DERMATOLOGY 51
Childhood atopic eczema David Buckley outlines a stepwise approach to managing atopic eczema – from emollients to effective application of topical steroids
much skin is involved and the size of the child. 2,3 It is important to warn parents that paraffin-based emollients can be slippery, especially in the bath or on tiles, and are flammable, especially if they impregnate cotton clothing. If the parent wants to try a non-paraffin-based emollient, pure virgin coconut oil can be tried, which can be inex- pensive in supermarkets’ grocery section. A recent study showed that daily appli- cation of moisturisers during the first 32 weeks of life reduces the risk of atopic eczema by 32% in infants at risk of atopic eczema due to a family history. 3 Eliminating irritants Soaps, shampoo, conditioners, shower gels and bath additives often contain detergents that break down oil, which is the last thing a child with atopic eczema needs as they already have too little oil in their skin. Therefore, it is important to use products that are free from soap, perfume and preservatives. Other irritants that need to be avoided are perfumes, bubble baths, talcs and deodorants. Topical treatments to control the itch Targeted therapies such as topical ster- oids or topical calcineurin inhibitors (TCIs) can be effective at easing itch (see Figure 1) .
Atopic eczema is a common, chronic, hereditary skin condition that affects up to one in five children. 1 It can be associated with other atopic diseases such as asthma, allergic rhinitis or allergic conjunctivitis in the patient or in other family members. The basic underlying problem in atopic eczema is a skin barrier defect resulting in porous skin that allows irritants, allergens and infectious agents to enter the skin, causing inflammation and itch. There is also increased transepidermal water loss leading to dry skin. Atopic eczema causes itchy skin which is sometimes intense and intolerable. If there is little or no itch, then the child probably does not have atopic eczema. The resulting scratching can lead to more skin damage that results in further skin barrier dysfunc- tion. While the majority of children with atopic eczema have mild to moderate dis- ease that clears as they get older, a small percentage of children with atopic eczema (10%) can have severe disease that causes misery for the child and also for parents and extended family. These children may continue to have atopic eczema into adult life. There are no characteristic histologi- cal features or blood tests to confirm the diagnosis of atopic eczema. However, Table 1: Diagnostic criteria for atopic eczema Must have: • An itchy skin condition (or report of scratching or rubbing in a child) plus three of the following: • History of itchiness in skin creases such as folds of the elbows, behind the knees, front of ankles or around neck (or cheeks in children under four years) • History of asthma or hayfever (or history of atopic disease in a first degree relative in children under four years) • General dry skin in the past year • Visible flexural eczema (or eczema affecting the cheeks or forehead and outer limbs in children under four years) • Onset in the first two years of life (not always diagnostic in children under four years)
there are agreed strict criteria to enable an accurate diagnosis to be made (see Table 1). Differential diagnosis of a child with an itchy rash includes scabies, sebor- rhoeic dermatitis, psoriasis, tinea infection, dermatitis herpetiformis, pityriasis rosea, discoid eczema and contact dermatitis. Management of atopic eczema The management of atopic eczema can be divided in to six main areas: emollients, eliminating irritants, topical treatments, dealing with infections, systemic treat- ments and dealing with allergens. Emollients Using emollients is the most effective and cheapest way to restore the defec- tive skin barrier. 2 The best emollient is the greasiest one the patient can toler- ate. Because they remain on the skin for a number of hours, they only need to be applied two or three times per day. Greasy moisturisers should be rubbed downwards (like you stroke a cat) especially on hairy skin, as rubbing them up and down can result in them blocking hair follicles which can cause folliculitis. Emollients are steroid sparing but suf- ficient quantities (eg 500-1,000g/month) should be applied, depending on how
Figure 1: Stepwise approach to atopic eczema
Atopic eczema in children
If clinical infection, give an oral antibiotic and consider Milton baths
At all stages use a greasy moisturiser and avoid soaps and other irritants
Mild Add a week topical steroid to face and body
Moderate Add a week topical steroid to face + moderate topical steroid to body + sedating topical steroid at night
Severe Add short course of
Unresponsive Review the diagnostics, check for compliance, check for infection.** Refer to dermatologist or allergist
potent topical steroids to body*+/– TCI for face and body + sedating and non-sedating antihistamine + consider allergy testing + consider wet wraps
= worse = better *Avoid using potent topical steroid in children < three years old **Infection (eg.staph aureus, herpes,scabies,fungal)
Consider maintenance treatment with twice weekly topical steroid or TCI to ‘at risk’ areas of skin
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