% in 1995 to 12.6% in • history of involvement of the skin
Azura Mohd Affandi 2003. AE has various clinical manifestations creases such as folds of elbows, behind
MBChB (UK), MRCP (UK), in different age groups. This makes the the knees, fronts of ankles, or around
AdvMDerm (UKM) diagnosis a challenge, leading to misdiagnosis the neck (including cheeks in children
Jabatan Dermatologi and mistreatment. Therefore, it is paramount under 10)
Hospital Kuala Lumpur, Wilayah to have evidence-based clinical practice • a personal history of asthma or hay
Persekutuan Kuala Lumpur guidelines (CPG) for effective and safe fever (or history of atopic disease
Malaysia management. in a first-degree relative in children
under 4)
Clinical Presentation • a history of generally dry skin in the
Ch’ng Chin Chwen last year
MBBS (UM), MRCP (UK), AE has both acute and chronic clinical • visible flexural eczema (or eczema
AdvMDerm (UKM) presentations. Acute eczema is characterized involving the cheeks/forehead and
Pusat Perubatan Universiti Malaya, by papulovesicular eruption with erythema, outer limbs in children under 4)
Kuala Lumpur, Wilayah Persekutuan weeping, edema, and excoriation, whereas • onset under the age of 2 (not used if
Kuala Lumpur, Malaysia chronic eczema is characterized by child is under 4)
lichenification and dry skin (xerosis).

Dawn Ambrose Diagnosis Severity Assessment

MD (UKM), MRCP (Ire),
Fellowship in Derm (MOH, M’sia) AE is diagnosed clinically and not by Assessment of disease severity and quality
Jabatan Dermatologi any specific laboratory investigation. The of life should be used in the management of
Hospital Ampang following criteria is used for the diagnosis of atopic eczema. The preferred tools are the
AE. following:

• Investigator’s Global Assessment (IGA)

• Dermatology Life Quality Index/Children’s
Dermatology Life Quality Index (DLQI/
CDLQI)

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 CPG UPDATE

Heah Sheau Szu Investigator’s Global Assessment (IGA)

MBBS (UM), MRCPCH (UK), Score Description
Fellowship in Paediatric Dermatology
0 = Clear No inflammatory signs of AD
(MOH, M’sia)
Institut Pediatrik, Hospital Kuala
1 = Almost clear Just-perceptible erythema and just-perceptible papulation/infiltration
Lumpur, Wilayah Persekutuan 2 = Mild disease Mild erythema and mild papulation/infiltration
Kuala Lumpur, Malaysia 3 = Moderate disease Moderate erythema and moderate papulation/infiltration
4 = Severe disease Severe erythema and severe papulation/infiltration
5 = Very severe disease Severe erythema and severe papulation/infiltration with oozing/crusting
Khor Yek Huan
MD (UKM), MRCP (UK),
AdvMDerm (UKM) Aggravating/Triggering Factors greasy in nature, whereas creams and lotions
Jabatan Dermatologi, Hospital contain water and are more user-friendly and
Pulau Pinang, Geogetown Various factors may worsen AE, which acceptable cosmetically. Creams (e.g., aqueous
Malaysia include the following: cream and urea cream), lotions, and gels contain
preservatives to protect against microbial growth
• aeroallergen in the presence of water. There is no reliable
Lalitha Pillay a/p B. Gopinathan (e.g., house dust mites, animal’s dander) evidence to show that one emollient is more
MD (Ind), Master of Paediatrics (UM), • physical irritants effective than another. Generally, emollients are
MRCPCH (UK) (e.g., nylon, wool, detergents, sweat) safe to be used in AE.
Jabatan Pediatrik, Hospital • environmental factors
Selayang, Batu Caves, Malaysia (e.g., extreme temperature) In infants with first-degree relatives with atopy,
• microbial colonization/infection daily use of an emollient significantly reduces
(e.g., Staphylococcus aureus) the risk of developing AE.
Leow Wooi Leong • patient factors
BPharm (USM) (e.g., pregnancy, stress) Topical corticosteroids
Jabatan Farmasi, Hospital • food
Kuala Lumpur, Wilayah Persekutuan Topical corticosteroids (TCS) are the first-
Kuala Lumpur, Malaysia The influence of food allergy on the clinical line anti-inflammatory agents for AE in both
course of AE remains unclear. Food may children and adults. They should be used to
worsen AE in children less than two years treat flares in AE. The choice of TCS depends
Mohd. Aminuddin Mohd. Yusof old, especially milk, eggs, and peanuts. In on the following factors:
MD (UKM), MPH (Epid) (UM) the prevention of AE, hydrolyzed formulas
Cawangan Penilaian Teknologi should not be offered to infants in preference • age of the patient
Kesihatan, Bahagian Perkembangan to breast milk. • site of skin lesions
Perubatan, Kementerian Kesihatan • chronicity of skin lesions
Malaysia Putrajaya, Malaysia Topical Therapy • severity of skin inflammation

Topical therapy is the mainstay of treatment The use of TCS should be monitored every 3–6
Noor Zalmy Azizan in AE. This includes emollients, topical anti- months to determine response and potential side
MB BCh (NUI), MRCP (UK), inflammatory agents, and topical antiseptic/ effects.
AdvMDerm (UKM) antimicrobial agents.
Jabatan Dermatologi, Hospital TCS are categorised into four classes according
Kuala Lumpur, Wilayah Persekutuan Emollient/moisturizer to their potencies:
Kuala Lumpur, Malaysia
Emollient therapy is the mainstay of • Class I (very potent; clobetasol propionate
management in AE in all age groups of 0.05% cream/ointment)
Sabeera Begum patients and in all stages of the disease, from • Class II (potent; betamethasone valerate
MBBS (Bangalore), Master of mild to severe. It improves the epidermal 0.1% cream/ointment, mometasone
Paediatrics (UM), Fellowship in Paeds barrier function and dryness, leading to a furoate 0.1% cream/ointment, fluticasone
Derm (MOH, M’sia) reduction in pruritus. Its application decreases propionate 0.05% cream)
Institut Pediatrik, Hospital the usage of topical corticosteroids. • Class III (moderate; clobetasone butyrate
Kuala Lumpur, Wilayah Persekutuan 0.05% cream/ointment)
Kuala Lumpur, Malaysia Emollients are available in different formulations • Class IV (mild; hydrocortisone acetate 1%
(ointments, creams, lotions, gels, and aerosol cream/ointment)
sprays). Ointments (e.g., petrolatum) are

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Siti Shafiatun Mohsin The medication should not be used as a

MBBS (MAHE), M. Med Family Practical guides for TCS application monotherapy or as a substitute topical therapy
Medicine (UKM) are the following: in AE.
Klinik Kesihatan Cheras, Kuala
Lumpur, Wilayah Persekutuan Kuala • TCS should be used concomitantly Immunomodulating agents
Lumpur, Malaysia with emollients.
• Fingertip unit can be used as a guide Corticosteroids, cyclosporin A, methotrexate,
to the amount of TCS required for azathioprine, mycophenolate mofetil,
Tan Wooi Chiang affected sites. intravenous immunoglobulin, and interferon
MD (USM), Dip STD/HIV (COTTISA) • Choice of vehicle of TCS depends on gamma are some of the immunomodulating
Dip Derm Glasgow), MRCP the affected sites (i.e., gel for scalp; agents used in AE. These agents are used
(Ire), Fellowship in Dermatology cream for face, genital and flexural in moderate to severe AE which are
(Singapore), AdvMDerm (UKM) areas; ointment for palm and sole). uncontrolled after optimization of topical
FAAD (US), AM (Malaysia) • Choice of potency of TCS depends treatment and/or phototherapy. They are
Jabatan Dermatologi, Hospital Pulau on the clinical severity of eczema (i.e., also considered in chronic AE where quality
Pinang, Geogetown, Malaysia potent to very potent TCS ointment of life is substantially impacted. A referral to
for thick lesions and mild to moderate a dermatologist should be considered when
TCS cream for thin lesions). patients require immunomodulating agents.
Tarita Taib • After resolution of eczema flares,
MD (UKM), MMed (UKM), discontinuation of TCS application Antimicrobials
AdvMDerm (UKM) should be done gradually to avoid
Jabatan Perubatan, Fakulti Perubatan rebound (i.e., twice a day followed Routine use of topical and systemic
Universiti Teknologi MARA Kampus by once a day, then 1–3 times a week antimicrobials among patients with non-
Selayang, Selangor before complete discontinuation). infected AE is not recommended. They may
• After resolution of eczema flares, be considered when there is clinical evidence
proactive therapy (mild TCS of infection.
Wong Ping Foo application intermittently once or
MBBS (IMU), Dr Fam Med (UKM), twice a week) can be used to maintain Antiseptics at appropriate dilutions, e.g.,
MAFP (Mal), FRACGP (Aus) remission. potassium permanganate, triclosan, or
Klinik Kesihatan Cheras Baru chlorhexidine, may be used as an adjunct
Kuala Lumpur, Wilayah Persekutuan therapy to decrease bacterial load in patients
Kuala Lumpur, Malaysia Topical calcineurin inhibitors who have recurrent infected AE.

Topical calcineurin inhibitors (TCIs), e.g., In a local setting, short-term antiseptic agents
Zaridah Zainuri tacrolimus and pimecrolimus, are non-steroidal may be used for weepy lesions in AE:
BSc in Dietetic (UKM), MMedSci in immune-modulating agents and may be
Human Nutrition (Sheffield) considered for treatment of flares in AE. They • diluted potassium permanganate solution
Institut Paediatrik, Hospital are licensed for the treatment of children older as bath/soak over the limbs and trunk
Kuala Lumpur, Wilayah Persekutuan than two years of age. • normal saline dab/wash over the face
Kuala Lumpur, Malaysia
Systemic Therapy Long-term continuous use of antiseptics should
be avoided.
Siti Mariam Tukimin Systemic therapy includes adjunctive
BSc Hons in Dietetic (UKM) treatment (e.g., antihistamines and systemic Educational Interventions
Institut Paediatrik, Hospital antibiotics) and specific treatment of AE (e.g.,
Kuala Lumpur, Wilayah Persekutuan immunomodulating agent and biologics). Educational and psychological interventions
Kuala Lumpur, Malaysia Specific systemic treatments should be used are used as an adjunct to conventional
only in severe cases of AE in patients where therapy in the management of AE. Patient
other management options have failed or education plays an important role in the
are not appropriate and where AE has a self-management of AE. The use of a written
significant impact on quality of life. eczema action plan (WEAP) may enhance
patients’ understanding and empower
Antihistamines patients/caregivers to better manage their
condition, thus reducing the frequency and
Itch is a common symptom in AE, and severity of flares and the frequency of clinical
sedating antihistamines may be considered encounters.
as a short-term measure at bedtime in
AE patients with sleep disturbance.

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WRITTEN ECZEMA ACTION PLAN

GREEN = GO : Use preventive measures
YELLOW = CAUTION : Use lower strength medications
NAME:
RED = FLARE : Use higher strength medications and consult
your doctor
GREEN ECZEMA UNDER CONTROL
REGULAR DAILY SKIN CARE
1. Bathe twice a day with a gentle cleanser for less than 10 minutes.
2. Apply moisturizer to all body parts immediately after bathing.
3. Apply moisturizer to all body parts a minimum of thrice a day.
4. Bathe and moisturize your skin before bed.
5. Wear suitable clothes/pajamas (preferably cotton) to bed.
YELLOW ECZEMA WORSENING
SKIN CARE DURING WORSENING
1. Continue regular skin care from GREEN phase.
2. Apply anti-inflammatory creams until eczema clears.
2a. Face: Apply hydrocortisone 1% twice a day for 5–7 days, then once a
day for 5–7 days until eczema clears.
2b. Body: Apply betamethasone (1:4) twice a day for 5–7 days, then once
a day for 5–7 days until eczema clears.
3. Take an antihistamine (anti-itch medication) as prescribed by doctor half
an hour before bed.
4. If eczema gets better, revert back to GREEN phase.
5. If eczema is not responding within 3 days or eczema and itch worsens,
move to RED phase.
RED FLARE
SKIN CARE DURING FLARE
1. Continue regular skin care from GREEN phase.
2. Bathe daily with antiseptic wash for 5–7 days.
3. Apply anti-inflammatory creams until eczema clears.
3a. Face: Apply betamethasone (1:8) twice a day for 5–7 days, then once a
day for 5–7 days until eczema clears.
3b. Body: Apply betamethasone (1:2) twice a day for 5–7 days, then once
a day for 5–7 days till eczema clears.
4. Take an antihistamine (anti-itch medication) as prescribed by doctor half
an hour before bed.
5. If eczema gets better, revert back to YELLOW phase, then subsequently to
GREEN phase.
6. If eczema is not responding within 3 days or eczema and itch worsens,
consult your doctor.

Referral 2. Non-urgent referral

Referral to a dermatology service may be • Diagnostic uncertainty

needed in the management of AE. The urgency • Severe or uncontrolled eczema:
of referral is dependent upon various factors. • requirement of potent and very
Referrals may be classified as either urgent or potent TCS
non-urgent. • frequent infections
• poor sleep or excessive scratching
1. Urgent referral (within 24 hours) • treatment failure with appropriate
topical therapy regimen
• AE with clinical suspicion of eczema • Parental concern
herpeticum (eczema with widespread • Need for treatment demonstration/
herpes simplex infection) education
• AE with severe skin bacterial infection • Involvement of sites that are difficult to
that requires intravenous antibiotics treat
• AE with acute erythroderma where the • Psychological disturbance on the patient
eczema is affecting more than 80% of or family
the body surface area

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A summary of the management of AE is illustrated in the following algorithm.

ALGORITHM: TREATMENT OF ATOPIC ECZEMA

Adjunct therapy:
• Topical/oral antibiotic/antiviral/antifungal
for bacterial, viral or fungal infections
• Oral sedating antihistamines for sleep
disturbance
E
• Topical antiseptics to reduce of A Step 4
ing
Staphylococcus aureus colonisation s en
• Psychological intervention Wor • TCS (moderate to very
potent) or TCI
f AE
nt o • Wet wrap therapy
ov em e Step 3
I mp r • Phototherapy
• TCS (moderate) or TCI • Systemic therapy:
• Wet wrap therapy o Oral corticosteroids
Step 2 • Phototherapy (short-term)
o Azathioprine
• TCS (mild) or TCI o Cyclosporin A
o Methotrexate
o Mycophenolate
Step 1 mofetil
• Skin care
o Emollients
o Bathing practices
• Educational intervention
• Identification and management of aggravating factors

IGA score: 0 to 1 2 3 4 to 5
Clear to Severe to
Severity: Mild Moderate
Almost clear Very severe

IGA: Investigators’ Global Assessment; TCS: topical corticosteroids; TCI: topical calcineurin inhibitors

Acknowledgement

Details of the evidence supporting the above statements can be found in Clinical Practice Guidelines
on the Management of Atopic Eczema 2018, available on the following websites: http://www.moh.
gov.my (Ministry of Health Malaysia) and http://www.acadmed.org.my (Academy of Medicine).
Corresponding organization: CPG Secretariat, Health Technology Assessment Section, Medical
Development Division, Ministry of Health Malaysia; contactable at [email protected].

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