Trip Answers

Question answered:22/10/07 Warning! this question is over two years old.

We searched the NLH Skin Disorders Specialist Library and the TRIP and Medline databases but were only able to general information to help answer this question. Few sources refer in particular to eczema affecting the nipples, apart from the DermNet guideline on atopic dermatitis that states:

 

“Commonly adults have persistent localised eczema, possibly confined to the hands, eyelids, flexures, nipples or all of these areas.”
Concerning treatment, it adds:
“Treatment of atopic dermatitis may be required for many months and possibly years.
It nearly always requires:
• Reduction of exposure to trigger factors (where possible)
• Regular emollients (moisturisers)
• Intermittent topical steroids.” [1]

 

The CKS (formerly PRODIGY) guideline on atopic eczema notes in its scenarios on localised and widespread flare ups in adults:

 

• “In adults
o Face, genitals, and flexures — treat with a mildly potent corticosteroid.
o The trunk and limbs:
? Select the lowest potency of corticosteroid that is likely to work within 7–14 days of treatment, based upon the severity of inflammation and response to previous treatment."

Please note the Management section of the guideline contains a useful section on the potency, dose and application of topical steroids.

 

CKS does not make recommendations on immunomodulatory treatments such as tacrolimus and pimecrolimus but does refers to these therapies:

 

“Topical immunosuppressant, tacrolimus, or pimecrolimus are useful when there is a serious risk of systemic or localized adverse effects due to topical corticosteroid, or when eczema cannot be controlled with topical corticosteroid. The long-term safety of topical immunosuppressants has not been established, and treatment should therefore only by initiated by physicians (including general practitioners) with a special interest and experience in dermatology, and only after careful discussion with the patient about the potential risks and benefits of all appropriate second-line treatment options.” [2]

 

The NICE technology appraisal, published in 2004, notes:

 

 

“Tacrolimus and pimecrolimus should not be used to treat mild atopic eczema. When atopic eczema is moderate or severe, tacrolimus and pimecrolimus should not be used as ‘first-line’ treatments – that is, they should not be used before other treatments have been tried [i.e. topical corticosteroids].” [3]

 

A second guideline, one produced by the Primary Care Dermatology Society and British Association of Dermatologists, discusses the treatment of bacterial infection in atopic eczema:

 

In the introduction to the guideline, it states:

 

“This information is a broad guideline only. Treatment of an individual patient should always be modified according to need and circumstances, and may involve a multidisciplinary approach.”

 

“Bacterial infection is suggested by:

 

– crusting, weeping, pustulation and/or surrounding cellulitis with erythema of otherwise normal-looking skin
– a sudden worsening of the condition
• Oral antibiotics are often necessary in moderate to severe infection or if the infection is recurrent or widespread: – a 7-day course should be given
– flucloxacillin orally is usually most appropriate for treating Staphylococcus aureus
– erythromycin or one of the new macrolides can be used if there is a penicillin allergy or penicillin resistance
– phenoxymethyl penicillin and flucloxacillin should be given if betahaemolytic streptococci are isolated or suspected on clinical evaluation
• Steroid-antibiotic combinations are effective in clinical practice although evidence for superiority in efficacy is lacking. They should be used in short courses (typically 1 week) to reduce the risk of drug resistance or skin sensitisation.” [4]

 

Both the guidelines list similar indications for referral. The CKS guideline referral criteria include:

 

• “Disseminated herpes simplex virus infection (eczema herpeticum). This is potentially life-threatening, and if suspected should prompt emergency admission for confirmation of the diagnosis and antiviral treatment.
• Unresponsive severe disease (often causing sleep disturbance or absence from school or work), including bacterially infected eczema unresponsive to treatment with oral antibiotics and topical corticosteroids.
• Eczema requiring a duration and/or potency of treatment with topical corticosteroids that risks systemic or localized adverse effects.” [1]

 

Given we found only general information to answer this query, the NLH Q & A Service would recommend contacting a local specialist for further advice.

 

References
1. DermNetNZ. Atopic dermatitis. 2004.( http://dermnetnz.org/dermatitis/atopic.html)
2. CKS. Atopic eczema. 2004. (http://www.cks.library.nhs.uk/eczema_atopic/)
3. NICE. Pimecrolimus and tacrolimus for atopic dermatitis (eczema). 2004 (Expected date of review for this technology appraisal is August 2007)
4. Guidelines for the management of atopic eczema. February 2006. (http://www.bad.org.uk/healthcare/guidelines/PCDSBAD-Eczema.pdf)

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