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Nursing Care Plan | NCP Eczema

Eczema is a noncontagious skin disease characterized by extremely itchy inflamed skin that often becomes cracked or weepy after scratching. It is grouped together with asthma and hay fever as an atopic disease. Atopic diseases are allergic conditions in which the affected parts of the body are not in direct contact with the allergen. In addition, these diseases are often inherited.

People with eczema develop an itching, scaling, and swelling rash on the skin that may form oozing open sores or yellow and red pimples. The rash is most likely to affect the skin of the hands and feet, the arms, the area behind the knees, and the ankles, wrists, face, neck, and upper chest. Some people develop eczema on their eyelids or the skin around the eyes. Scratching in this facial area may eventually cause the eyebrows and eyelashes to fall out. Other people may develop an extra fold of skin under the eyes from rubbing or scratching. The most troublesome symptom of eczema for most patients is the intense itching that accompanies the disease. An officer of the National Eczema Association said in an interview, “It’s like having poison oak or poison ivy twenty-four hours a day, seven days a week, forever.” The itching in turn can lead to sleeping difficulties—children with severe eczema may lose as much as two hours of sleep per night—as well as self-consciousness in social situations and other psychological disturbances.

Eczema is more common among children than adults; 95 percent of cases occur in children five years or younger. Between 10 and 12 percent of American children are diagnosed with eczema. Of these children, 30 percent will develop asthma and 35 percent will develop hay fever in later childhood. The disease often goes into remission (quiet period without symptoms) in late childhood or adolescence and then flares up again in the early adult years. According to the American Academy of Dermatology (AAD), about half of children diagnosed with eczema will improve by the time they are fifteen; the other half will have symptoms of eczema throughout their adult lives. It is unusual for a person to develop eczema for the first time after age thirty unless they are working in a harsh climate or a wet environment.

Eczema is a very common skin disorder, affecting people in all racial and ethnic groups. The National Institutes of Health (NIH) estimates that about 15 million people in the United States have some form of eczema. The rate in adults is about 0.9 percent. It is slightly more common in women than in men. Eczema almost never causes death; however, it is a severe psychological and economic burden to patients and their families. Flare-ups may cause children to miss school and eventually fall behind their classmates. Among adults, eczema frequently leads to taking time off from work. The National Institutes of Health estimate that U.S. health insurance companies spend more than $1 billion per year on eczema; this is a figure comparable to the health care costs of asthma and diabetes.

Nursing Care Plan Signs and Symptoms

The causes of eczema are a matter of debate among doctors. For many years it was thought that eczema is primarily an allergic disease that leads to skin dryness and rashes. Doctors maintained that eczema develops from an immune overreaction inside the body that leads to inflammation and cracked, itchy skin. The breaks in the skin then let in more allergens, irritants, and microbes that made the skin itch and burn even more. The theory was supported by the observation that patients with eczema often develop other atopic ailments such as asthma, food allergies, and hay fever.

In 2006, however, a researcher in Scotland found that children with chronic eczema have a defective gene for filaggrin, a protein in the skin that normally holds in moisture. The researcher discovered that between a third and a half of his patients had a defective filaggrin gene on chromosome 1. A genetic factor may help to explain why eczema has increased in developed countries since the 1980s; air pollution and the widespread use of air conditioning and central heating could further dry out skin that is already dry and fragile, allowing irritants to enter and trigger the inflammation that characterizes eczema. On the other hand, many patients with eczema do not have the defective filaggrin gene, while others with the gene do not develop eczema.

At one time it was thought that emotional stress caused eczema. It is now known that while stress can make a flare-up of eczema worse, it does not cause the disorder.

The symptoms of eczema may include:
• Areas of dry, leathery, or discolored skin.
• Intense itching in the affected areas.
• Blisters that ooze tissue fluid and then crust over.
• Rash. In children, the rash is most often found on the face, elbows, and knees; in adults, it is more common on the skin inside the knees and elbows.
• Raw areas of skin from scratching.
• Reddened or inflamed skin around the blisters.
• Bacterial infections that develop in the broken skin.

Nursing Care Plan Diagnosis

The doctor will usually base the diagnosis on the basis of an examination of the patient’s skin, together with a personal and family history of atopic disorders. The patient may be referred to a dermatologist (a doctor who specializes in disorders of the skin) to rule out the possibility that the skin problems are caused by other diseases. The dermatologist may take a skin biopsy in order to exclude other causes, but this type of test is not necessary to make the diagnosis.

Nursing Care Plan Treatment

Treatment of eczema focuses on reducing itching (and therefore scratching); lowering inflammation; and preventing flare-ups. The specific medications that are used depend somewhat on the severity of the patient’s symptoms.
Common treatments include:
• Moisturizers. Lubricating creams or ointments should be applied to the skin after bathing or showering to seal moisture in the upper layer of skin cells. The most effective moisturizers are those that contain petrolatum (petroleum jelly).
• Creams or powders that contain cortisone. Different formulations may be tried, as some people are allergic to the preservatives used to make the creams. These products should be discontinued during remissions because long-term use can cause skin irritation or discoloration, thinning of the skin, infections, and stretch marks on the skin.
• Severe eczema may be treated with oral antihistamines or oral steroid medications. The steroid drugs are effective in relieving itching but, like cortisone creams, they should not be used for long periods of time because of potentially serious side effects. These side effects include cataracts, osteoporosis, muscle weakness, lowered resistance to infections, high blood pressure, and thinning of the skin.
• Antibiotic creams or oral antibiotics. These may be prescribed if the patient develops a bacterial infection in broken or inflamed skin.
• Immunomodulators. This newer, prescription-only class of drugs is sometimes recommended for children over two years of age and adults. The Food and Drug Administration (FDA) issued a warning in 2006, however, that these drugs should be used only in patients who are not helped by other treatments, because of the risk of long-term damage to the immune system.
• Phototherapy. Phototherapy is the use of natural sunlight or ultraviolet light. While some patients benefit from phototherapy, it also speeds up aging of the skin and increases the risk of skin cancer.

Patients who want to try this approach to treating eczema should consult their doctor first. Alternative treatments that are sometimes recommended for eczema include evening primrose oil, vitamin therapy, various Chinese herbal medications, and nutritional supplements, though none of these have been scientifically proven effective.

Nursing Care Plan Prognosis
About half of children with eczema will have relatively clear skin and few flare-ups as adults. The other half are likely to be troubled with recurrent eczema in adult life.

Nursing Care Plan Prevention
There is no cure for eczema. Treatment largely consists of identifying the specific substances that trigger skin reactions, avoiding contact with them whenever possible, and applying products that relieve the itching, dryness, and inflammation of the skin.

The Future
Eczema is becoming a more common disease in the developed parts of the world, with rates as high as 18 percent in children of some countries. It is also rising among people who migrate from less developed to more developed countries. It may be possible in the future to develop medications that would stimulate filaggrin production in patients with a defective gene for this skin protein. Another area of research is focused on the benefits of early protective skin care in children with eczema. Some doctors think that early treatment of the skin condition may prevent hay fever, food allergies, and asthma from developing in later childhood, or at least reduce their severity.
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