Undoubtedly, eczema is the most common disease in dermatology. All types of eczema can account for up to 20% of dermatology outpatient visits. With the accelerated modernization of our country, the spectrum of skin diseases among our people has also undergone important changes, with an increasing number of allergic (allergic) diseases, and it has been studied that the impact of eczema on the quality of life is greater than that of certain medical diseases such as diabetes.
Because the causes of eczema are diverse and difficult to find, and the clinical manifestations are varied, this has led to difficulties and inconsistencies in diagnosis and, consequently, inconsistencies and irregularities in treatment. In order to standardize the behavior of dermatologists and general practitioners in the treatment of eczema in China, the Dermatology and Venereology Division of the Chinese Medical Association organized experts in the field of dermatology and immunology in China to develop and launch the “Chinese Eczema Treatment Guidelines” (Chinese Journal of Dermatology, 2011, 44(1):5-6) after several discussions, with the aim of standardizing the diagnosis and treatment of eczema in China. The purpose is to standardize medical practice in the diagnosis and treatment of eczema-related diseases in China, so that patients can receive accurate diagnosis and scientific treatment.
I. Background for the development of eczema treatment guidelines.
The incidence of eczema is on the rise: according to research, the prevalence of eczema in Western countries is as high as 10% or more, 10.7% in the United States, and an epidemiological study conducted in 2008 showed that the prevalence of the general population in China is about 7.5%, which is close to that of Western countries, and the incidence in industrialized countries is still rising in the last 20 years. China is continuously promoting industrialization, the people’s living standards have improved significantly, infectious skin diseases are gradually decreasing, while allergic skin diseases are gradually increasing, and the results of epidemiological surveys in the last two decades also show that the incidence of eczema is increasing. Therefore, awareness of this disease among dermatologists should be increased.
Eczema has a significant impact on the quality of life of patients: eczema is a chronic recurrent disease that can last for months, years or even decades. The most significant symptom is intense itching, which can significantly affect the patient’s school, work and life, and in severe cases can also affect sleep. In one study, the impact of eczema and diabetes on the quality of life of patients was compared, and it was found that the impact of eczema on the quality of life of patients was much higher than that of diabetes.
There are Chinese and foreign differences in the concept of eczema: the incidence of atopic dermatitis in developed countries such as Europe and the United States is much higher than in China, and there are guidelines for the treatment of atopic dermatitis in Europe, the United States and Japan. There are considerable differences in the understanding of atopic dermatitis and eczema between Chinese and foreign dermatologists. The biggest difference is that the diagnosis rate of eczema in China is much higher than that of atopic dermatitis, while the diagnosis of eczema in foreign countries is becoming less and less. Many cases diagnosed by Chinese doctors as generalized eczema are generally considered endogenous atopic dermatitis in Europe and the United States. Because a large number of patients in China are diagnosed with eczema, it is necessary to develop guidelines for the treatment of eczema in China.
The level of understanding of eczema among domestic dermatologists varies and needs to be improved: In China, dermatitis and eczema are often referred to clinically as dermatitis eczema-like diseases, and many physicians do not seriously study the difference between dermatitis and eczema, and when they encounter patients with rashes (papules) accompanied by itching, they all diagnose them as eczema (or dermatitis), thus leading to simplistic or even incorrect treatment. In fact, most dermatitis is an allergic skin disease with a clear cause, while eczema is often an allergic skin disease with a less clear cause; dermatitis is often not more limited, while eczema is often large and symmetrical in scope; dermatitis often subsides after the cause is removed, while eczema tends to go through a significant process, alternating between remission and recurrence. Many doctors do not know how to find the cause, how to make a differential diagnosis, which makes the treatment taken not ideal results.
Treatment is not standardized enough: it is mainly reflected in three aspects: first, inappropriate treatment, second, insufficient treatment, and third, excessive treatment. Inappropriate treatment is reflected in incorrect or imperfect treatment strategies. Many doctors attach importance to medication, but do not pay attention to patient education, do not understand or pay attention to basic treatment, do not know how to choose drugs, such as do not know how to choose to use hormonal and non-hormonal drugs, and therefore often do not achieve good results; inadequate treatment is reflected in some doctors dare not use drugs, such as some patients and family members fear or even refuse to apply hormonal drugs. For example, some patients and their families are afraid of or even refuse to apply hormonal drugs, so doctors often accommodate patients and dare not use drugs with definite efficacy, but instead use drugs with inaccurate efficacy, which leads to relapse or aggravation of the disease prematurely. Excessive treatment is the opposite, regardless of the condition, the application of many unnecessary systemic treatment drugs, resulting in some adverse reactions. In addition to the level of doctors, the lack of an easy to implement treatment guidelines can not be said to be one of the reasons for the occurrence of the above three aspects.
Second, the characteristics of eczema diagnosis and treatment guidelines.
1, concise, easy to read and easy to use: In the development of this guide, we adhere to the concept of clinical, grassroots services, to adopt the principle of concise, easy to read and easy to use, the pathogenesis of the compressed as much as possible, highlighting the clinicians most concerned about the clinical manifestations of eczema, diagnosis and treatment of the three parts. The aim is to be small, readable, easy to remember and easy to use.
2, the diagnosis and differential diagnosis of eczema is confusing to primary care physicians and the biggest problem, in order to enable the majority of doctors to improve the level of diagnosis of eczema, in the guide we proposed a roadmap for the diagnosis of eczema, what to do in the first step, what to do in the second step is written very clearly, the steps are clear, the pulse is clear, doctors along this step can correctly diagnose eczema. This will help primary care physicians to follow a standardized step in the diagnosis and differential diagnosis of eczema, thus reducing the rate of missed and misdiagnosis.
3, emphasizing patient education and basic treatment in the treatment of eczema, patient education and basic treatment is placed in a very important position, instructing doctors how to communicate with patients, how to explain the disease to patients, how to guide patients in the use of drugs, how to observe the condition, how to pay attention to “clothing, food, housing, transportation, washing” and other aspects of the matter, improve the doctor Awareness of patient education.
4. Reflecting the latest treatment concepts and advances in treatment: In terms of treatment, efforts were made to reflect the latest international treatment concepts and advances in eczema treatment, emphasizing topical glucocorticoids as the first line of eczema treatment, as well as the role of infection and bacterial colonization in the recurrence and exacerbation of eczema, and guiding clinicians in the rational application of anti-infective drugs. In addition, in addition to the introduction of traditional drugs and methods, new drugs such as calcium-modulated neurophosphatase inhibitors and leukotriene inhibitors that have begun to be used clinically in recent years, as well as treatments such as narrow-wave ultraviolet light, have also been introduced in an effort to reflect the latest advances.
5. Guidance to physicians on the analysis of the causes and response guidance for certain stubborn, treatment-resistant patients is one of the features of this guideline. Because eczema is difficult to treat and often encounters unsatisfactory results, it is of great importance to properly guide physicians to objectively analyze the reasons for unsuccessful treatment in order to revise treatment strategies, change the types and means of medication, and ultimately improve the efficacy and relieve patients’ pain, in the hope of turning stones into gold.
Third, eczema refers to the treatment of South of the applicable target.
All levels and types of dermatologists: This guide applies first of all to dermatologists at all levels, including the chief physician. Attending physicians, residents, residents in standardized training, doctoral students, master’s students, etc. It provides them with the process, steps for the proper diagnosis of eczema, and options for proper treatment.
General Practitioners: In primary care, especially in remote areas, many skin conditions are treated by general practitioners, and eczema is the most common skin condition that general practitioners should learn to diagnose and treat. If the guidelines are followed for diagnosis and treatment, it is not easy to misdiagnose and mistreat, and the diagnostic level and treatment level of general practitioners can be improved.
Physicians of other clinical disciplines; may use the principles of this guideline for treatment in special circumstances, such as when they encounter eczema patients at the primary level and are not in a position to consult a dermatologist.
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Attachment: Chinese Eczema Treatment Guidelines
Eczema is an inflammatory skin disease with a pronounced tendency to exude caused by a variety of internal and external factors, accompanied by pronounced itching, prone to recurrence, and seriously affecting the quality of life of patients (1,2). It is a common disease in dermatology, with a prevalence of about 7.5% in the general population in China and 10.7% in the United States (3,4).
I. Etiology and pathogenesis
The etiology of eczema is still unclear. Endogenous factors include abnormal immune function (such as immune imbalance, immunodeficiency, etc.) and systemic diseases (such as endocrine diseases, nutritional disorders, chronic infections, tumors, etc.) and hereditary or acquired skin barrier dysfunction, external factors such as environmental or food allergens, irritants, microorganisms, environmental temperature or humidity changes, sun exposure, etc. can trigger or aggravate eczema. Psychosocial factors such as stress and anxiety can also trigger or aggravate the disease.
The pathogenesis of this disease is not clear. Currently, it is believed that the disease is the result of a combination of internal and external factors based on internal factors such as abnormal immune function and skin barrier dysfunction. Both immune mechanisms such as allergic reactions and non-immune mechanisms such as skin irritation are involved in the pathogenesis. Microorganisms can trigger or aggravate eczema through direct invasion, superantigenic action or induction of immune response (5).
II. Clinical manifestations
The clinical manifestations of eczema can be divided into three phases: acute, subacute and chronic.
The acute phase is characterized by erythema, edema on the basis of corn-like papules, papules, blisters, vesicles and exudate, the center of the lesion is often heavy, and gradually spread to the periphery, and scattered papules, papules, so the boundary is unclear.
In the subacute stage, the redness and exudation are reduced, and the vesicular surface is crusted and desquamated.
Chronic eczema mainly manifests as rough hypertrophy, moss-like changes, may be accompanied by pigment changes, hand and foot eczema can be accompanied by nail changes. The rash is generally symmetrically distributed, often recurrent, and the conscious symptoms are pruritus and even severe itching.
Laboratory tests
Blood tests may include eosinophilia, increased serum eosinophilic cationic protein, increased serum IgE in some patients, allergen tests to help find possible allergens, patch tests to help diagnose contact dermatitis, fungal tests to identify superficial fungal disease, scabies tests to help rule out scabies, serum immunoglobulin tests to help identify The congenital disease with eczema dermatitis lesions, bacterial culture of skin lesions can help diagnose secondary bacterial infections, etc., and skin histopathological examination should be performed when necessary.
IV. Diagnosis and differential diagnosis
The diagnosis of eczema is mainly based on clinical manifestations, combined with the necessary laboratory tests or histopathological examinations. Special types of eczema are diagnosed according to clinical characteristics, such as lack of lipid eczema, self-sensitivity dermatitis, coin-shaped eczema, etc.; non-specific cases can be diagnosed according to clinical sites, such as hand eczema, calf eczema, perianal eczema, breast eczema, scrotal eczema, ear eczema, eyelid eczema, etc.; generalized eczema refers to eczema that occurs in multiple sites at the same time. The severity of eczema can be scored according to its size and the characteristics of the rash (6).
The following diseases need to be differentiated: (1) other diseases that resemble eczema, such as scabies, superficial fungal disease, lymphoma, eosinophilia, and pellagra; (2) congenital diseases with eczematous lesions, such as Wiskott-Aldrich syndrome, selective IgA deficiency, and hyper-IgE recurrent infection syndrome; (3) other types of dermatitis with specific etiology or clinical manifestations, such as atopic dermatitis, and contact dermatitis. such as atopic dermatitis, contact dermatitis, seborrheic dermatitis, bruising dermatitis, polymorphic heliotrope, etc. (7). A brief flow of eczema diagnosis and differential diagnosis is shown in Figure 1.
V. Treatment
The main goal is to control symptoms, reduce recurrence, and improve the patient’s quality of life. Treatment should be considered as a whole, taking into account both immediate and long-term efficacy, with special attention to medical safety in treatment.
(1) Basic treatment
①Patient education: the nature of the disease, possible regression, the impact of the disease on physical health, the presence of infectiousness, the clinical efficacy of various treatment methods and possible adverse effects need to be explained. Instruct patients to look for and avoid common allergens and irritants in the environment, and to avoid scratching and excessive washing. Corresponding advice should also be given on the environment, diet, use of protective equipment, and skin cleansing methods.
② Avoid triggering or aggravating factors: Through detailed history taking, meticulous physical examination, and reasonable use of diagnostic tests, carefully search for various suspected causes and triggering or aggravating factors in order to achieve the goal of removing the causes and thorough treatment. For example, the factors that make the skin dry should be removed for lack of lipid eczema, and the primary infection should be treated for infectious eczema.
③Protect the skin barrier function: eczema patients have damage to the skin barrier function, easy to secondary irritant dermatitis, infection and allergy and aggravate the lesions, so it is very important to protect the barrier function. Treatment that does not irritate the patient’s skin should be selected, secondary infections should be prevented and treated in a timely manner, and moisturizers should be added for subacute and chronic eczema with dry skin.
(2) Topical treatment:
It is the main means of eczema treatment. Suitable drug formulations should be selected according to the stage of the lesion. In the acute stage without blisters, vesicles and exudation, it is recommended to use glyburide lotion, glucocorticoid cream or gel; when there is a lot of exudation, cold wet compresses should be chosen, such as 3% boric acid solution, 0.1% berberine hydrochloride solution, 0.1% Levanox solution, etc.; when there are vesicles but not much exudation, zinc oxide oil is available. For subacute lesions, topical zinc oxide paste and glucocorticoid cream are recommended. For chronic lesions, topical glucocorticoid ointment, hard cream, emulsion or tincture are recommended, and moisturizers and keratolytic agents, such as 20%-40% urea ointment and 5%-10% salicylic acid ointment, can be used in combination.
Topical glucocorticoid preparations are still the mainstay of eczema treatment. Initial treatment should be based on the nature of the lesions and the choice of the appropriate strength glucocorticoid: for mild eczema, weak glucocorticoids such as hydrocortisone and dexamethasone cream are recommended; for severe hypertrophic lesions, strong hormones such as harcinexide and halometasone cream are recommended; for moderate eczema, medium-acting hormones such as tretinoin and mometasone furoate are recommended. Those suspected to be related to bacterial infections may combine topical antibiotic preparations or use compound preparations containing antibacterial effects. Weak or medium-acting hormones are generally effective in pediatric patients, lesions on the face and skin folds. Strong glucocorticosteroids should not be used continuously for more than 2 weeks to reduce acute tolerance and adverse effects.
Calcium-regulated neurophosphatase inhibitors such as tacrolimus ointment and pimecrolimus cream have a clear therapeutic effect on eczema without the side effects of glucocorticoids and are particularly suitable for the treatment of eczema on the head, face and inter-rub areas.
Bacterial colonization and infection can often induce or aggravate eczema8, so antibacterial drugs are also an important aspect of topical treatment. Various topical preparations of antimicrobials and chemical antibacterial drugs are available, as well as a combination of glucocorticoids and antibacterial drugs.
Other topical drugs such as tar, antipruritic agents, and topical preparations of nonsteroidal anti-inflammatory drugs can be selected for application according to the situation.
(3) Systemic treatment.
①Antihistamines: appropriate antihistamines are selected to stop itching and anti-inflammation according to the patient’s condition.
②Antibiotics: For those with extensive infection, systemic application of antibiotics for 7-10 days is recommended.
③Vitamin C and calcium gluconate have some anti-allergic effect and can be used for acute attacks or obvious itching.
④ Glucocorticoids: routine use is generally not advocated. They are suitable for patients with clear etiology and short-term elimination of etiology, such as those caused by contact factors, drug factors or auto-sensitive dermatitis; for severe edema, generalized rash, erythrodermatitis, etc., they can also be applied short-term for rapid symptom control, but caution must be exercised to avoid systemic adverse reactions and rebound of the disease.
⑤ Immunosuppressants: They should be used with caution, and the indications should be strictly controlled. They should be used only in patients with severe disease who have contraindications to the application of glucocorticosteroids and whose condition has been significantly relieved by short-term systemic application of glucocorticosteroids, and who need to reduce or stop the use of hormones.
(4) Physical therapy.
Ultraviolet therapy includes UVA1 (340-400 nm) irradiation, UVA/UVB irradiation and narrow-spectrum UVB (310-315 nm) irradiation, which has good efficacy for chronic intractable eczema.
(5) Chinese herbal medicine therapy.
Chinese herbal medicine can be treated internally as well as externally, and should be administered according to the condition. Chinese herbal extracts such as compound glycyrrhizin and tretinoin polysaccharide are effective for some patients. It should be noted that herbal medicines can also lead to serious adverse reactions, such as allergic reactions, liver and kidney damage, etc.
(6) Follow-up and follow-up prevention.
The disease is prone to recurrence and patients are advised to follow up regularly. Patients with acute eczema should preferably be seen once 1 week after treatment, 1-2 weeks after treatment for subacute patients, and 2-4 weeks after treatment for chronic patients. The follow-up visit is to evaluate the efficacy, changes in condition, the need for further tests, and to evaluate compliance. In cases of recurrent attacks and persistent non-resolution, attention should be paid to analyze the presence of: (i) irritating factors; (ii) neglected exposure to allergens; (iii) cross-allergy; (iv) secondary allergy: e.g., allergy to topical medications in treatment; (v) secondary infection; (vi) unfavorable environmental factors and (vii) adverse systemic factors.
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