Eczema - Children Flashcards
Classification of eczema (endogenous vs exogenous)
Atopic, seborrhoea, discoid, pompholyx, varicose
Vs
Allergic, irritant, photosensitive
Always … sparing in infant eczema
Always perioral sparing in infant eczema due to drooling/moist area, also nappy area
Atopic eczema/dermatitis
Starts in infancy
80% + mild
Commonest in children (1 in 5 in UK)
‘Atopic march’ - The progression from eczema to later developing food allergies, allergic rhinitis and asthma is called the allergic march. The allergic march is also called the atopic march.
Diagnostic criteria for eczema
Itching + 3 or more of:
visible flexural dermatitis involving the skin creases, such as the bends of the elbows or behind the knees (or visible dermatitis on the cheeks and/or extensor areas in children aged 18 months or under)
© NICE 2022. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and- Page 13 conditions#notice-of-rights). Last updated 2 March 2021 of 36
1.1
Atopic eczema in under 12s: diagnosis and management (CG57)
• personal history of flexural dermatitis (or dermatitis on the cheeks and/or extensor areas in children aged 18 months or under)
• personal history of dry skin in the last 12 months
• personal history of asthma or allergic rhinitis (or history of atopic disease in a first-degree relative of children aged under 4 years)
• onset of signs and symptoms under the age of 2 years (this criterion should not be used in children aged under 4 years).
Clinical features of eczema in children
Dry skin - Reflects impaired skin barrier function
Episodic pattern with periodic flares + remissions
Sleep disturbance caused by itching - marked impairment of QOL for child and family
Pathogenesis of atopic eczema
Deficiency of filaggrin - chromosome 1q21
Overproduction of serum IgE
Genes regulating inflammation and production of inflammatory cytokines, alteration in T-cell TH1:TH2 - hygiene hypothesis
Chromosomal loci implicated in atopic eczema - 1q21, 3q21, 13q14, 11q13,5q
What is filaggrin?
Formed in keratohyalin granules is necessary for maturation of corneal layer and production of natural moisterising factors
Thenar eminence - look for hyperlinea - can link to eczema
History + exam for eczema
Time of onset, pattern, severity
Response to previous and current treatment
Possible trigger factors
The impact of the atopic eczema on children and their parents or carers
Dietary history including any dietary manipulation
Growth and development
Personal and family history of atopic disease
Filaggrin details
Filaggrin, when broken down on the skin surface, also goes on to produce so-called ‘natural moisturizing factor’ which also helps to keep the skin hydrated and act as a barrier. Filaggrin breakdown products also inhibit the growth of micro-organisms such as Staphylococcus aureus, a common organism found on the skin of eczema patients.
What is the ‘atopic march’?
This is where atopic eczema is found to precede the development of food allergies, hayfever and asthma in chronological order.
Investigations in eczema
Usually none
Skin swab for bacteriology/virology if infection suspected
Allergy testing
Food allergy - 30% of children with moderate to severe eczema
Suspect if reaction/GI problems, FTT
Ix - RAST, SPT, food challenge
Mx - 6 week trial of hydrolysed milk
Airborne allergy
Pollens, house dust mite, pet dander, moulds
Usually >2yr
Exposed sites
Cow milk allergy
Usually improves by 1 year of age
Extensively hydrolysed formula is recommended as first choice for infants under 6 months of age for treating immediate cows milk allergy (non-anaphylactic), food protein-induced enterocolitis syndrome, atopic eczema, gastrointestinal symptoms and food protein-induced proctocolitis.
Starting any baby on hydrolysed formula, why do dieticians need to get involved?
To stop later life milk allergy developing - if avoided for too long can lead to anaphylaxis when introduced later in life
Management of eczema in children
Establish diagnosis, severity, and extent of disease
Check growth parameters
Determine any possible trigger factors + treat accordingly
Spent time with parents to explain eczema and management - it is aimed at controlling and although no cure symptoms usually improve with age
Good education is vital - veraal and written and clear written treatment plan
Community nurses
Websites - national eczema society
Psychological support and school support
General measures for treating atopic eczema
Keep cool - fan in bedroom
Avoid soap and detergents - wash with emollients
Reduce allergens as far as possible
Use emollients
Keep nails short
Use cotton clothes and bed sheets
Synthetic duvet and pillows
Protective glove and bandages
Keep animals out of the bedroom
Use non-biological washing powder and avoid fabric conditioner
Avoid dusty environmental like attacks or house renovation
Avoid playing in long grass or walking amongst trees during pollen season
Stepped approach to managing eczema
Mild - emollient and mild potency topical corticosteroid
Moderation - can step this up
Severe - can further step up corticosteroid
First-line treatment for eczema
Emollients, topical corticosteroids, oral antihistamines
Second-line treatment for eczema
Consider bandages/ skinnies
Emollients
Medical moisturises used to treat eczema. Unperfumed and no “anti-aging” additives
Safe and effective to use - a will help to reduce flares
Apply in direction of hair, like ‘icing on cake’ - so it isnt rubbed in too much, remains on surface of skin
Several times over the day
Leave on emollients - lotion, cream, ointment
Lotion - more water + less fat, preservatives, not effective for dry skin, used for hairy and weeping skin
Creams - mixture of fat and water, preservatives, easy to spread over sore and weepy skin, preferred by many people
Ointments - stiff and greasy, very less preservative, useful for very dry skin
Can use bath and shower oil
Topical corticosteroids in eczema
Use for actively inflamed itchy skin
Can thin the skin though
Benefits of it outweigh the risks when applied correctly
Only be applied to areas of active atopic eczema
Do not use TCS on face and neck, under 12months without specialist input
Potencies of topical corticosteroids
4 different potencies:
Mild - hydrocortisone 1%/2.5%
Moderate - Emma ate
Potent - betamethasone, mometasone
Super potent - dermovate
TCS guidance in eczem
Ensure condition being treated is not complicated by infection - can make it worse
Creams are more likely to produce contact irritation
Sometimes 6 week regime is needed
In inflamed area of eczema only
Oral antihistamines in eczema?
Not for routine use
Non sedating can be used
Calcinerium inhibitors
Acts by inhibiting inflammatory cytokine transcription in activated T cells
Licensed for 2 years and above in atopic dermatitis, quantities similar to TCS, all sites eg face and neck, twice daily, advise on sun protection
Protopics
Can cause acne, skin sensitive, infection, stinging, soreness
Wet wraps and skinnies
Not to be used to treat infected eczema
To be used with emollients for chronic localised lichenified area
Outcome is soothing, sleep and breakage of scratch cycle
- During eczema flare-ups with severe itch or pain, wet wrap therapy can work wonders to rehydrate and calm the skin and help topical medications work better.
Phototherapy for eczema
Specialist treatment
Bacterial infection + Eczema
Give flucloxacillin - staph and strep
Weeping, pustule, crust, failing to respond to therapy, rapidly worsening atopic eczema, fever and malaise
Ezcema vs impetigo
Impetigo - honey coloured!
Symmetric, punched out, 3mm lesions, vesicular on eczema skin…
Suspect herpes - very serious, children can be unwell very quickly
Aciclovir treatment - IV usually then to oral and fluclox in case of staph
Viral herpes on skin
Signs of eczema herpeticum are:
Areas of rapidly worsening, painful eczema
Clustered blisters consistent with early stage cold sore
Punched out erosion, (circular, depressed, ulcerated) usually 1-3mm unform in appearance
If involves eyes - ophthalmology input needed and IV
Discoid eczema
Infantile seborrheic dermatitis
ISD is an eryhtematosquamous skin disease of early infancy
Begins in first month of life and clears by 4-6months
Thick adherent yellow or whitish, greasy skin
May use vegetable oil to treat
Frequent nappy changes
Ketoconazole shampoo on scalp
Pompholyx
Aetiology unknown - warm weather, atrophy, expression of allergy to nickel
Mostly pubertal age
Few days to weeks, subside spontaneously
Treatment - avoid contact with nickel, topical steroids - medium or high potency, zinc oxide, oral antihistamines
Allergic contact dermatitis
Well demarcated area
Patch testing
Treat - identify culprit and avoid, steroids, emollient
