Eczema – an itchy problem

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Eczema is a chronic inflammatory skin condition. In most cases it develops in early childhood. It is typified by dry itchy skin and is episodic in nature (except in severe cases). Most children with eczema will experience flares, sometimes as often as three- four times per month. (NICE Guidelines 2007). In today’s part we will look at an overview of eczema and it’s potential impact on patients who suffer from it. Tomorrow we will focus on management strategies.

A filigrin deficiency is thought to be a main cause of eczema leading to a ‘leaky skin’. A break in the filigrin barrier means moisture can leave the skin and irritants can penetrate. Think ‘lego bricks’,tightly packed all in a row. That’s how skin should be but eczematous skin has a break in those lego bricks leading to dry skin and flares.

There is little understanding as to why children get eczema. We know genetics plays a huge part. According to Cantani (1999) a child with two parents that have eczema will have a 50-70% likelihood of developing eczema, with one parent around 35 % and then if neither parents have eczema, the chance of spontaneous development is around 5-10 %. For example, in my family, I have eczema and my father has eczema. I have two children, one with eczema, one without. I’ve seen families in the clinic with sets of twins (identical) – one has eczema, one does not.

We know that eczema can have an allergic driver behind it. Allergies do not cause the eczema but exposure to allergens can exacerbate flares. Food and inhalant allergies can exacerbate eczema. In infants eggs, cows milk and peanuts have a direct link to eczema exacerbations (Cantani 1999).

Although most will grow out of eczema by the time they are about 7 years old, 30% of children with eczema will go onto to have some form of eczema as an adult.

 

What does eczema look like?

Eczema in children can look different for different age groups. In infants it often begins on the cheeks and can become widely distributed across the abdomen and limbs. It’s typically dry and scaly with erythematous patches. Toddlers are able to scratch vigorously. They are more mobile and their eczematous patches can become dry and thickened (lichenified) from scratching. Often you’ll see lichenification at the ankles where they vigously rub their feet together or on a carpet. Babies and young children may also develop peri-oral eczema associated with drooling often due to teething or self feeding. Peri-orbital eczema can also be an issue and is associated with sore, itchy eyes – children tend to rub the eyes exacerbating the issue. As children become older the eczema tends to develop a flexural pattern.

In hot climates, like a Queensland summer for example, eczema exacerbations can be seen where children typically sweat. Waist bands of shorts or nappies, folds of chubby necks and in the creases of thighs or groin area.

 

What is it like living with eczema?

Irritating!

Kids with eczema scratch. They have disturbed sleep (and so does everyone else). School work may suffer. They report feeling self conscious about appearance and being restricted in what they can wear. They may suffer bullying at school and sometimes have difficulty forming relationships when older. School camps and trips away can be problematic and spending time away from those usually helping with treatment can cause anxiety for both child and carers.

Carers report worrying about their children’s future and how they’ll manage living alone. There is concern over treatment and still a huge steroid phobia (Zuberbier et al 2005).

Eczema can and does affect quality of life. I’ve known many children unable to have the same experiences as their peers. Starting pre-school/day care can be difficult. Carpet time can cause exacerbations, especially if a child has a dust mite allergy. Playing in the sandpit irritates. Being out in the sun and sweating hurts. Children may have to miss swimming carnivals due to exacerbations and a sensitivity to chlorine. Even basic things like wearing the school uniform (which is rarely pure cotton) can make eczema worse. I have known some families who have had special school uniforms made for their children and I have written many care plans for the schools as children attend for the first time. Parental anxiety at these times is often high.

Eczema has no cure. It can be a life long disease that often causes great distress for families and children. Treatment can often be time consuming and constant but with good support and consistent treatment, children can be successfully supported through flares and gain an improved quality of life. It’s never ‘just’ eczema.

Bottom line:

  • Recognising that it’s not ‘just’ eczema is important – eczema is difficult to live with and families may be in crisis
  • Eczema is a chronic condition that can have acute flares-ups requiring families to seek help out of hours or when they can’t see their specialist
  • Severe eczema is painful and infection is common
  • Children and families may need to be admitted to a children’s ward to help manage their eczema and provide support
  • A written eczema management plan has been shown to be useful and aid compliance and treatment understanding. We readily give out asthma management plans but not so often eczema plans. Good, easy to use plans, can be found on the Royal Children’s Melbourne Website for those departments that do not have their own.
  • Emollients and topical corticosteroids are the cornerstone of eczema management

 

References

  • Cantani A 1999 ‘ The growing genetic links and the early onset of atopic diseases in children stress the unique role of the atopic march:a meta-analysis ‘Invest Allergol Clin Immunol 9:314-320
  • NICE Clinical Guidelines(2007) ‘Atopic Eczema in Children’ National Collaborating Centre for Women’s and Children’s health
  • Mooney,E. Rademaker,M. Dailey,R Daniel,B,S. Drummond,C Fischer,G. Foster,R Grills,C.Halbert,A . Hill,S King,E. Leins,E Morgan,V. Phillips,R,J. Relic,J .Rodrigues,M.Scardamaglia,L. Smith,S. Su,J. Wargon,O and OrchardD(2015) ‘Adverse effects of topical corticosteroids in paediatric eczema: Australasian consensus statement’ Australasian Journal of Dermatology doi: 10.1111/ajd.12313 accessed 17/01/2016
  • Royal Childrens, Melbourne (2007) ‘Paediatric Eczema Nurse Practitioner Clinical Practice Guidelines’
  • Rork,J,F.Sheehan,W,J.Gaffin,J,M.Timmons,K,G.Sidbury,R.Schiender,L,C.Phipatanakul,W.(2012) ‘Parental Response to Written Eczema Action Plans in Children With Eczema’ Arch Dermatol.148(3):391-392
  • Sigurgeirsson,B.Boznanski,A.Todd,G.Vertruyen,A.Schuttelaar,M.Zhu,X,Schauer,U.Qaqundah,P.Poulin,Y.Kristjansson,S.Von Burg,A. Nieto,A. Boguniewicz,M. Paller,A. Dakovic,R. Ring,J and Luger,T (2015) ‘Safety and Efficacy of Pimecromlimus in Atopic Dermatitis : A 5 year Randomised Trial.’ Paediatrics doi: 10.1542/peds.2014-1990 accessed 30/08/2015
  • Zuberbier,T. Orlow,S,J.Paller,A,S.Taieb,A.Allen,R.Hernanz-Hermosa,Jose.Ocampo-Candiani,J.Cox,M.Langeraar,J.Simon,J,C.(2006) ‘Patient perspectives on the management of atopic dermatitis ’The Journal Of Allergy and Clinical Immunology Vol 118,issue1 pp 226-232
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About 

Andrea Coe is a Paediatric Nurse Practitioner specialising in Allergies and particularly children with eczema. She has an extensive paediatric background spanning 20 years after training in the UK as Children's Nurse. She now works in a Specialist Allergy Clinic in Brisbane working with families with eczema and supporting those with a new diagnosis of allergy with potential anaphylaxis (among other things!).