Eczema: Clinical Guidelines

List of Abbreviations

ACTH — adrenocorticotropic hormone

ALT – alanine aminotransferase

AST – aspartate aminotransferase

HIV – human immunodeficiency virus

IL-1 — interleukin-1

IL-2 — interleukin-2

PG — prostaglandin

TSH – thyroid-stimulating hormone

TNF-α — tumor necrosis factor alpha

ALP — alkaline phosphatase

cGMP — cyclic guanosine monophosphate

CNS – central nervous system

HBsAg (hepatitis B surface antigen) — hepatitis B virus surface antigen

IgE — immunoglobulin E

IgG – immunoglobulin G

Terms and Definitions

Eczema (from Greek ekzeō — to boil out) is a chronic relapsing allergic skin disease developing under the influence of exogenous and endogenous trigger factors, characterized by the appearance of a polymorphic rash.

PUVA therapy (synonym photochemotherapy) is the combined use of photosensitizers from the psoralen group and long-wave ultraviolet radiation (UVA) 320–400 nm.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Eczema (from Greek ekzeō — to boil out) is a chronic relapsing allergic skin disease developing under the influence of exogenous and endogenous trigger factors, characterized by the appearance of a polymorphic rash and an inflammatory reaction.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Eczema develops as a result of the complex effect of endogenous factors (genetic predisposition, presence of sensitization to various allergens) and exogenous factors (household, occupational, environmental, etc.).

Genetic predisposition determines impaired immune regulation as well as nervous and endocrine system functions. Eczema is characterized by polygenic multifactorial inheritance with pronounced expressivity and penetrance of genes. If one parent is affected (predominantly the mother), the child's risk of developing eczema is approximately 40%; if both parents are affected, it is 50%–60%. Stressful situations, peripheral nerve lesions, and skin trophism disorders are important trigger factors in the development of eczema in genetically predisposed individuals. Patients with eczema frequently exhibit functional changes in CNS activity, the predominance of unconditioned reflex activity over conditioned reflex activity, and an imbalance between the sympathetic and parasympathetic divisions of the autonomic nervous system (with a predominance of parasympathetic influences). Pronounced disorders in the glucocorticoid and thyroid links of the endocrine system have been established in eczema: elevated levels of ACTH, cortisol, TSH, and triiodothyronine. Free radical processes ("oxidative stress") play a certain role in the pathogenesis of eczema. Free radicals activate phospholipase A2, leading to the release of arachidonic acid, which, upon the action of cyclooxygenase and lipoxygenase, gives rise to inflammatory mediators: leukotrienes, prostaglandins, and thromboxanes. In individuals with a hereditary predisposition, the synthesis of prostaglandin (PG) F2α increases, causing enhanced stimulation of cyclic guanosine monophosphate (cGMP) synthesis, which activates the production of histamine, serotonin, and other mediators of allergic reactions. Exhematous skin changes are the result of delayed-type hypersensitivity. According to modern concepts, T lymphocytes (mainly Th1) play the primary role in the development of eczema; they carry specific antigen receptors on their surface and secrete a number of pro-inflammatory cytokines: interleukin-1 (IL-1), IL-2, tumor necrosis factor alpha (TNF-α), and interferon-γ. The release of biologically active substances (prostaglandins, leukotrienes, histamine) causes tissue inflammatory reactions, clinically manifested as hyperemia, edema, and pruritus. Pathology of the gastrointestinal tract and hepatobiliary system—accompanied by enzymopathies, dyskinesias, intestinal dysbiosis, and impaired membrane digestion and absorption—has significant pathogenetic importance in the development and further course of eczema, particularly in children. Intestinal barrier failure, most characteristic of early childhood, leads to the absorption of insufficiently digested products into the bloodstream, including un cleaved protein.

1.3 Epidemiology of the Disease or Condition

Global statistics indicate that the prevalence of eczema is approximately 1–2% of the global adult population, and its proportion among other skin conditions is 30–40%.

1.4 Features of Coding the Disease or Condition

L30.0 Nummular eczema

L30.1 Dyshidrosis (pompholyx)

L30.2 Cutaneous autosensitization (eczematous)

L30.3 Infectious eczema

L30.4 Erythematous intertrigo

L30.5 Pityriasis alba

L30.8 Other specified dermatitis

L30.9 Eczema, unspecified

1.5 Classification of the disease or condition

There is currently no unified classification of eczema. Depending on the clinical features, the following forms of the disease are distinguished:

- true eczema (idiopathic, dyshidrotic, pruriginous, corneal (tylotic));

- microbial eczema (nummular, paratraumatic, mycotic, intertriginous, varicose, sycosiform, eczema of the nipples andareola of the female breast);

- seborrheic eczema;

- infantile eczema;

- occupational eczema.

Each of them has an acute, subacute, or chronic course.

1.6 Clinical presentation of the disease or condition

The acute stage is characterized by the appearance of vesicles on erythematous and edematous skin, punctate erosions with weeping ("serous wells"), serous crusts, excoriations, and less commonly, papules and pustules. Along with the involution of the rash, new elements are formed; therefore, a polymorphic pattern of rashes is typical for true eczema.

The subacute stage is characterized by erythema, infiltration, lichenification, scales, and excoriations.

The chronic stage is characterized by more pronounced infiltration and lichenification, as well as post-inflammatory hypo- and hyperpigmentation.

A common sign of eczema is pruritus, which intensifies during disease exacerbations, burning, and pain.

True eczema (idiopathic). Manifests as acute inflammatory erythema and edema, against the background of which microvesicles and exudative papules form. Microvesicles rapidly rupture, forming punctate erosions in their place, the so-called serous wells, from which exudate is released, forming areas of weeping with macerated and desquamated epithelium. The serous fluid gradually dries, forming grayish-yellow crusts. Skin lesions in true eczema typically begin in the area of the hands and/or feet. The rashes are usually symmetrical, with a tendency to spread to the skin of the forearms, lower legs, and other areas of the skin. Eczema lesions vary in size with blurred borders. Alternating affected and unaffected skin areas ("archipelago of islands") is characteristic. Patients are troubled by pruritus of varying intensity, which contributes to the development of neurotic disorders, anxiety, and sleep disturbances. The eczematous process can transition into a chronic course, clinically manifested by areas of dryness, flaking, and fissure formation. Eczema is frequently complicated by secondary infection with the appearance of pustules and purulent crusts.

Dyshidrotic eczema (a variant of true eczema) is characterized by the appearance of itchy blisters and vesicles with a tight roof, sometimes multilocular and the size of a pinhead, on the lateral surfaces of the fingers and toes, palms, and soles. Located deep in the epidermis, the vesicles shine through it, resembling grains of boiled rice. After the rupture of the tight vesicle roofs, weeping erosions, serous crusts, fissures, and desquamation are formed.

Pruriginous eczema is characterized by small, itchy papulovesicles on a firm base that do not rupture and do not form crusts. Preferred localization: face, extensor surfaces of the limbs, elbow and knee folds, genitalia. The course of the process is chronic, with the development of infiltration, dryness, and lichenification against the background of scratching.

Cornal (tylotic) eczema manifests as hyperkeratosis of the palms and soles, sometimes with deep, painful fissures. The course is chronic and treatment-resistant.

Microbial eczema manifests as asymmetrical lesions, the central part of which is covered with purulent and serous crusts; upon their removal, an erosive surface with weeping in the form of "wells" is exposed. The borders of the lesions are distinct, outlined by a border of exfoliating epithelium. The rashes are accompanied by intense pruritus. Often, foci of microbial eczema are located at the periphery of trophic ulcers of the lower leg, around fistulas, on an amputation stump, and against the background of varicose changes. In such cases, microbial eczema is called paratraumatic.

Nummular eczema is a variant of microbial eczema. The lesions are almost always round in shape, have distinct borders, and are usually localized on the upper and lower limbs, and much less frequently on the trunk. The plaques represent a cluster of small papules, vesicles, seropurulent crusts, and desquamation against a background of erythema.

Paratraumatic (periwound) eczema develops in the area of postoperative scars, bone fractures, osteosynthesis, and sites of improperly applied plaster casts. It is characterized by the onset of acute inflammatory erythema, exudative papules and/or pustules, and crust formation. Superficial skin sclerosis and the deposition of hemosiderin in the tissues are possible.

Varicose eczema occurs against the background of varicose veins. The development of the disease is favored by trauma, skin maceration, and irrational topical therapy for varicose ulcers. Lesions are localized on the lower limbs, predominantly in the lower third of the shanks, often in close proximity to varicose ulcers and areas of skin sclerosis.

Sycosiform eczema develops against the background of sycosis vulgaris, with the process extending beyond the hair-bearing area; "serous wells", weeping, and pruritus are noted, and skin lichenification appears over time. Preferred localization of the process: upper lip, chin, axillary region, pubis.

Nipple eczema is often a consequence of trauma during child-rearing or a complication of scabies, but in some cases, the cause of the disease remains unknown. Nipple eczema is characterized by the development of mild infiltration against the background of slight erythema, weeping with the presence of sero-hemorrhagic crusts, desquamation; fissures and pustules may appear. Nipple eczema is usually bilateral, is not accompanied by nipple induration, and responds to corticosteroid treatment.

Seborrheic eczema. The process usually begins on the scalp. Lesions are typically localized in the retroauricular areas and on the neck, lack distinct borders, and are accompanied by exudation and the formation of yellowish or dirty-gray seborrheic crusts and marked pruritus. The process develops against the background of oily seborrhea. Characteristic signs include the appearance of yellowish-pink erythematous infiltrated patches with clear or blurred borders, and fine flaky desquamation in the form of greasy-consistency yellow scales. Seropurulent exudation is possible, forming moist, greasy seropurulent scale-crusts. On the scalp, hair may be glued together by exudate, with scales and crusts present.

Eczema in children. Manifests with clinical signs of true, seborrheic, and microbial eczema. Signs of eczema in children most commonly appear at the age of 3–6 months. The clinical picture is dominated by exudative processes: brightly expressed erythema, edema, weeping, and the layering of serous crusts. The so-called milk crust or milk scabs appears. Erythematous lesions have a shiny surface and are hot to the touch. Children suffer from insomnia and pruritus. The course of eczema is chronic and relapsing.

Occupational eczema develops in the presence of occupational allergens (chemical, bacteriological, etc.) and alterations in the body's allergic reactivity. Occupational allergens include amine hardeners, synthetic glues, paraphenylenediamine, dinitrochlorobenzene, epoxy resins, phenol-formaldehyde, penicillin and semi-synthetic antibiotics, salts of heavy metals (e.g., chromium, nickel, cobalt), turpentine and its derivatives, mercury compounds, alloys of precious and semi-precious metals, etc. Occupational eczema involves a delayed-type hypersensitivity reaction to a substance used in production that acts as an occupational allergen. The clinical presentation of occupational eczema is quite variable, yet it shares all the features of conventional eczema. Most commonly, occupational eczema develops on exposed skin areas, i.e., sites of contact with the irritant (face, neck, sternal area, dorsal hands, forearms, lower legs). Upon removal of the etiological factor, the condition resolves quite rapidly. When polyvalent sensitization develops, eliminating the etiological factor does not prevent recurrence. Occupational eczema is frequently accompanied by respiratory changes, bronchospasm, allergic rhinitis, and allergic conjunctivitis. The diagnosis of occupational eczema is established using specific diagnostic examinations. The most common among these are skin patch tests with suspected occupational irritants, allergological and immunological tests, and functional diagnostics. Patients with occupational eczema undergo work capacity assessment and are assigned a disability rating based on the occupational disease.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for diagnosis/condition establishment

The diagnosis of eczema is established based on:

1) analysis of complaints;

2) anamnestic data;

3) physical examination;

4) results of pathomorphological examination of skin biopsy material from lesion sites when differential diagnosis with other conditions is necessary.

The diagnosis of eczema is based on the analysis of complaints, anamnesis data, and assessment of the clinical presentation of the disease.

In true eczema, the clinical presentation is typical; in rare cases, true eczema must be differentiated from atopic dermatitis, toxicoderma, pyoderma, and allergic contact dermatitis.

Dyshidrotic eczema should be differentiated from palmoplantar psoriasis, Andrews' pustular bacterid, dermatophytosis, chronic acrodermatitis continua of Hallopeau, and in exceptional cases, from bullous pemphigoid.

Differential diagnosis of pruriginous eczema is performed with scabies, childhood prurigo, persistent papular urticaria, and dermatitis herpetiformis (Duhring's disease).

In microbial eczema, differential diagnosis is performed with streptoderma, allergic contact dermatitis, subcorneal pustular dermatosis, Duhring's disease, and leishmaniasis.

Differential diagnosis of nummular eczema is performed with plaque parapsoriasis, pityriasis rosea, and seborrheic eczema.

Sycosiform eczema should be differentiated from vulgaris and parasitic sycosis.

Differential diagnosis of paratraumatic eczema is performed with contact dermatitis, psoriasis, hypertrophic lichen planus, and Schamberg disease.

Differential diagnosis of nipple eczema is performed with scabies and Paget's disease.

Seborrheic eczema should be differentiated from psoriasis, parapsoriasis, ulerythema ophryogenes, discoid lupus erythematosus, Darier's disease, pityriasis rubra pilaris, Senear-Usher pemphigus foliaceus, and benign familial pemphigus (Hailey-Hailey disease).

Differential diagnosis of keratotic (tylotic) eczema is performed with palmoplantar psoriasis, dermatophytosis, and keratoderma.

2.1 Complaints and Anamnesis

Complaints and medical history are described in the section "Clinical Presentation".

2.2 Physical Examination

Physical examination findings are described in the section "Clinical Presentation".

2.3 Laboratory Diagnostics

microscopic stool examination for helminth eggs and larvae [1].

GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)

or

determination of blood antibodies of classes A, M, G (IgM, IgA, IgG) to Giardia [2].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

or

determination of antibodies to Ascaris lumbricoides [2].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

or

determination of antibodies to the causative agent of opisthorchiasis (Opisthorchis felineus) in the blood [3].

GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comments: one of the factors triggering the development of eczema is sensitization to food, chemical, domestic, and other allergens. If sensitization to household, pollen, food, or other allergens is present, the patient should be referred for a consultation with an allergist-immunologist.

Comments: The results of microbiological (culture) examination of skin lesion discharge for susceptibility to antibacterial and antifungal agents allow for the targeted prescription of effective antibacterial therapy.

2.4 Instrumental Diagnostics

Not applicable.

2.5 Other Procedures

Comments: Histological examination of a skin biopsy in acute eczema reveals spongiosis, numerous small vesicles within the epidermis, and intracellular edema of the spinous layer cells. In the dermis, there is dilation of the superficial vascular plexus, papillary edema, and perivascular lymphoid cell infiltration. Pathohistological changes in the chronic process are characterized by a perivascular dermal infiltrate consisting of lymphocytes, fibroblasts, histiocytes, and eosinophils, along with epidermal acanthosis, hyperkeratosis, parakeratosis, and mild edema.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

The management of patients with eczema involves systemic and topical pharmacotherapy, as well as ultraviolet skin irradiation (phototherapy).

3.1 Conservative Treatment

For topical therapy, patients with eczema are prescribed dermatological corticosteroids or other dermatological agents (#pimecrolimus**, #tacrolimus**, zinc pyrithione). The anti-inflammatory potency of #tacrolimus** corresponds to low-potency corticosteroids (Group I), while that of #pimecrolimus** corresponds to high-potency corticosteroids (Group III) [16].

In cases of secondary infection of skin lesions in eczema, topical corticosteroids combined with other agents or combined with antibiotics may be used for topical therapy. Patients with microbial eczema may be prescribed topical antibiotics or topical anti-acne antimicrobials. If patients with eczema develop lymphangitis, lymphadenitis, or fever, systemic antibacterial agents may be prescribed. [22]

To reduce the intensity of pruritus, patients with eczema are prescribed systemic antihistamines. In the presence of pronounced inflammation or lack of tendency for lesions to resolve, systemic corticosteroids may be prescribed. Various methods of ultraviolet skin irradiation may also be utilized. [22]

alclometasone 0.05%, cream, 0.05%, ointment [95, 96]

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

Comments: Alclometasone 0.05% cream/ointment should be applied evenly in a thin layer to affected skin areas 2–3 times daily for 10–20 days. In children, treatment should not exceed 3 weeks; prolonged use must be carried out strictly under medical supervision. A contraindication to the use of alclometasone 0.05% cream and ointment is age under 6 months

or

methylprednisolone aceponate 0.1% cream, 0.1% ointment applied in a thin layer once daily to affected skin areas for 2–4 weeks [19 – 21]

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

Comments: A contraindication to the use of methylprednisolone aceponate cream and ointment is age under 4 months.

or

For adults, methylprednisolone aceponate + urea 0.1% + 2% cream applied in a thin layer once daily to affected skin areas for 2–4 weeks [22, 97]

GCR BLE 4Grade of Recommendation B (Level of Evidence – 4)

Comments: A contraindication to the use of methylprednisolone aceponate 0.1% + urea 2% cream is age under 18 years.

or

hydrocortisone** 0.1%, cream, ointment applied in a thin layer to affected skin areas twice daily for 2–4 weeks [23–26]

GCR ALOE 2Grade of Recommendation A (Level of Evidence – 2)

Comments: The use of 0.1% hydrocortisone** cream and ointment is possible from the age of 6 months; in children, the frequency of application and duration should comply with the instructions for use.

or

mometasone** 0.1% cream, ointment, cutaneous solution; apply a thin layer to affected skin areas 1 time per day for 2–4 weeks [27–29]

GCR ALOE 2Grade of Recommendation A (Level of Evidence – 2)

Comments: A contraindication to external therapy with mometasone** is age under 2 years. When applied to the face, areas with thin skin, and in children, the course of treatment must be limited to 5 days

or

betamethasone** 0.1% cream, 0.1% ointment [26, 30]

GCR ALOE 2Grade of Recommendation A (Level of Evidence – 2)

Comments: Apply betamethasone** 0.1% cream 1 time per day. The duration of treatment must not exceed 2 weeks. Apply betamethasone** 0.1% ointment 1 time per day for 7–20 days. A contraindication to external therapy with betamethasone** 0.1% cream and 0.1% ointment is age under 6 months.

or

betamethasone** 0.05% spray, cream, ointment [24]

GPR ALEL 2Grade of Recommendation A (Level of Evidence – 2)

Comments: Apply betamethasone** 0.05% spray, cream, or ointment 2 times per day for 7–14 days. A contraindication to prescribing betamethasone** 0.05% cream and ointment for external use is age under 1 year. A contraindication to prescribing betamethasone** 0.05% spray for external use is age under 2 years. In children and patients with facial skin lesions, the course of treatment must not exceed 5 days.

or

clobetasol 0.05% cream, 0.05% ointment [22, 31, 32]

GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)

Comments: Apply clobetasol 0.05% cream or ointment in a thin layer to affected skin areas 2 times per day for 7–10 days. A contraindication to prescribing clobetasol is age under 1 year. When prescribing clobetasol cream and ointment to children, the drug should not be used for more than 5 days or applied under an occlusive dressing.

or other agents used in dermatology:

zinc pyrithione 0.2% cream for external use, 0.2% aerosol for external use [33, 34]

GPR CLEL 5Grade of Recommendation C (Level of Evidence – 5) – for adults

GPR CLEL 4Grade of Recommendation C (Level of Evidence – 4) – for children

Comments: Apply zinc pyrithione 0.2% cream for external use in a thin layer to affected areas 2–3 times per day; spray zinc pyrithione 0.2% aerosol for external use onto the affected skin area from a distance of 15 cm 2–3 times per day. A contraindication to prescribing zinc pyrithione 0.2% cream and 0.2% aerosol is age under 1 year.

or

#pimecrolimus** 1% cream 2 times per day for up to 6 weeks, maintenance therapy – 2 times a week as needed [35, 36, 98, 106]

GPR BLEL 2Grade of Recommendation B (Level of Evidence – 2) – for adults

GPR CLEL 4Grade of Recommendation C (Level of Evidence – 4) – for children

Comments: A contraindication to prescribing #pimecrolimus** is age under 3 months.

or

#tacrolimus** 0.03% ointment, 0.1% ointment [27, 37–39, 106]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: #Tacrolimus** 0.03% ointment, 0.1% ointment 2 times per day for up to 6 weeks. The use of #tacrolimus** 0.1% ointment is contraindicated in children under 16 years of age. A contraindication to prescribing #tacrolimus** 0.03% ointment is age under 2 years. Use in children aged 2 to 16 years. Treatment should be initiated by applying 0.03% ointment twice daily. The duration of treatment using this regimen must not exceed three weeks. Subsequently, the frequency of application is reduced to once daily, and treatment is continued until complete clearance of lesions. Use in adults and children over 16 years of age. Treatment should be initiated with 0.1% Tacropic ointment twice daily and continued until complete clearance of lesions. As improvement occurs, the frequency of 0.1% ointment application can be reduced or switched to 0.03% ointment. In case of recurrence of disease symptoms, treatment with 0.1% ointment should be resumed twice daily.

Comments: The following are used as antiseptics and disinfectants: Boric acid + Resorcinol + Phenol + Fuchsin solution for topical use 2–3 times a day (Boric acid + Resorcinol + Phenol + Fuchsin solution is not used in women during pregnancy and breastfeeding); brilliant green topical solution [alcoholic] 1%, 2% applied directly to the damaged surface, involving the surrounding healthy tissue 2–3 times a day for 5–14 days [99]; chlorhexidine 0.05% aqueous solution 2–3 times a day; #potassium permanganate** powder for solution for local and topical use - 0.01–0.1% solution baths 2 times a day for 4-7 days [99]; methylthioninium chloride (methylene blue) 1% aqueous solution 2–3 times a day (methylthioninium chloride (methylene blue) may be used during pregnancy and breastfeeding).

betamethasone + gentamicin + clotrimazole 0.05% + 0.1% + 1% ointment for topical use, 0.05% + 0.1% + 1% cream for topical use; apply a small amount to the affected skin areas, rubbing in slightly, 2 times a day for 7–14 days [22, 43–48,100].

Level of Evidence CGrade of Evidence 5Level of Evidence C (Grade of Evidence – 5)

Comments: A contraindication to prescribing betamethasone + gentamicin + clotrimazole ointment and cream is children under 2 years of age.

or

betamethasone + gentamicin 0.1% + 0.1% cream for topical use, 0.1% + 0.1% ointment for topical use; apply in a thin layer to the affected skin areas 2 times a day for 7–14 days [22, 49, 100].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: A contraindication to prescribing betamethasone + gentamicin 0.1% + 0.1% cream and ointment is children under 6 months of age.

or

hydrocortisone + natamycin + neomycin ointment for topical use, cream for topical use [50–52].

GGR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

Comments: Hydrocortisone + natamycin + neomycin ointment for topical use, cream for topical use; apply to the affected skin areas 2–4 times a day for 7–14 days. A contraindication to prescribing hydrocortisone + natamycin + neomycin cream and ointment is children under 1 year of age.

or

neomycin + fluocinolone acetonide ointment for topical use [10, 41, 53]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: Neomycin + fluocinolone acetonide ointment for topical use in a thin layer to the affected skin areas 2 times a day for 7–14 days A contraindication to prescribing neomycin + fluocinolone acetonide ointment is children under 2 years of age. In children, apply once a day, in a short course on limited areas.

or

betamethasone + fusidic acid cream for topical use; apply for 7–14 days [10, 24, 43, 54, 55, 101]

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

Comments: Betamethasone + fusidic acid cream for topical use; apply in a thin layer 2 times a day for 7–14 days. A contraindication to prescribing betamethasone + fusidic acid cream is children under one year of age.

or

#hydrocortisone + fusidic acid cream for topical use; apply to the affected skin area in a thin layer 2 times a day for 7–14 days [10, 41, 55, 22]

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

Comments: A contraindication to prescribing #hydrocortisone + fusidic acid cream is children under 2 years of age.

or

gentamicin + dexpanthenol + mometasone + econazole cream for topical use; apply [56]

GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comments: Gentamicin + dexpanthenol + mometasone + econazole cream for topical use; apply to the affected skin areas in a thin layer, rubbing in slightly, 2 times a day for 1–2 weeks. A contraindication to prescribing gentamicin + dexpanthenol + mometasone + econazole cream is children under 18 years of age.

fusidic acid 2% cream for topical use, 2% ointment for topical use [24, 57, 101].

Level of Evidence CGrade of Evidence 5Level of Evidence C (Grade of Evidence – 5)

Comments: fusidic acid 2% cream for topical use, 2% ointment for topical use; apply to the affected skin areas in a thin layer 3–4 times a day for 7–10 days. There are no age restrictions for the use of 2% fusidic acid cream and 2% ointment.

or

mupirocin 2% ointment for topical use [43, 58, 59]

Level of Evidence CGrade of Evidence 5Level of Evidence C (Grade of Evidence – 5)

Comments: Apply a small amount of 2% mupirocin ointment topically to the affected skin surface 2–3 times daily for 7–10 days. There are no age restrictions for the use of 2% mupirocin ointment. However, the drug should be used with caution in elderly patients.

or

apply 3% tetracycline ointment to affected skin areas 1–2 times daily for 7–10 days [22].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: Contraindications to prescribing 3% tetracycline ointment include age under 11 years.

or

apply 0.1% gentamicin ointment topically [22, 24, 101]

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

Comments: Apply 0.1% gentamicin ointment topically in a thin layer to the affected area 3–4 times daily for 7–14 days. There are no age restrictions for the use of 0.1% gentamicin ointment. However, the drug should be used with caution in premature infants, newborns, and elderly patients.

birch tar topical liquid [41, 42, 102].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: Apply birch tar topical liquid to skin lesions initially for 15 minutes once daily, gradually increasing the application time to up to 30 minutes. Contraindications for prescribing birch tar include acute skin diseases and exacerbations of chronic skin diseases, especially with pronounced exudation.

or

naphthalan oil 10% liniment (can be compounded extemporaneously) [41, 42, 103].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: Apply naphthalan oil 10% liniment (can be compounded extemporaneously) to skin lesions twice daily. Naphthalan oil has anti-inflammatory, antipruritic, disinfecting, and healing effects.

or

ichthammol [60, 61, 2, 104]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: Apply ichthammol 10% or 20% topical ointment (compounded extemporaneously) to skin lesions 1–2 times daily. A contraindication to prescribing ichthammol is age under 12 years.

#zinc oxide 12.5% topical suspension, applied to skin lesions 1–2 times daily for 4–7 days [62, 105, 2]

or

zinc oxide 10% ointment [62, 114]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: zinc oxide 10% ointment in a thin layer 4–6 times a day, course of treatment up to 1 month. The only contraindication to prescribing zinc oxide is hypersensitivity to the components of the drug.

Comments: Second-generation systemic antihistamines (#loratadine**, cetirizine**, levocetirizine, #desloratadine, #fexofenadine) are the medical therapy of choice. If pruritus cannot be adequately controlled, first-generation systemic antihistamines (mebhydrolin [107], dimindene, clemastine, chloropyramine**, quifenadine) possessing sedative effects are prescribed (alternation is possible).

dimindene orally [63, 64, 108]

Level of Evidence CGrade of Recommendation 5Level of Clinical Effectiveness C (level of evidence – 5)

Comments: Dimindene oral prolonged-release capsules for adults and children over 12 years – 4 mg once daily for 10–20 days. Children aged 1 month to 12 years (drops): the recommended daily dose is based on 0.1 mg/kg of body weight, which is equivalent to 2 drops per kg of body weight. The daily dose must be divided into 3 doses.

Children aged 1 month to 1 year should take the medication (drops) only as prescribed by a physician. The dosing regimen for children over 12 years does not differ from the dosing regimen for adults and is used in accordance with the instructions. Dimindene oral drops are contraindicated in children under 1 month of age, and in capsules under 12 years of age.

or

quifenadine [64, 65, 22]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: Quifenadine orally for adults 25 mg twice daily for 10–20 days. Quifenadine orally for children aged 3–7 years – 10 mg twice daily, aged 7–12 years – 10–15 mg 2–3 times daily. Contraindications to prescribing quifenadine in tablet form include age under 3 years (for the 10 mg dosage) and age under 18 years (for the 50 mg dosage).

or

chloropyramine** [43, 66, 67, 22]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: chloropyramine** 25 mg for children aged 1 month to 1 year orally ¼ tablet (6.5 mg) 2–3 times daily, crushed into powder and mixed with baby food; for children aged 1 year to 6 years – ⅓ tablet (8.3 mg) 3 times daily or ½ tablet twice daily; for children aged 6 to 14 years – ½ tablet 2–3 times daily; for children over 14 years and adults – 1 tablet 3–4 times daily (75–100 mg per day) for 10–20 days Chloropyramine** in tablet form is contraindicated, depending on the drug manufacturer, under the age of 1 month or under 14 years.

or

clemastine 1 mg, orally for adults and children over 12 years – 2–3 tablets (1 mg) daily for 10 days [68].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: Clemastine in tablet form is contraindicated under the age of 6 years. In refractory cases, the daily dose may be up to 6 tablets (6 mg); the maximum single dose must not exceed 2 tablets per administration; for children aged 6–12 years – ½–1 tablet before breakfast and at bedtime.

or

cetirizine** orally in tablet form [22, 43, 66, 67]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: Cetirizine in tablet form for adults and children aged 6 to 12 years orally 10 mg once daily for 10–20 days; alternatively, for children aged 6 to 12 years, the dose may be divided into two administrations (1/2 tablet morning and evening). Cetirizine** in tablet form is contraindicated under 6 years of age; #cetirizine** in oral drops from 6 months to 1 year – 2.5 mg (5 drops) once daily, from 1 year to 6 years – 2.5 mg twice daily, from 2 to 6 years – 2.5 mg twice daily or 5 mg (10 drops) once, over 6 years – 10 mg (20 drops); in dyshidrotic eczema, it is advisable to use it for 3–4 weeks once daily 20 minutes before bedtime, both during remission and during exacerbations in the spring-autumn period (period of autonomic crises) [115]. once

or

levocetirizine orally [69, 70]

SOR BLoE 3Strength of recommendation B (level of evidence – 3) – for adults

SOR CLoE 5Strength of recommendation C (level of evidence – 5) – for children

Comments: Levocetirizine orally 5 mg once daily for 10–28 days. Contraindications to prescribing levocetirizine include age under 6 years for levocetirizine in tablet form and age under 2 years for levocetirizine in drop form; the dosing regimen in children should follow the manufacturer's instructions.

or

loratadine** orally [43, 66]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: Loratadine** in tablet form: for children aged 2 to 5 mg (1/2 tablet) once daily, for adults and children over 12 years weighing more than 30 kg – 10 mg once daily. Loratadine** in syrup form: for children aged 2 to 12 years weighing less than 30 kg – orally 5 mg once daily, for adults and children weighing more than 30 kg – 10 mg once daily, Loratadine** in tablet and syrup forms is contraindicated under 2 years of age; the dosing regimen in children should follow the manufacturer's instructions.

or

#desloratadine for adults orally 5 mg and #desloratadine for children orally 1–2.5 mg once daily for 10–20 days [43, 66]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: #Desloratadine in tablet form is contraindicated under 12 years of age; #desloratadine in syrup form is contraindicated under 6 months of age.

or

#fexofenadine orally 120–180 mg once daily for 10 days [71–74, 22].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: Contraindications to prescribing #fexofenadine at a dose of 120–180 mg include age under 12 years, and at a dose of 30 mg – age under 6 years.

chloropyramine** solution for injection [22]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: Chloropyramine** solution for injection for children aged 1 month to 1 year, 5 mg (0.25 ml of solution) intramuscularly once daily; for children aged 1 year to 6 years – 10 mg (0.5 ml of solution) intramuscularly once daily; for children aged 6 to 14 years – 10–20 mg (0.5–1 ml of solution) intramuscularly once daily; for children over 14 years and adults – 20–40 mg (1–2 ml of solution) intramuscularly once daily for 5–7 days Chloropyramine** in solution for injection form is contraindicated in newborns.

or

clemastine solution for injection [68]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: Clemastine solution for injection intramuscularly in adults: 2 mg (2 ml) 2 times a day (morning and evening); in children: 0.025 mg per kg of body weight per day intramuscularly, divided into 2 injections for 5–7 days. A contraindication to prescribing clemastine in solution for injection is age under 1 year.

or

hydroxyzine** orally 25 mg 2–4 times a day for 3–4 weeks [71, 75]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: A contraindication for prescribing hydroxyzine** is age under 3 years.

calcium gluconate** 10% solution, 10.0 ml intramuscularly once daily #10–15 daily or every other day [68]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: A contraindication for the intramuscular administration of calcium gluconate** is age under 18 years due to the potential risk of necrosis.

or

#sodium thiosulfate** 30% solution administered intravenously slowly, 5.0–10.0 ml once daily #10–15 daily or every other day [61, 68, 109]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: #Sodium thiosulfate** is used with caution in patients with renal impairment, in elderly patients, and in children under 18 years of age (under 1 year: 0.1 ml per month of life; from 1 to 3 years: 1 ml per year of life) in combination with systemic antihistamines

or

#magnesium sulfate 25% solution, 5–10.0 ml administered intramuscularly #10–15 daily or every other day [68]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: #Magnesium sulfate is contraindicated in severe chronic renal failure, pregnancy, breastfeeding, and in children under 18 years of age.

betamethasone suspension for injection 1.0 ml intramuscularly #1–4 at 10-day intervals [41]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: Betamethasone suspension for injection is contraindicated during breastfeeding and in children under 3 years of age.

or

prednisolone** orally [41]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: in adults, 30–35 mg per day for 5–25 days until a clinical effect is achieved, followed by a taper of 0.5 mg every 3–5 days until complete discontinuation; in children aged 3 years and older, the initial dose is 1–2 mg/kg of body weight per day in 4–6 doses, maintenance dose is 0.3–0.6 mg/kg/day. Prednisolone** is contraindicated during breastfeeding and in children under 3 years of age. In children during their growth period, GCS should be used only for absolute indications and under the exceptionally careful supervision of the attending physician

or

dexamethasone** [22, 75]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: dexamethasone** orally 4–8 mg per day or solution for injection 1–2 ml intramuscularly for 3–7 days. Dexamethasone** is contraindicated during breastfeeding. In children during their growth period, dexamethasone** is used only for absolute indications and under exceptionally careful supervision by the attending physician. The recommended dose of dexamethasone** for children in tablet form (depending on age) is 0.0833–0.3333 mg/kg – 0.0025–0.0001 mg/m² per day in 3–4 doses.

fabomotizole orally in adults 10 mg 3 times a day for 12–15 days [76]

GCR BLEL 3Grade of Recommendation B (Level of Evidence – 3)

Comments: A contraindication for prescribing fabomotizole is age under 18 years.

cefazolin** [75]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: #cefazolin** 1 g intramuscularly 2 times a day for 7–10 days Cefazolin** is contraindicated in infants under 1 month of age and premature infants. In children aged 1 month and older, the dose of the drug is 25–50 mg/kg/day, divided into 3–4 administrations. In severe infections, the daily dose of the drug may be increased to the maximum recommended dose of 100 mg/kg.

or

cefotaxime** [75]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: cefotaxime** 1 g intramuscularly 3 times a day for 7–10 days Cefotaxime** is contraindicated in children under 2.5 years of age. The dose of cefotaxime** in children under 12 years of age is 100–150 mg/kg/day, divided into 2–4 administrations.

or

ceftriaxone** 1 [74, 75]

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

Comments: ceftriaxone** 1–2 g intramuscularly or intravenously once daily for 7–10 days. Ceftriaxone** is contraindicated in premature infants under 41 weeks of gestational age and in full-term newborns up to 28 days of age. Neonates, infants, and children under 12 years of age: in accordance with the instructions.

or

#azithromycin** orally [22, 41, 110, 111]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: #azithromycin** orally in adults and children over 12 years of age with a body weight over 45 kg: 500 mg/day on the 1st day, then 250 mg once daily for 4 days. #Azithromycin** is contraindicated in children aged 0 to 12 years with a body weight of less than 45 kg (for the 500 mg dose), and in children aged 0 to 3 years (for the 125 mg dose). For children, in accordance with the instructions depending on the dosage form.

or

clarithromycin** days [41, 111]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: clarithromycin in adults and children over 12 years of age: 250 mg 2 times a day. In case of more severe infections, the dose is increased to 500 mg 2 times a day. The usual duration of treatment is from 5 to 14 days.

Clarithromycin** is contraindicated in children under 12 years of age and during breastfeeding.

or

#doxycycline** [75]

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

Comments: #doxycycline** orally 200 mg as a single dose, then 100 mg 2 times a day for 7–10 days. #Doxycycline** is contraindicated in children under 8 years of age (due to the risk of tooth discoloration), in pregnant women, and during breastfeeding, in children over 8 years of age in accordance with the instructions depending on the dosage form

or

#levofloxacin** orally in adults 250 mg or 500 mg 1–2 times a day for 5–7 days [74, 75]

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

Comments: #Levofloxacin** is contraindicated in children under 18 years of age, pregnant women, and during breastfeeding.

or

ofloxacin** 200 mg orally in adults 2 times a day for 5–7 days [75]

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

Comments: Ofloxacin** is contraindicated in children under 18 years of age, pregnant women, and during breastfeeding.

or

#ciprofloxacin** in adults 250 mg or 500 mg orally 2 times a day for 5–7 days [75]

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

Comments: #Ciprofloxacin** is contraindicated in children under 18 years of age, pregnant women, and during breastfeeding

retinoids for psoriasis treatment are prescribed in accordance with the instructions for use [77–80, 116].

GCR BLEL 2Grade of Recommendations B (Level of Evidence – 2)

Comments: The drug is taken with meals or milk. Prior to prescribing retinoids for psoriasis treatment and during therapy with retinoids for psoriasis treatment, patient monitoring must be performed. Liver function should be monitored before starting treatment with retinoids for psoriasis treatment, every 1–2 weeks during the first month after starting treatment, and then every 3 months. If test results indicate pathology, monitoring should be performed weekly. If liver function does not normalize or worsens, the drug should be discontinued. In this case, it is advisable to continue monitoring liver function for at least 3 months. Fasting serum cholesterol and triglyceride levels must be monitored.

In patients with diabetes mellitus, retinoids for psoriasis treatment may impair glucose tolerance; therefore, in the early stages of treatment, blood glucose concentrations should be checked more frequently than usual. Due to the potential for impaired night vision, careful monitoring of visual disturbances is necessary. Because of the high teratogenicity of retinoids for psoriasis treatment, a negative pregnancy test result must be obtained 2 weeks prior to starting treatment. During treatment, it is advisable to conduct additional pregnancy tests at least once a month. It is absolutely essential that every woman of childbearing potential uses effective non-stop contraception for 4 weeks before starting treatment, during treatment, and for two years after completing treatment with retinoids for psoriasis treatment. Retinoids for psoriasis treatment must not be prescribed to nursing mothers. In children, retinoids for psoriasis treatment are prescribed only when all other treatment methods are ineffective.

or

ultraviolet skin irradiation [23, 81–83]

GCR ALOE 2Grade of Recommendation A (Level of Evidence – 2)

Comments: Before prescribing ultraviolet skin irradiation (phototherapy), a clinical examination of the patient and a comprehensive laboratory assessment are recommended to rule out contraindications. This includes a complete blood count (CBC), urinalysis, general clinical blood chemistry, and consultations with a general practitioner, endocrinologist, obstetrician-gynecologist (for female patients), and ophthalmologist (if prescribing a method of ultraviolet skin irradiation such as psoralen plus ultraviolet A (PUVA) therapy involving oral photosensitizers). Evaluations by other specialists are performed as indicated. Narrowband UVB phototherapy at 311 nm wavelength can be used in children aged 7 years and older for severe or treatment-resistant forms of the disease. Selective phototherapy (SPT) is used in children from 7 years of age. PUVA therapy is used from 18 years of age. The initial irradiation dose is determined based on individual skin sensitivity by measuring the minimal phototoxic dose before starting PUVA therapy, or the minimal erythemal dose before starting UVB therapy, or without determining minimal phototoxic/erythemal doses based on skin phototype (according to the T.B. Fitzpatrick classification). The degree of sun tan, affected body surface area, and severity of the skin inflammatory response should also be taken into account. Across all phototherapy methods, the primary immediate adverse reactions are erythema and pruritus.

Blisters, hyperpigmentation, or skin dryness are observed less frequently. Long-term multi-course phototherapy leads to dose-dependent symptoms of chronic photoaging of the skin. Lentigines, diffuse hyperpigmentation, and actinic elastosis develop most frequently. Reticular seborrheic keratosis, telangiectasias, and mottled skin pigmentation are less common. Because psoralens can enter the lens of the blood circulation and bind to lens proteins under the influence of UVA, there is a potential risk of cataract development during PUVA therapy. Long-term multi-course PUVA therapy increases the risk of cutaneous squamous cell carcinoma. Factors increasing the carcinogenic risk of PUVA therapy include a total number of sessions exceeding 200; a cumulative UVA dose exceeding 1100 J/cm²; irradiation of male genitalia; a high frequency of sessions over a short period; skin phototypes I and II; prior skin malignancies; ionizing and X-ray radiation therapy; arsenic therapy; and other carcinogenic factors (smoking, sun exposure, treatment with cyclosporine**, methotrexate**, etc.). To reduce itching and skin dryness, patients must use emollients or moisturizers during the treatment course. In cases of persistent pruritus, systemic antihistamines and/or sedatives and hypnotics are prescribed.

If skin hyperpigmentation appears, zinc paste or sunscreen should be applied to the pigmented areas to protect the skin from further irradiation. During phototherapy, the following precautions must be observed: throughout the entire treatment course, patients must avoid sun exposure and protect exposed skin areas with clothing or sunscreen; during phototherapy sessions (and throughout the entire day in the case of PUVA therapy), eyes must be protected with side-shielded protective goggles to prevent keratitis, conjunctivitis and cataracts; during procedures, the lips, auricles, nipples, and areas subject to chronic sun exposure (face, neck, dorsum of the hands) should be protected with clothing or sunscreens if they are free of lesions; the use of other photosensitizing drugs and cosmetics—such as tetracycline, griseofulvin, sulfonamides, thiazides, phenothiazine derivatives, and aromatic oils—should be avoided.

local narrowband UVB phototherapy at 311 nm wavelength, 25 to 30 procedures, 3 times a week [84, 112]

GRB BLEL 2Grade of Recommendation B (Level of Evidence – 2) – for adults

GRB CLEL 5Grade of Recommendation C (Level of Evidence – 5) – for children

Ultraviolet skin irradiation. Phototherapy with oral photosensitizers (PUVA) 4 times a week for a course of 15–20 procedures. Systemic psoralens are taken at a dose of 0.6–0.8 mg per kg of body weight in a single dose, 1.5–2 hours before long-wave UV irradiation. The initial UVA dose is 50–70% of the minimal phototoxic dose. When dosing irradiation based on the patient's skin type and tan level, the initial dose is 0.25–1.0 J/cm2. Procedures are performed 2–4 times a week. In the absence of erythema, the single irradiation dose is increased every 2nd procedure by a maximum of 30%, or by 0.25–1.0 J/cm2. If mild erythema appears, the irradiation dose is kept constant. Maximum single doses of UVA are 15–18 J/cm2 [23, 84, 86–88, 113]

GCR BLEL 3Grade of Recommendation B (Level of Evidence – 3)

phototherapy + systemic retinoids for psoriasis. Administration of systemic retinoids for psoriasis is initiated 7–14 days before starting phototherapy, or less commonly, simultaneously with it. Depending on the patient's individual sensitivity, irradiation is started at a dose of 30–50% of the minimal erythemal dose (MED) or minimal phototoxic dose (MPD). Subsequently, the single dose is increased by 10–30% of the MED or MPD. If mild erythema appears, the irradiation dose is not increased, and in the event of pronounced erythema and skin pain, a treatment break is required [89, 117].

GCR CLoE 3Grade of Recommendation C (Level of Evidence – 3)

Comments: Phototherapy in combination with systemic retinoids for psoriasis produces a synergistic effect. Systemic retinoids for psoriasis are combined with various phototherapy modalities: UVB therapy, ultraviolet skin irradiation, PUVA therapy with oral photosensitizers, and PUVA baths. It should be kept in mind that systemic retinoids for psoriasis can cause increased desquamation and a reduced thickness of the epidermal stratum corneum, which in turn may lead to increased penetration of UV light through altered skin and an increased risk of erythema. Therefore, in the initial phase of combination therapy, single doses of systemic retinoids for psoriasis and UV irradiation should be lower than those used in monotherapy, and the dose escalation regimen should be more cautious to avoid unwanted phototoxic reactions. Before prescribing systemic retinoids for psoriasis to patients receiving UVB or PUVA monotherapy, the irradiation dose should be reduced by 50%. When switching patients receiving high-dose systemic retinoid monotherapy to combination treatment, the daily dose of the drug should be reduced to 10–35 mg/day, and UV irradiation should be started at 50% of the monotherapy dose [86, 89].

3.2 Surgical Treatment

Not applicable.

3.3 Other Treatment

Not applicable.

Pain management is not used.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

After achieving remission, patients with eczema may undergo spa-and-resort treatment [68, 90].

Comments: Eczema is an indication for marine climate therapy. Seaside health resorts include: resorts of the Southern Coast of Crimea, the southern and northern parts of the Black Sea coast of the Caucasus, and the Sea of Azov resorts [92]. Rehabilitation of patients with eczema in a mountain climate (North Caucasus) is also considered effective [92]. A forest climate has a favorable effect on the course of chronic eczema. In the spring and summer periods, increased phytogenesis results in a high concentration of volatile aromatic substances in forest air, which have sedative and bactericidal effects (aerophytotherapy) [92].

5. Prevention and Dispensary Observation

Secondary prevention methods aimed at preventing eczema relapses are used.

avoidance of contact with potential allergens;

limitation of stressful situations and water procedures;

following a diet;

compliance with personal hygiene;

prophylactic use of emollients, corneoprotectors, and neutral cleansers;

clothing should not cause overheating and must not contain wool or synthetic components;

indoor air should be humidified [68].

GCR CLEL 5Neighborhood/local translation nuance: Grade of Recommendations C (Level of Evidence – 5)

6. Organization of Medical Care

Medical care for patients with eczema is provided by dermatovenereologists.

As part of primary health care, district general practitioners, district pediatricians, and general practitioners (family physicians), upon detecting skin rashes, symptoms, or signs of eczema in patients, shall refer the patient to a dermatovenereological medical organization to receive primary specialized health care, and also provide medical care in accordance with the recommendations of the dermatovenereological medical organization when there are no medical indications for referral to it.

If it is impossible to provide medical care within the framework of primary specialized medical care and if there are medical indications, the patient is referred to a medical organization providing specialized medical care.

Specialized medical care for patients with eczema is provided by dermatovenereologists in inpatient settings.

If it is necessary to use physiotherapeutic treatment methods, patients with eczema are referred by a dermatovenereologist from consultative-diagnostic and inpatient departments, including day and 24-hour hospitals, for a consultation with a physical therapy doctor.

Indications for planned hospitalization in a medical organization:

1) Indications for providing medical care in an inpatient setting:

- insufficient effectiveness of treatment performed on an outpatient basis in a patient with localized rashes;

- disease progression with the appearance of new rashes in a patient with localized skin lesions;

- widespread skin lesions.

2) Indications for discharging a patient from a medical organization:

- partial or complete regression of rashes.

7. Additional Information

Comments: Emollients are traditionally used in all types of skin diseases associated with epidermal pathology and barrier dysfunction [50, 52]. Emollients are available in the form of lotions, creams, ointments, cleansers, and bath products. The choice of dosage form is determined by the clinical and morphological form of inflammation [59]. When chronic eczema lesions form (including hand eczema, dyshidrotic eczema, microbial eczema, etc.), the use of skin-moisturizing products is rational. The prescription of emollients as part of combination dermatological treatment primarily helps increase the efficacy of ongoing therapy and shorten the duration of the main treatment course [51, 53, 93]. Maintenance treatment with moisturizing agents significantly extends the time to eczema relapse [49].

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Kubanov Alexey Alekseevich – Academician of the RAS, Doctor of Medical Sciences, Professor, President of the Russian Society of Dermatovenereologists and Cosmetologists, Director of the State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health.

2. Olga G. Artamonova – Candidate of Medical Sciences, Member of the Russian Society of Dermatovenereologists and Cosmetologists.

3. Vorontsova Anastasia Alexandrovna – Member of the Russian Society of Dermatovenereologists and Cosmetologists.

4. Zaslavsky Denis Vladimirovich – Doctor of Medical Sciences, Professor, Member of the Russian Society of Dermatovenereologists and Cosmetologists.

5. Znamenskaya Lyudmila Fedorovna – Doctor of Medical Sciences, Member of the Russian Society of Dermatovenereologists and Cosmetologists.

6. Zubareva Elena Yuryevna – Candidate of Medical Sciences, Member of the Russian Society of Dermatovenereologists and Cosmetologists.

7. Karamova Arfenya Eduardovna – Candidate of Medical Sciences, Associate Professor, Member of the Russian Society of Dermatovenereologists and Cosmetologists.

8. Laseev Denis Ivanovich – Candidate of Medical Sciences, Member of the Russian Society of Dermatovenereologists and Cosmetologists.

9. Monchakovskaya Ekaterina Sergeevna – Member of the Russian Society of Dermatovenereologists and Cosmetologists.

10. Novikov Yury Alexandrovich – Doctor of Medical Sciences, Professor, Member of the Russian Society of Dermatovenereologists and Cosmetologists.

11. Pravdina Olga Valerievna – Candidate of Medical Sciences, Member of the Russian Society of Dermatovenereologists and Cosmetologists.

12. Radul Elena Vladimirovna – Candidate of Medical Sciences, Member of the Russian Society of Dermatovenereologists and Cosmetologists.

13. Hardikova Svetlana Anatolyevna – Doctor of Medical Sciences, Professor, Member of the Russian Society of Dermatovenereologists and Cosmetologists.

14. Chikin Vadim Viktorovich – Doctor of Medical Sciences, Member of the Russian Society of Dermatovenereologists and Cosmetologists.

Conflict of Interest: The authors declare no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Medical specialists: dermatovenereologists.

2. Residents and trainees of continuing professional education courses in the specified specialty.

3. Lecturers at medical educational institutions specializing in Dermatovenereology.

Table 1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Level of Evidence (LoE) grading scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Grade of Recommendation (GoR) scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

These clinical guidelines were developed taking into account the following regulatory legal documents:

1. Procedure for the provision of medical care in the profile «dermatovenereology», approved by Order of the Ministry of Health of the Russian Federation No. 924n dated November 15, 2012.

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Disease recurrence can be prevented by following these recommendations:

1. Protective regimen: avoidance of contact with potential allergens and histamine liberators, reduction of stress, limitation of water procedures, and at least 8 hours of sleep.

2. Timely treatment of focal chronic infections and internal organ pathologies.

3. Balanced diet.

Cooperation between the physician and the patient will eliminate trigger factors and reduce the frequency of relapses.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Special rating scales, indices, and questionnaires are not used during the examination of patients with eczema.