Eczema management

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In part 1 we considered the difficulties of being a patient with eczema, in this part we look at management. Knowing what we do – how can we manage patients with eczema?

Skin barrier

Skin barrier maintenance is vital. A good emollient used twice per day should be recommended even in the absence of a current flare. Creams and emollients should be low in pH. As a general rule creams with no added plant or food substances should be recommend as these children may be sensitive to ingredients or become sensitive to them. The idea is to apply so there is a ‘shine’ on the skin. Applying too thickly can cause sweating and may irritate the child. Compliance with emollients is hugely important and making sure the child can tolerate emollients is vital for compliance. If a thick emollient is difficult to tolerate, a thinner cream can be applied and then an emollient to the problem areas. I recommend thick emollients overnight at a minimum and for the babies with severe eczema we apply emollients at least three times per day and often with each nappy change.

Steroid creams

Corticosteriod creams are vital in the treatment of exacerbations. A class three steroid, like Advantan or Elocon (both have very good safety data) should be applied once to twice daily for as long as needed to the areas that are inflamed (with the exception of peri-oral or peri-orbital regions). Applying liberally and no longer sparingly is now the advice and we no longer use a week on, week off approach. As a general rule, if a good steroid is used twice a day for two weeks and the eczema hasn’t cleared, then something else is going on. Either the diagnosis of eczema is incorrect or, more commonly, there is underlying infection.

This new advice is controversial. The fear of steroids is ingrained into parents, clinicians and pharmacists alike. So much so that leading expert paediatric dermatologists in Australia released a consensus paper in 2015. The advice is that the use of corticosteroids should be the cornerstone of eczema management and liberal application once to twice per day should be advised. There is little evidence of long term adverse effects of corticosteroid use in children with eczema where topical steroids are used when the eczema is flared and ceased when the eczema is not.

A non steroidal inhibitor of inflammatory cytokines, such as Elidel (pimecromlimus) can be safely used around the peri-oral and peri-orbital regions (Sigurgeirsson et al 2015) and has good long term safety data in children. They work differently to steroids in as much as they are an immunosuppressant that directly target the T-cells. Steroids are anti-inflammatory and anti-puritic. Of note, Elidel can sometimes sting, and so mixing it with a small amount of emollient may be helpful.

Wet dressings

Wet wrapping is hugely effective. Tubifast or crepe bandages, soaked in luke warm water with emollients, can be applied to dry exacerbated areas. Covering with a dry bandage can protect bed sheets and clothing. Usually remove once dry, or respray with water bottle if needed, but if used overnight, we advise to leave in place if the child is sleeping. Wet dressings applied after steroids and emollients is the most effective strategy if there is a flare. Wet dressings can also be applied to just xerosis (in the absence of an active flare) without steroids to aid moisturisation. Cool compresses can be applied to the face and other areas not easily wrapped.

Wet wrapping is a technique used to help aid the moisturisation of skin and improve the efficacy of steroids. It is also used to cool down hot inflamed skin and aid with the reduction of damage that scratching does to eczematous skin.

Families can either use crepe bandages or tubifast. I use tubifast because it’s easy to apply and can be cut to size prior to application. It’s also fairly soft and tolerated well.

There are a number of techniques/products used, but the one I find most useful and user friendly is as follows:

  • Fill a bowl with luke warm water and add emollients (either QV/Dermeeze oil or a product like Epaderm which is designed to be used in water too).
  • Cut the tubifast to size. Use a tight fitting singlet or t-shirt for the torso. Socks can be used for the feet. Gloves can be used for the hands but if not tolerated a thumb hole can be cut in the tubifast used for the arms and this will give some coverage for hands.
  • Soak for 10 minutes.
  • Apply steroids to the sore, red skin and emollients to everywhere else.
  • Wring it out the tubifast and apply damp to the skin. Place a dry dressing over the top.
  • Leave in place until dry then remove. If needed a spray bottle can be used to re-dampen the dressings. If using overnight remove if child wakes.

Wet dressings should be used for no more than 14 days in a row. If used longer than this, then the skin can become macerated. If skin is infected, then treat the infection prior to commencing wet dressings.

For severe eczema we wrap at least three times per day and overnight too. Obviously we only use the topical steroids for two of these wraps, emollients are used in between times.

Wet dressing can be intensive and parents and children may need time off school and work. Consider the need for a medical certificate to ensure compliance.

During this intensive period families will need extra support from expert clinicians.

Infection

Treatment of infection is vital. Oral antibiotics and topical antibiotics may be needed in active infection. The most challenging eczema we usually deal with is when the eczema is infected so it’s really important to recognise when skin is infected and use the appropriate treatment. Infected eczema is often crusting and weepy. Skin can be broken and children may complain of pain. Infected eczema can also look like ‘scalded skin’ and those patients tend to be ‘on fire’ with widespread erythema.

For mild infections that is not widespread, topical muprocin (bactroban) may be used initially. Take a swab prior to commencing treatment to ensure the correct sensitivities. Kelfex or Bactrim are first line treatments if a systemic treatment is needed. A 10-14 day course may be needed and on occasions we use a low dose Bactrim as a prophylaxis post treating active infection if the skin has been chronically infected – this gives the skin chance to heal and re-cover.

Bleach baths

To reduce the burden of a staph infection, twice weekly bleach bathing can help to reduce the staph load for the child. We recommend 150 litres bath with 175 mls of White King bleach. An emollient must be used in the bath at the same time and children should rinse off afterwards. A diluted version can be used for smaller children. However, if bleach baths are recommended then written information should be given to families to reduce the risk of error with dilution. If parents are reluctant to use bleach, then condyze crystals are another alternative. Similar to the treatment of impetigo, eradication therapy for the whole family should also be recommended. Bactroban to the nares and chlorhexidine washes twice a day for 14 days is the standard advice.

Other options for treating eczema can be considered such as antihistamines for itch, oral steroids and even stronger immunosuppressants. Children with severe eczema should be referred to a dermatologist, allergist or paediatrician for specialist support. I see children in my eczema clinic who actually see all of these specialists to help manage their 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!).

Author: Andrea Coe

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!).