| ||||||||||||||||||||||||||||||||||||||||||||||||||
Childhood atopic eczema
Executive Editor, InnovAiT
E-mail: chantal.simon{at}oxfordjournals.org
 |
Abstract |
|---|
TOP
Abstract
The GP curriculum and...The term eczema comes from the Greek meaning ‘to boil over’. Atopic eczema affects 15–20% of schoolchildren. It usually starts under the age of 6 months and by 1 year of age, 60% of those likely to develop eczema will have done so. It is an important condition as it has considerable impact on the quality of life of affected children. Atopic eczema is associated with other atopic conditions such as asthma and hay fever. In young children, atopic eczema may be associated with food allergy. Remission occurs by 15 years of age in 75% (Fig. 1), although some children develop worsening symptoms in their teenage years and others relapse later in adulthood.
Eczema is listed as a common and important condition forming part of the knowledge base of curriculum statement 15.10: Skin problems. GPs in training should be able to:
|
|
Presentation of atopic eczema |
|---|
Diagnosis of atopic eczema is usually clinical. It is a waxing and waning itchy condition of the skin. The pattern of eczema varies according to the age of the child.
Presentation in infants
Infants under the age of 18 months usually present with an itchy, vesicular, exudative eczema on the face and/or hands, often with secondary infection (Fig. 2). There may be sleep disturbance due to itching. More than half of those affected by infantile eczema are symptom free by the age of 18 months.
|
|
Presentation in children over 18 months of age
Eczema tends to involve the antecubital and popliteal fossae, neck wrists and ankles in children over the age of 18 months (Fig. 3). Lichenification, excoriation and dry skin are common. The face may be erythematous and have typical infraorbital folds (Morgan's folds; Fig. 4). The child may have lost self-esteem or be affected by behaviour and/or sleep problems. In Asian, black Caribbean and black African children, atopic eczema can affect the extensor surfaces rather than the flexures and discoid (circular) or follicular (around hair follicles) patterns may be more common.
|
|
|
Criteria for diagnosis |
|---|
A diagnosis of atopic eczema can be made if the child has itchy skin PLUS at least three of the following features:
- History of itching around the skin creases (elbows, knees and wrists) or neck (or cheeks if the child is under 4 years of age). For a young child, a report of scratching or rubbing in these areas is sufficient.
- Visible flexural eczema (or eczema affecting cheeks, forehead and/or outer limbs in children under the age of 18 months)
- History of asthma or hay fever (for children under 18 months, a history of asthma or hay fever in a first-degree relative is sufficient)
- Generally dry skin
- Onset in the first 2 years of life (this criterion does not apply to children under 4 years of age).
|
Differential diagnosis |
|---|
Consider other itchy skin conditions such as ringworm and scabies. Psoriasis may also be confused with eczema. Rare conditions such as dermatitis herpetiformis (associated with coeliac disease) may also present with eczema-like symptoms and eczema may be a component of other rare syndromes such as Wiskott–Aldrich syndrome (a genetic immune deficiency syndrome characterized by recurrent infection, bleeding tendency and eczema).
|
Assessment in primary care |
|---|
Ask:
- Is there a personal or family history of atopy or eczema? Two-thirds of children with a new diagnosis of eczema have a family history.
- How did the symptoms start?
- What areas of the body are affected? Look and see, assessing extent and severity (Box 1). Exudate or crusting suggests secondary bacterial infection.
- Does anything make the eczema worse or better? Consider irritants such as bubble bath or soap, inhaled allergens, contact allergens, food allergens and stress.
- Do the symptoms interfere with quality of life (Box 2)? Ask specifically about sleep disturbance and interference with school or home life. Validated quality of life measures, such as the Children's dermatology life quality index (Box 3), may be helpful.
- What has the child tried before? Ask about specialist referral, prescribed medication (both for eczema and other conditions), over-the-counter medications, complementary therapies and special diets.
- What does the child and family understand about eczema and what are their expectations of treatment?
Box 1. Assessing severity of eczema
|
This box is based on information from the NICE guidance on atopic eczema in children.
Box 2. Impact of eczema on quality of life
|
Box 3. CHILDREN'S DERMATOLOGY LIFE QUALITY INDEX
|
This box is based on information from the NICE guidance on atopic eczema in children.
|
Management of eczema |
|---|
Acknowledge the child's and parents’ concerns. Explain the condition and generally good prognosis (Box 4). Provide verbal and printed information for the family to take home including information on the stepped approach to care and management of flare-ups.
Box 4. Information for parents about treatment of eczema
Further information and support for children and parents: National Eczema Society, Tel. 0870 241 3604, website: www.eczema.org.uk
|
Give advice about avoiding excessive heat (warm but not hot baths) and biological washing powders. Advise loose cotton clothing and avoidance of wool as this can exacerbate eczema. Gloves worn in bed may reduce night-time scratching. Keeping the child's nails short minimizes damage due to scratching. If a specific irritant is identified (for example, house dust mite or pets), then avoidance of that trigger can be helpful.
Few (less than 10%) benefit from dietary manipulation. Egg and milk are the most common allergens. NICE recommends a 6- to 8-week trial of an extensively hydrolyzed protein formula or amino acid formula, in place of cow's milk formula, for bottle-fed infants aged under 6 months with moderate or severe atopic eczema that has not been controlled by optimal treatment with emollients and mild topical corticosteroids.
Advise dietician supervision to avoid malnutrition for any child on an exclusion diet or cow's milk-free diet for more than 6 weeks.
Emollients
Emollients are useful to soothe, smooth and hydrate the skin. Apply in the direction of hair growth. Effects are short lived, so advise frequent application (3–4 times daily) even after improvement occurs. Ensure sufficient emollient is supplied (Table 1). Suitable first-line agents are aqueous cream or white soft paraffin. Severity of the condition, patient preference and site of application guide choice of emollient and it may be necessary to try several emollients to find the one that suits. Some ingredients of emollients rarely cause sensitization of the skin. Preparations such as aqueous cream and emulsifying ointment can be used as soap substitutes for hand wash and in the bath. Addition of an emollient bath oil, such as Oilatum or Balneum, may also be helpful. Addition of an antipruritic substance (for example, lauromacrogol) to the emollient may help break the scratch–itch cycle. Consider addition of an antiseptic to bath emollient if infection is present or a frequent complication.
|
Steroids
Topical steroids alongside emollients are the mainstays in eczema treatment. Prescribe the least potent strength that is effective (for example, start with hydrocortisone 1%; Table 2). Apply once daily to affected areas only depending on severity and response. Emphasize steroid creams are for short-term intermittent use and to avoid application near the eyes. Ointments are preferable on dry, scaly eczema and creams on wet, exudative eczema. Emollients reduce steroid requirement. Step up the potency of steroid cream during exacerbations. Doctors’ and parents’ fears about side effects of topical steroid treatment can lead to chronic under treatment—a short course of a more potent steroid may be necessary to gain control. Step down and/or stop application of steroids 48 hours after symptoms improve.
|
There is rarely any need for use of oral steroids in the treatment of childhood eczema. Reserve their use for rescue therapy for severe eczema while waiting for an urgent consultant opinion. Only use short courses, for example, prednisolone 10–30 mg daily for 5 days.
Antibiotics
Antibiotics are effective in the treatment of infected eczema. They can be prescribed as topical preparations, either alone (for example, fusidic acid cream) or in combination with a steroid (Table 2). Oral preparations, such as flucloxacillin or erythromycin for a week, are useful for more severe or widespread infections. Take a swab if antibiotic treatment is not effective. Prescribe new supplies of topical medication after treatment of infected eczema as products in containers may become contaminated.
Bandages and wet wrapping
Bandaging can be useful for treatment of excoriated or lichenified eczema. Parents should be taught to apply bandages by specially trained individuals. Refer via dermatology departments. Suitable bandages include ones impregnated with ichthammol (Icthband) or zinc and calamine (Calaband). Bandages can be applied at night on top of steroid ointment. Wet wrapping can be used for exudative eczema. A tubigrip bandage (or tubular gauze) soaked in emollient is applied to the affected area and covered with a dry bandage. Refer to dermatology for supervision.
Other treatments
Topical immunosuppressants such as tacrolimus can be a useful adjunct in children with unresponsive moderate or severe eczema. Prescribe only under the direction of a consultant or GP with special interest. Sedative antihistamines, such as chlorphenamine given at night, reduce the desire to itch and may help sleep.
|
Complications of eczema |
|---|
Skin infection can be a problem for children with atopic eczema. Secondary bacterial infection, usually with Staphylococcus aureus, commonly causes exacerbations of eczema. It is suggested by presence of crusting or weeping. Suspect infection if there is a sudden deterioration of eczema even without obvious features of infection.
Children with atopic eczema also have an increased susceptibility to viral skin infections, such as viral warts and molluscum contagiosum. Children with eczema may also develop eczema herpeticum. The child develops widespread, severe lesions as a result of herpes simplex or Varicella zoster (chickenpox) infection and may require emergency admission for intravenous aciclovir. Consider prescribing oral aciclovir in the community if a child with eczema develops a localized lesion suspected to be herpes simplex.
Although skin thickening and scaling is common among children with eczema, rarely older children and young adults with very severe eczema may develop cataracts as a result of their eczema. Younger children with very severe eczema may suffer from growth restriction. Keep a growth chart for all children with chronic severe eczema.
|
Referral to secondary care |
|---|
Box 5 lists indications and urgency of referral to secondary care services.
Box 5. Indications for secondary care referral of children with atopic eczema
E, Emergency admission; U, Urgent; S, Soon; R, Routine
|
Key points
|
|
References |
|---|
-
Barnetson RS, Rogers M. Childhood atopic eczema. British Medical Journal (2002) 324:1376–79. Accessed via www.bmj.com/cgi/content/full/324/7350/1376 [date last accessed 29.05.2008].
British Association of Dermatologists/Primary Care dermatology Society. Guidelines for the management of atopic eczema (2005) Accessed via www.bad.org.uk/healthcare/guidelines/PCDSBAD-Eczema.pdf [date last accessed 29.05.2008].
Lewis-Jones MS, Finlay AY. The Children's dermatology life quality index (CDLQI): initial validation and practical use. British Journal of Dermatology (1995) 132:942–949. Accessed via www.dermatology.org.uk/index.asp?portal/quality/cdlqi.html [date last accessed 29.05.2008].[Web of Science][Medline]
NICE. Atopic eczema in children (2007) Accessed via www.nice.org.uk/nicemedia/pdf/CG057FullGuideline.pdf [date last accessed 29.05.2008].
RCGP. Curriculum statement 15.10: Skin problems. Accessed via www.rcgp-curriculum.org.uk/pdf/curr_15_10_Skin_problems.pdf [date last accessed 29.05.2008].
Santer M, Lewis-Jones MS, Fahey T. Childhood eczema. British Medical Journal (2005) 331:497. bmj.bmjjournals.com/cgi/content/full/331/7515/497 [date last accessed 29.05.2008].
Van Dorp F, Simon C. Oxford GP Library: Child health (2007) Oxford: Oxford University Press. ISBN: 0199215685.
Williams HC. Established corticosteroid creams should be applied only once daily in patients with atopic eczema. British Medical Journal (2007) 334:1272.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||