Nummular discoid eczema

Mild: ... Slight but definite erythema (pink), slight but definite induration/papulation, and/or slight but definite lichenification. No oozing or crusting. Disease limited in extent.   

• Advise patient on the avoidance of irritants (e.g. soap). 
• Prescribe generous amounts of emollients; advise frequent and liberal use. 
• Moderate potency topical corticosteroids eg.  betamethasone valerate 0.025% or clobetasone butyrate 0.05% 

Moderate: … Clearly perceptible erythema (dull red), clearly perceptible induration/papulation, and/or clearly perceptible lichenification. Oozing and crusting may be present. Disease fairly widespread in extent. 

• Advise patient on the avoidance of irritants (e.g. soap). 
• Prescribe generous amounts of emollients; advise frequent and liberal use. 
• Potent topical corticosteroids eg. betamethasone valerate 0.1% or mometasone 0.1%. If no improvement, may require the use of clobetasol propionate 0.05% (super potent) daily for up to 2 weeks, then review (trunk and limbs, not face and flexures). 
• Sedating antihistamine at night if sleep disturbed and non-sedating antihistamine for daytime itch if required. 
• Treatment of secondary infection: antibiotic as appropriate according to swab result. 

Severe: … Marked erythema (deep or bright red), marked induration/papulation, and/or marked lichenification. Oozing or crusting may be present. Disease is widespread in extent. 

• Advise patient on the avoidance of irritants (e.g. soap). 
• Prescribe generous amounts of emollients; advise frequent and liberal use. 
• Refer to dermatologist. Commence treatment in primary care whilst waiting for appointment. 
• Super potent topical corticosteroids eg. clobetasol propionate 0.05% daily for up to 2 weeks, then review (trunk and limbs, not face and flexures). 
• Sedating antihistamine at night if sleep disturbed and non-sedating antihistamine for daytime itch if required.. 
• Treatment of secondary infection: antibiotic as appropriate according to swab result. 
• Other treatments may be required, such as phototherapy or oral immunosuppressant drugs. 

Mild: ... Slight but definite erythema (pink), slight but definite induration/papulation, and/or slight but definite lichenification. No oozing or crusting. Disease limited in extent.

Manage in primary care; do not refer.  

Seek advice and guidance where there is diagnostic uncertainty. 

Moderate: … Clearly perceptible erythema (dull red), clearly perceptible induration/papulation, and/or clearly perceptible lichenification. Oozing and crusting may be present. Disease fairly widespread in extent. 

Manage in primary care.  

Refer to secondary care service if multiple treatments in primary care have failed. 

Severe: … Marked erythema (deep or bright red), marked induration/papulation, and/or marked lichenification. Oozing or crusting may be present. Disease is widespread in extent.

Refer to dermatologist if the patient has not responded to optimum topical therapy (including super potent topical corticosteroids). Could be offered a video consultation. 

https://cks.nice.org.uk/topics/eczema-atopic/ 

https://cks.nice.org.uk/topics/fungal-skin-infection-body-groin/diagnosis/differential-diagnosis/ 

PCDS guidance – discoid/nummular eczema: http://www.pcds.org.uk/clinical-guidance/eczema-discoid-syn.-nummular-eczema  

• Initially, these plaques are often swollen, and ooze fluid. The appearance can be confused with secondary infection. 
• Antibiotics are rarely indicated for discoid eczema.  
• Plaques tend to be very itchy, particularly at night. 
• Over time, the plaques may become dry, crusty, cracked and flaky. The centre of the plaque also sometimes clears, leaving a ring of discoloured skin that can be mistaken for ringworm. Tinea would be suggested by asymmetrical distribution and can be confirmed with skin scrapings for mycology. Tinea corporis is not commonly seen in adults. 
• Discoid eczema usually requires at least potent topical corticosteroids. 
• On lighter skin, plaques will be pink or red. On darker skin, plaques can be dark brown or paler than the skin around them. Discolouration can persist for months after the condition has cleared. 
• Differs from psoriasis in that plaques tend to be a lighter red, the border fades gradually at the periphery and the presence of exudate / crust as opposed to scale. 

1. Discoid eczema – BAD Patient info leaflet
2. Patient.info leaflet – Discoid eczema 
3. NHS Choices – Discoid eczema- https://www.nhs.uk/conditions/discoid-eczema/  

Inflammatory 

ICD11 code - EA82