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Eczema

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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 (except in severe cases). Most children with eczema will experience flares, sometimes as often as three to four times per month. (NICE Guidelines 2007).

Jean Robinson at DFTB19

A filaggrin deficiency is a primary cause of eczema leading to ‘leaky skin’. A break in the filaggrin barrier means moisture can leave the skin, and irritants can penetrate. Think Lego bricks, tightly packed all in a row. That’s how the 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 and one without. I’ve seen families in the clinic with sets of twins (identical) – one has eczema, and one does not.

We know that eczema can have an allergic driver behind it. Allergies do not cause eczema, but exposure to allergens can exacerbate flares. Food and inhalant allergies can aggravate eczema. In infants, eggs, cow milk and peanuts are directly linked to eczema exacerbations (Cantani 1999).

Although most will grow out of eczema by the time they are about seven years old, 30% of children with eczema will go on 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 can scratch vigorously. They are more mobile, and their eczematous patches can dry and thicken (lichenified) from scratching. Often, you’ll see lichenification at the ankles where they vigorously 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 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.

For example, in hot climates, like a Queensland summer, eczema exacerbations can be seen where children typically sweat. Waistbands 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). Schoolwork may suffer. They report feeling self-conscious about appearance and restricted in what they can wear. They may suffer bullying at school and sometimes have difficulty forming relationships when they are older. School camps and trips away can be problematic, and spending time away from those usually helping with treatment can cause anxiety for the child and carers.

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

Eczema can and does affect the quality of life. I’ve known many children who cannot have the same experiences as their peers. Starting preschool/daycare 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 miss swimming carnivals due to exacerbations and sensitivity to chlorine. Even basic things like wearing the school uniform (rarely pure cotton) can worsen eczema. 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 lifelong 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.

Managing eczema

Steroid creams

There are four different strengths:

Mild: 1% hydrocortisone (Fucidin H: Fucidin & Hydrocortisone)

Moderate: Eumovate (clobetasone butyrate 0.05%) is the strongest you should use on the face, and Betnovate RD (reduced dilution 0.025%). These can be used for those over one year (if repeated courses are needed despite eczema not improving, then the patient should be referred to dermatology)

Potent: Betamethasone 0.1%, Fucibet (Fucidin and betamethasone) –  microbial resistance is high in the UK, so only use for 14 days),  Elocon (mometasone furoate). These are the strongest for the body. They can be used for short-term treatment, i.e. one to two weeks, but you probably need a dermatology opinion if there is no response to the initial course.

Super-potent: Dermovate (clobetasol propionate), Clobaderm. These are dermatology-recommended only.

Corticosteroid 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 inflamed areas (except for 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. Generally, if a good steroid is used twice daily for two weeks and eczema hasn’t cleared, something else is happening. Either the diagnosis of eczema is incorrect or, more commonly, there is an underlying infection.

This new advice is controversial. The fear of steroids is ingrained in 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 corticosteroids should be the cornerstone of eczema management, and liberal application should be advised once to twice per day. 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 (pimecrolimus), 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 from steroids because they are immunosuppressants that directly target T-cells. Steroids are anti-inflammatory and anti-pruritic. Elidel can sometimes sting, so mixing it with a small amount of emollient may be helpful.

How do you choose a steroid cream?

Start with hydrocortisone on the face. If the eczema is severe, you can use a moderately potent steroid (e.g. Eumovate) on the face and potent on the body. Still, often, this should be discussed with dermatology and should undoubtedly be discussed if it does not improve after two weeks. However, be more cautious in babies – from four months of age, and you can use Eumovate (moderately potent) on the body.

Do not use potent steroids without specialist advice.

Only apply the steroids to active eczema. Use the steroids for seven days; you can stop if it has completely cleared with no inflammation. For small, persistent parts, more prolonged steroid use may be necessary, e.g., for 14 days, 28 days, or 33 days.

Chronic relapse is very common, and people struggle for a long time with too weak steroids. Often, it is better to try short doses of stronger steroids. Moderate or potent steroids for short periods can only be used in the axillae and groin – they can be complex with skin folds to get to the active area. Generally, do not use potent steroids in children (e.g. Betnovate) without specialist advice. You can go up to potent/moderately potent on the scalp.

Ensure you show people how to use the steroids, i.e. consider it the same as checking the inhaler technique.

How do you apply steroid creams?

As a rough guide – one finger-tip unit (i.e. squeezed over an adult finger) should cover two adult palm-sized areas.

It is much easier to say, ‘Apply enough, so it looks shiny. ‘ Make all the applications with a finger, not with the hand. Otherwise, the majority will be absorbed before it reaches the child.

Make sure steroids are applied to inflamed areas, including open areas. But don’t apply it on surgical wounds or ulcers.

Skin thinning is rarely an issue (we hardly see skin thinning from topical steroid use, but we see loads of undertreated children), so avoid saying, ‘Apply a thin layer. ‘

Start with a pea-sized lump.

Apply to all active areas, including lichenified and hyperpigmented areas.

Leave the healthy bits.

In papular areas, anything thickened is inflamed and needs treatment with steroids.

Apply steroids twice a day in general, but there is a move to use them once a day (Mometasone is once a day)

Emollients

Maintenance of the skin barrier 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. Generally, creams with no added plant or food substances should be recommended. 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 ensuring 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 babies with severe eczema, we apply emollients at least three times per day and often with each nappy change.

Use the greasiest the family are happy to use. If the child has very sore skin, then 50/50 is the greasiest.

With paraffin, beware of smoking and open fires.

Lotions are acceptable but not as greasy, so they should be used only if the family finds a greasy emollient too difficult.

The rough estimate is using one pot every two weeks (250g-500g) and using it four times a day if it’s bad enough for hospital presentation. Otherwise, they can step it down to twice a day.

Pump dispensers are cleaner, but you cannot use emollients in a pump dispenser. From a tub, use a clean spoon at home, ideally with a saucer. Apply the emollient in the direction of the hair so that it does not upset the hair and potentially lead to folliculitis. After a bath, the skin is very moist, so there is better absorption.

Put the steroid on first, wait for 20-30 minutes, and then put the emollient on top.

Keep going with emollients even when the eczema is clear. If the child is still scratching, use emollients.

Wet dressings

Wet wrapping is hugely effective. Tubifast or crepe bandages, soaked in lukewarm 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 a water bottle if needed, but if used overnight, we advise leaving it in place if the child is sleeping. Wet dressings applied after steroids and emollients are the most effective strategy if there is a flare. Wet dressings can also be applied to just xerosis (without an active flare) without steroids to aid moisturisation. Cool compresses can be applied to the face and other areas that are not easily wrapped.

Wet wrapping is a technique used to help moisturise skin and improve the efficacy of steroids. It is also used to cool down hot, inflamed skin and reduce the 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 before application. It’s also fairly soft and tolerated well.

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

Fill a bowl with lukewarm water and add emollients (QV/Dermeeze oil or a product like Epaderm designed to be used in water).

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, giving some coverage.

Soak for 10 minutes.

Apply steroids to the sore, red skin and emollients everywhere else.

Wring out the Tubifast and apply it 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 the child wakes.

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

We wrap at least three times per day and overnight for severe eczema. We only use topical steroids for two of these wraps; emollients are used between times.

Wet dressing can be intensive, and parents and children may need time off school and work. Consider obtaining 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 it is infected, so it’s important to recognise when the 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’; those patients tend to be ‘on fire’ with widespread erythema.

For mild infections that are not widespread, topical mupirocin (Bactroban) may be used initially. Take a swab before commencing treatment to ensure the correct sensitivities. Keflex or Bactrim are first-line treatments if systemic treatment is needed. A 10-14-day course may be needed, and we often use a low dose of Bactrim as a prophylaxis post-treating active infection if the skin has been chronically infected—this gives the skin a chance to heal and recover.

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 a 150-litre bath with 175 ml of White King bleach. An emollient must be used in the bath simultaneously, 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, condyze crystals are another alternative. Like treating impetigo, eradication therapy for the whole family should also be recommended. Bactroban to the nares and chlorhexidine washes twice daily for 14 days is the standard advice.

We used to advise bathing for 15 minutes daily in lukewarm water with added oil.

The recent publication of the BATHE trial has turned this advice on its head. The Southampton-based trial randomised 483 children with atopic dermatitis to either have an emollient added to the bath for 12 months or no emollient added to the tub for 12 months. The outcomes were eczema control and eczema severity. The BATHE trial showed no benefit in adding emollients to the bath.

However, there is an ongoing debate amongst dermatologists as to whether this study applies to those being treated by specialist dermatology teams.

  1. The BATHE trial was conducted on patients being managed in primary care.
  2. No benefit was shown in the group who bathed four times or less per week; however, a clinically meaningful benefit was demonstrated when looking at those who washed more frequently (although it was small).

So, for now, our hospital-based dermatology team at my hospital in London still recommends emollients in bath oils.

For bath oil, use Oilatum Junior or Hydromol. Use one capful for one baby bath. If a regular bath is used, use two to three capfuls and ensure it is mixed well.

Oilatum Plus has antiseptic and can cause bad dermatitis if not mixed in water well. Many centres do not recommend this version anymore.

When washing with water – use a soap-free cleanser, as the water on its own will dry out the skin. The most infected use Dermol 500 as a soap substitute, which can be used on the face. Consider applying this after washing hands at the nursery (this can be hard to do at school).

These are all prescribable: we should encourage GPs and us to prescribe it so that parents do not have to buy it (to improve compliance)

Reactions to aqueous cream in children are so common that it should only be used as a soap substitute, not as a leave-on emollient.

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

Can we cure eczema?

Atopic eczema affects 15-20% of children. There is no cure, so treatment aims to control rather than cure eczema. The aim is to get it under control. With topical therapies, 80% will improve by puberty/teenage years. Remits and relapses will occur, and children and families require education and support.

50% will resolve by age 7, but be careful with the figures you share with parents, as they may be disappointed when it does not improve. 85% of eczema sufferers have mild eczema, and most start with symptoms after one year.

Bad disease is usually due to poor management from the practitioner or being on the proper treatment but having poor compliance.

Poor adherence is the number one reason for a flare. There are often many psychological issues: embarrassment, bullying, and confusion around treatment. Well-meaning relatives/friends can give contradictory advice and suggest alternative therapies.

Families will present with a mixture of frustration, stress, and reduced quality of life and are often miserable, with sleep disturbance. Eczema needs to be taken seriously and managed well. There is a similar reduction in quality of life to families of other chronic disease patients – partly due to sleep disturbance but also because it is a very visible disease.

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 with
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 is useful and aids 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 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

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

NICE Clinical Guidelines(2007) ‘Atopic Eczema in Children’ National Collaborating Centre for Women’s and Children’s Health

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

Royal Childrens, Melbourne (2007) ‘Paediatric Eczema Nurse Practitioner Clinical Practice Guidelines’

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

Authors

  • 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!).

  • Tessa Davis is a Consultant in Paediatric Emergency Medicine at the Royal London Hospital and a Senior Lecturer at Queen Mary University of London.

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1 thought on “Eczema”

  1. Thank you for this really concise run through of a common paediatric problem- lots of tips to give to parents. More articles like this, please!

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