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Atopic eczema in children: current best management

Carolyn Charman
BM BCh MRCP
Specialist Registrar in Dermatology
Queen's Medical Centre
University Hospital
Nottingham
E:carolyn.­charman@­nottingham.ac.uk

Atopic eczema (or atopic dermatitis) is the most common inflammatory skin disease among children, affecting around 15% of UK schoolchildren. Approximately 70% develop the disease in the first 5 years of life, and 60-70% of patients will be clear of the condition by early adolescence. Nurses in both primary and secondary care are playing an increasingly ­important role in atopic eczema management, which is likely to expand over the next few years if the prevalence of the disease continues to increase (see Table 1).

[[NIP15_table1_37]]

Diagnosis
Atopic eczema is diagnosed by clinical features and is characterised by itchy, red, inflamed skin, often affecting the skin creases (see Figure 1). Simple diagnostic criteria for use in primary care are illustrated in Table 2.(3)

[[NIP15_fig1_37]]

[[NIP15_table2_37]]
 
Educating parents and children
Atopic eczema often runs a chronic course, and patients need to be actively involved in management from the start. Primary care management includes providing basic information about the aetiology of the disease and educating families on how to treat the disease safely and effectively in the long term. It is ­important to recognise the psychological and social implications of the disease (see Table 3) and to provide appropriate support for both children and their families. Written information about aetiology and treatment can be extremely valuable (see Resources).

[[NIP15_table3_38]]

Aetiology: why has my child developed eczema?
Although parents often want a simple explanation for why their child has developed the condition, atopic eczema is a complex disease with many contributing and interacting factors. Genetic factors are certainly important, although no single gene has been universally implicated. However, atopic eczema is much more common in industrialised countries, and current research is focusing on the role of environmental factors associated with "Western" lifestyles, which may trigger eczema in genetically predisposed individuals (eg, decreased exposure to infections, increased exposure to pollution, exposure to more varied diets and changes in the home environment). Although manipulation of these individual factors may help some patients, there is currently no "cure" for the disease, and management revolves around symptom control.

Management
Simple lifestyle advice includes:

  • Avoidance of irritants (eg, soaps and detergents).
  • Regular use of emollients.
  • Avoidance of overheating (eg, keeping the ­bedroom cool at night).
  • Avoidance of rough clothing (eg, wool and some synthetic fibres).
  • Keeping nails short to reduce damage from scratching.
  • Avoidance of known allergens.
  • Recognition of bacterial or viral superinfection.

Emollients
Emollients (or moisturisers) should be applied regularly, even during remission periods, to keep the skin hydrated. Application immediately after bathing is ideal, with regular use throughout the day as required. Emollients should be applied in the direction of hair growth, preferably allowing at least 30 minutes before applying other treatments such as topical steroids. Ointments (eg, liquid and white soft paraffin, Epaderm(®) [SSL], and emulsifying ointment) are greasier and more moisturising, although lighter creams (eg, aqueous cream, Diprobase(®) [Schering Plough], Cetraben(®)[Sankyo]) are often preferred on the face.

Topical corticosteroids
Although emollients are beneficial, they will not improve active atopic eczema sufficiently if used alone. Topical corticosteroids have formed the mainstay of atopic eczema treatment for over 40 years, and are extremely safe if used appropriately. Side-effects, such as skin thinning, can be minimised by using the lowest potency needed to control the disease and applying treatment intermittently. Although GPs have traditionally been reluctant to use potent topical steroids in children, a recent 18-week trial in children (aged 1-15 years) showed that the potent corticosteroid 0.1% betamethasone valerate (Betnovate(®); GlaxoSmithKline), applied twice daily for 3-day bursts, was as safe as the weak corticosteroid 1% hydrocortisone applied twice daily for 7-day bursts, with both treatments being equally effective.(4) Guidelines on the safe use of topical steroids in primary care have been published recently,(5) and evidence for their safe use from therapeutic trials has been summarised in a recent editorial.(6)

Bandaging
Wet wrap bandaging with Tubifast(®) (SSL) applied over emollients or mild-to-moderately potent topical steroids can be helpful for short bursts at night. Wet wrapping enhances topical steroid absorption, so prolonged application or use over potent topical steroids should be supervised by a dermatologist. Readymade Tubifast garments are now available to simplify wet wrapping and improve patient compliance. Paste bandages containing zinc and ichthammol (eg, Ichthopaste(®); Smith & Nephew) can be useful over topical steroids to treat lichenified eczema of the limbs.

Other treatments
Antihistamines may have a useful sedative effect if used at night, but there is no good evidence that they improve the itch associated with atopic eczema. Topical steroid/antibiotic combinations (such as Fucidin H(®) and Fucibet(®); Leo) are sometimes prescribed, although evidence that they are superior to topical steroids alone is lacking, and they should not be used for longer than 2 weeks to prevent bacterial resistance developing. Avoidance of house dust mite is difficult and time-consuming, and although regular vacuuming is sensible there is currently insufficient evidence to recommend routine use of more ­aggressive measures such as antihouse-dust-mite sprays, removal of carpets and use of bedding covers in all patients. Evening primrose oil/gamma-linolenic acid is of no proven benefit in atopic eczema.(7)

What's new in atopic eczema management?

Pimecrolimus 1% 
Pimecrolimus 1% (Elidel(®); Novartis) is a steroid-free immunosuppressant cream that became available on prescription in the UK in October 2002. It is licensed for twice-daily use in mild-to-moderate atopic eczema in children (>2 years) and adults, and has also been promoted for the prevention of flare-ups.(8) As it contains no steroid, it is not associated with skin atrophy and can be applied to the whole body, including the face and flexures, until the eczema clears. Transient skin irritation is common, but long-term side-effects such as photocarcinogenicity are unknown. Elidel should not be used in the context of recurrent herpes simplex infection. It is less effective than 0.1% betamethasone valerate but costs more than 12 times as much. Although the majority of patients with mild atopic eczema can be managed safely and more cost-effectively with mild-to-moderately potent topical steroids, Elidel can be particularly useful for body sites at greater risk of steroid atrophy, such as the face, and in those with poor compliance to topical steroids.(2)

Tacrolimus 0.1% and 0.03%
Tacrolimus 0.1% and 0.03% (Protopic(®); Fujisawa) is a steroid-free immunosuppressant ointment with a similar chemical structure to Elidel. It became available on prescription in the UK in April 2002 for children (>2 years, 0.03%) and adults (0.1%) with moderate-to-severe atopic eczema unresponsive to conventional therapies.(9) The 0.1% ointment is as effective as potent topical steroids, but side-effects and cost are similar to Elidel. It is therefore currently recommended as a secondary care therapy to be initiated by dermatologists.

When to refer to a dermatologist
Table 4 lists the occasions when referral to secondary care is necessary. See also the NICE Referral Guidelines (see Resources).

[[NIP15_table4_39]]

Conclusions
Most children with atopic eczema can be managed effectively in primary care with emollients and topical steroids, although the new topical immunomodulators (Elidel and Protopic) are likely to play an increasing role in future management. The ultimate research goal is to identify factors that can be manipulated prenatally or in early infancy to prevent atopic eczema development; until then good management can significantly improve the quality of life of affected children. 

References

  1. Emerson RM, Williams HC, Allen BR. Severity ­distribution of atopic dermatitis in the community and its relationship to secondary referral.Br J Dermatol 1998;139:73-6.
  2. Charman C, Morris AD, Williams HC. Topical corticosteroid phobia in patients with atopic dermatitis. Br J Dermatol 2000;142:931-6.
  3. Williams HC, Burney PG, Hay RJ, et al. The UK Working Party's diagnostic criteria for atopic dermatitis.Br J Dermatol 1994;131:383-416.
  4. Thomas KS, Armstrong S, Avery A, et al. Randomised controlled trial of short bursts of a potent topical ­corticosteroid versus prolonged use of a mild ­preparation for children with mild or moderate atopic eczema. BMJ 2002;324:768-71.
  5. Anon. Topical steroids for atopic dermatitis in primary care.Drug Ther Bull 2003;41(1):5-8.
  6. Lock S. Topical corticosteroids in atopic dermatitis. BMJ 2003;327:942-3.
  7. Williams HC. Evening primrose oil for atopic dermatitis. BMJ 2003;327:1358-9.
  8. Anon. Pimecrolimus cream for atopic dermatitis. Drug Ther Bull 2003;41(5):33-6.
  9. Anon. Topical tacrolimus - a role in atopic dermatitis? Drug Ther Bull 2002;40(10):73-5.

Resources for healthcare professionals
British Association of Dermatologists
W:www.bad.org.uk
Website contains Guidelines for the management of atopic eczema, produced by BAD and Primary Care Dermatology Society (links: Doctors_Service Provision_Primary Care), and over 15 patient ­information sheets covering aetiology and management (links: Patients_Skin Disease Information_Atopic Eczema)
National Eczema Society Professional W:www.eczemapro.org Membership £20 per year - allows online access to community nurses handbook, ­guidance notes on topical steroids and emollients for GPs, and a variety of patient ­information leaflets
Drugs & Therapeutics Bulletin
W:www.dtb.org.uk/dtb/index.html Useful "Treatment Notes" for patients on steroid ­treatments for eczema
National Institute for Clinical Excellence (NICE)
W:www.nice.org.uk

Resources for patients
British Association of Dermatologists
W:www.bad.org.uk
Patient ­information sheets - useful ­information sheets covering aetiology and management National Eczema Society 
W:www.eczema.org

Further ­reading
Ellis C, Luger T. International Consensus Conference on Atopic Dermatitis II. Br J Dermatol 2003;148 Suppl 63:1-10.
Barnetson RS, Rogers M. Childhood atopic eczema. BMJ 2002;324:1376-9.