52 DERMATOLOGY
Topical steroids are divided into four main categories: • Mild (1% hydrocortisone ointment for the face) – suitable for children of all ages • Moderate topical steroid (Eumovate) ointment for the body – suitable for chil- dren of all ages • Potent topical steroids – should be avoided in children under the age of three and should only be used for a maximum of two weeks in children with severe atopic eczema aged three to 12 years • Super potent topical steroids – should never be used in children. Ointments are safer than creams as they can act as an emollient and contain fewer preservatives. There is a lot of fear around using topical steroids in children and some parents are steroid phobic. However, when used cor- rectly under medical supervision, topical steroids are extremely safe and effective. It is important to know which strength ster- oid to apply to which part of the body and what is the correct amount to use. Words like ‘use sparingly’ are unclear and unhelp- ful and can be alarming to worried parents. It is far more useful to give a parent a par- ticular size tube of topical steroids and tell them how often to apply it (usually once at night to affected areas), which area of the body to apply it to (face, flexures or the body) and give them some indication as to how long that particular size and strength tube should last (see Table 2) . TCIs include tacrolimus ointment which is as potent as a potent topical steroid but has none of the potential steroid side effects such as skin thinning or suppress- ing of the adrenals. Because it is expensive and slow to work, tacrolimus ointment is usually reserved for the more severe resist- ant cases of atopic eczema. The 0.03% strength may be used in children from the age of two to 16 years. Adults can use the more potent 0.1% strength. It should be applied twice a day to affected areas for up to three weeks and then twice a week to prevent relapse. It can be used on any part of the body including the face, flexures and genitalia. One difficulty with tacroli- mus ointment is it can cause a transient irritation and apparent worsening of the rash in the first week of use in up to 50% of patients. It is impossible to predict who will react. Around 10% of children cannot tolerate tacrolimus ointment, even after the first week of application. Systemic treatments to control the itch If the itch is keeping the child awake at night, a sedating antihistamine, such as
Table 2: Diagnostic criteria for atopic eczema
Potency
Adult
12 years
Three years
Infant < 12 months old
Mild
No max
No max
200g***
100g***
Moderate
200g
100g
60g
30g
Potent*
90g
30g
15g (for acute use only)
Avoid
Very potent Avoid * Adapted from: Position paper on diagnosis and treatment of atopic eczema.EADV (2005)19,286-295 ** Four times this amount can be prescribed if using Betnovate RD *** This is for demonstration purposes only. In practice it would be impractical to use this much mild topical steroid in a child. They probably a need moderate potent topical steroid rather than a large quantity of mildly potent one 30-60g Avoid Avoid
promethazine hydrochloride can be useful to prevent itch and promote sleep. How- ever, it is not licensed for children under two years of age. The new generation, non-sedating oral antihistamines may be helpful for severe atopic eczema and can be given in the morning. Oral steroids are rarely necessary in managing atopic eczema in primary care as topical steroids are safer and more effective in the majority of cases. 4 Dealing with infections Atopic eczema is usually dry and itchy. If it is wet, sticky, weepy or sore, this usually implies that the skin has become infected (see Image 1) . Topical steroids and TCIs do not work if there is infection present. The most common organism to cause clinical infection is Staph aureus, which is usually sensitive to fucidic acid cream and/or flu- cloxacillin or clarithromycin orally. If the child is prone to recurrent skin infections, it might be worth bathing them in a Milton bath (1ml of Milton per litre of water; soak for a maximum of five min- utes and then rinse off with shower head). 5 Children with atopic eczema are also prone to viral infections such as molloscum con- tagiosum and herpes simplex virus. Herpes simplex can present as a fever or worsening eczema and multiple vesicles or punched out small ulcers in one area of the body (eczema herpeticum) . This usually requires hospital admission for systemic anti-viral treatment. Dealing with allergens Allergy testing should only be consid- ered for children with moderate or severe atopic eczema not responding to standard therapies. While many parents may sus- pect food allergies, non-food allergies such as animal dander, pollen and house dust mite might also aggravate atopic eczema. Allergy tests such as skin prick tests, blood tests for IgE and RAST and skin- patch tests may identify underlying offending allergens. However, these tests are difficult to carry out on small children and are not 100% sensitive or specific.
Image 1: Infected atopic eczema (staph aureus)
The most commonly implicated foods that can cause an allergic reaction resulting in atopic eczema in some children include dairy produce, soya, eggs, peanut and wheat. 6,7,8 It is reasonable to try a dairy-free diet in children with severe atopic eczema – the best substitute is an extensively hydro- lysed formula. Hydrolysed formulas are better than soya-based dairy substitutes or goat’s milk as children who are allergic to cow’s milk are often also allergic to soya. Exclusion diets should be limited to six weeks. The restricted food should then be gradually re-introduced. If the itch and rash clear up on stopping the food and recur once the food is re-introduced, this is a reasonably accurate test of food allergy. Eggs, wheat, peanuts or soya can also be eliminated for six weeks if there is sufficient suspicion that the child is allergic to one of these foods. If the child is to be left on a restricted diet, a dietitian should be involved. Children often grow out of food allergies so restriction should be reviewed annually. Severe cases of atopic eczema in chil- dren may need to be referred to a skin or allergy specialist as some may need spe- cific allergen immunotherapy 9 or systemic treatments such as methotrexate, cyclo- sporin or some of the newly developed biological agents. David Buckley is a GP at the Kerry Skin Clinic,Tralee
References available on request.Email nursing@ medmedia.ie (Quote Buckley D.WIN 2019: 27(4):51-52
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