Jean Robinson is paediatric dermatology nurse specialist working at the Royal London Hospital. Her area of expertise is something we could all be a bit better managing – eczema. She might be one of the few people that can actually describe a rash in twenty words or less. She also knows more than just steroids and wet dressings.
This talk was recorded live at DFTB19 in London, England. With the theme of “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.
This post is based on teaching by Jean Robinson, Clinical Nurse Specialist in Paediatric Dermatology at the Royal London Hospital; and notes by Joe Piper.
The broad principles are of eczema are:
Emollients are to put moisture into the skin
Steroids are to reduce inflammation
Note: a skin flare up is always itchy – if it’s not, then question the diagnosis.
Can we cure it?
Atopic eczema is seen in 15-20% of children. There is no cure, and so treatment aims to control rather than cure the eczema. The aim is to get it under control. 80% will improve by puberty/teenage years with topical treatments. There will be remits and relapses, 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 of age.
Bad disease is usually due to poor management from the practitioner, or being on the right treatment but having poor compliance.
Poor adherence is the number one reason for a flare. There are often lots of psychological issues: embarrassment; bullying; confusion around treatment. Well-meaning relatives/friends can give contradictory advice and suggests alternative therapies.
Families will present with a mixture of frustration, stress, 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 a because it is a very visible disease.
Management principle 1 – Bathing
Bathing was previously advised 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 emollient added to the bath for 12 months or no emollient added to the bath for 12 months. Outcomes were eczema control and eczema severity. The BATHE trial showed no benefit in adding emollients to the bath.
However, there is ongoing debate amongst dermatologists as to whether this study is applicable to those being treated by specialist dermatology teams.
The BATHE trial was conducted in patients being managed in primary care.
No benefit was shown in the group who bathe 4 times or less per week; however, when looking at those who bathed more frequently, a clinically meaningful benefit was demonstraed (although it was small).
So for now, our hospital-based dermatology team at my own 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 normal bath is being used, then use two to three capfuls and make sure it is mixed in well.
Oilatum Plus has antiseptic in it, and hence can cause bad dermatitis if not mixed in water well. Many centres do not recommend this version any more.
When washing with water – use a soap-free cleanser when washing as the water on its own will dry out the skin. The most infected use Dermol 500 as a soap substitute, and it can be used on the face. Consider applying this after washing hands, at 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, and not as a leave-on emollient.
Moderate: Eumovate (clobetasone butyrate 0.05%) – this is the strongest you should use on the face, Betnovate RD (reduced dilution 0.025%). These can be used for those over one year (if repeated courses are needed despite the eczema not improving then the patient should be refered to dermatology)
Potent: Betamethasone 0.1%, Fucibet (fucidin & 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.
Know the generic names as well as the brand names and check the percentage.
Hydrocortisone cream vs ointment – ointment is oilier and better.
The cream has more water and more additives. Only give the cream if the patient doesn’t like ointments.
Note: If very very infected and ointment will slide off, then cream has better application, but this is very rare, even within dermatology (<2%).
How do you apply steroids?
As a rough guide – one finger tip unit (i.e. squeezed over adult finger) should be enough to cover two adult palm-sized areas.
It is much easier to say ‘apply enough so it looks shiny’. Do all the application 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 ever see skin thinning from topical steroid use, but we see loads of under treated children) – so avoid saying ‘apply a thin layer’.
The advice should be:
Start with pea-sized lump
Apply to all of the active area, including lichenified areas, hyperpigmented areas
Leave the healthy bits
For papular areas – anything that is thickened is inflamed and needs treating 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)
Which steroids to choose?
Start with hydrocortisone on the face. If the eczema is severe, you can go up to a moderately potent steroid (e.g. Eumovate) on the face and potent on the body, but often this should be discussed with dermatology, and should certainly be discussed if it is not improving after two weeks. However, be more cautious in babies – from four months of age, 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, and you can stop if it has completely cleared with no inflammation. There may be a need for longer steroid use e.g. for 14 days, 28 days, or 33 days for small, persistent parts.
Chronic relapse is very common and people struggle on for long time with too weak steroids. Often it is better to then try short dose of stronger steroids. Moderate or potent steroids for short periods only can be used in the axillae and groin – it can be difficult with skin folds to get to the active area. Generally, do not use potent steroid in children (e.g. Betnovate) without specialist advice. You can go up to potent/moderately potent on scalp.
Make sure you show people how to use the steroids i.e. consider it the same as checking inhaler technique.
Management principle 3 – Emollients
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 should be used only if the family are finding a greasy emollient too difficult.
The rough estimate is using one pot every two weeks (250g-500g), and use 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 hairs, so that it does not upset hairs and potentially lead to folliculitis. After a bath, the skin is very moist and so there is better absorption.
Put the steroid on first and then 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.
If you want to dive a little deeper then read these previous posts…
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.
Loss of the outer aspect of the eyebrow, Allergic pleats and shiners and peri-oral pallor
What is it like living with eczema?
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.
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
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
Cradle cap (infantile seborrhoeic dermatitis) is a self-limiting greasy, scaly rash of unknown cause that most commonly affects the scalps of babies. Overactive sebaceous glands, maternal hormones and skin yeasts have been suggested as possible causes.