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How to treat atopic eczema in children

Jean Robinson
RSCN BSc MA
Clinical Nurse Specialist Paediatric Dermatology
Barts and The London NHS Trust

Atopic eczema or dermatitis is a chronic pruritic or itchy inflammation of the epidermis and dermis with a strong genetic aetiological component. It is often associated with the other atopic conditions of asthma, rhinitis and seasonal allergies. In all of these conditions the body's immune system overreacts to common things in the environment, such as pollen, foods, animal fur and house dust mites, which would not normally cause harm. It affects all ethnic groups with variable worldwide incidence, but has increased over the last 30 years in the UK for reasons that are unclear and now affects up to a fifth of school children.(1)
The main types of eczema seen in children are atopic and seborrhoeic. Less common are irritant eczema, contact eczema and pompholyx eczema of the hands and feet.
Atopic eczema usually starts in the first year of life (often on the face) before spreading to the limbs. It is not curable, but it should be possible to control with appropriate treatment in most cases. It is a chronic condition characterised by periods of flare-up and remission. Up to 90% of children with early onset eczema will grow out of it by adult years. In severe cases it is a "family disorder" because it can disrupt the lives of all family members. Nurses have a very important role in providing information and support, and demonstrating the correct use of treatments.(2)

Pathophysiology
Atopic eczema affects the dermis and epidermis with inflammation as the main feature. It may be helpful to use the anomaly of a brick wall to understand this better.(1) The outer layer of the epidermis is like a strong brick wall that retains moisture in the skin and keeps harmful substances out. Intracellular lipids hold the cells or bricks together. Healthy skin cells are plump with water and fit tightly together, forming a strong barrier. In eczema this mortar is not formed properly, which allows the cells to dry out and leaves gaps in the wall. This allows harmful substances such as allergens and irritants through to cause further damage and possible infection. Although itch is a major symptom it is not currently understood why.(3) The constant scratching in eczema causes the epidermis to regenerate more quickly and thicken. Therefore treatment needs to try to re-establish skin barrier function.

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Diagnosis
Atopic eczema is diagnosed by its appearance and symptoms. Children with atopic eczema will often have a high level of IgE but this is not a diagnostic blood test, as some children will have normal levels. Atopic eczema is diagnosed in children with an itchy rash and three or more of the following symptoms:(4)

  • lThe itchy rash is present in skin creases, such as the folds of the elbows, behind the knees, in front of the ankles or around the neck (or the cheeks in children less than four years old).
  • A history of asthma or hay fever in the child or in an immediate relative in children under four years.
  • Generally dry skin in the past year.
  • Visible eczema in the skin creases (or eczema affecting the cheeks, forehead, or outer part of the arms or legs in children less than four years old).
  • Onset of the itchy rash in the first two years of life.

Note there are different patterns of eczema in different racial groups.(3) In Black African and Black Caribbean and Asian children eczema sometimes shows a reverse pattern, affecting the extensor surfaces rather than the flexures. The eczema is also more likely to produce:

  • Thickening of the skin or lichenification.
  • Papular or follicular eczema.
  • Pigmentary changes with hyperpigmentation and post-inflammatory pigmentation when the eczema has settled down.

Treatment
There is no single correct treatment for eczema as many different approaches may produce the same outcome and what works for one child may not work for another. The most important aspect relies on the application of creams and ointments. Treatment will be needed for as long as the eczema lasts.
Therapy combines:

  • Bath oils and soap substitutes for cleansing.
  • Regular and liberal use of moisturisers or emollients.
  • Intermittent use of the least potent topical steroids possible.

It is vital that health professionals work in partnership with parents and carers as management is not curative, but aims to achieve control of the symptoms. It is also vital that children, parents and carers receive clear explanations of how to apply treatments, how frequently, and in what quantities, with input from an interpreter or health advocate if necessary.(5)

Bathing
Bathing and the use of emollients is the mainstay of any skincare regime. Bathing is useful for cleansing the skin and removing old treatments and scale and any crusting. It will also help to rehydrate the skin. Bathing daily is therefore recommended and may be best done in the evening before the child's bedtime. Showering does not immerse the child so is of less benefit. Bath water should be warm rather than hot as hot water will irritate skin. Irritant bubble baths and soaps should be avoided. A medicated oil must be added to the water to prevent the skin from drying out. The child should also be washed with a soap substitute such as aqueous cream. This can be used on children's faces as well as their bodies. The child should stay in the bath for 15-20 minutes. The oil will make the bath (and the child!) slippery so a bath mat may be needed and the child will need close supervision. If bathing a baby, it may be helpful for two adults to be present.
Bathing practices vary and some families may rinse the child with fresh water after bathing which will rinse away the oil. Rinsing with water with added medicated oil should be advised in these circumstances. After bathing the child should be patted rather than rubbed dry.

Moisturisers/emollients
Emollients come in a variety of forms, eg, creams, lotions and ointments, and work by providing a surface lipid film, preventing water evaporation from the epidermis. The emollient for each child should reflect their individual needs and may also be decided by child and family preference as some will not like using greasy ointments. Remember one moisturiser does not work for all. In practice very few families use sufficient moisturiser. Black-skinned and Asian children tend to have drier skin and will therefore need greasier treatments. In general the more occlusive the product, the better it will seal in moisture. Lotions are the least effective as they often contain more water, alcohol, preservatives and fragrance.
Moisturisers should be applied as often as necessary to prevent the child's skin from drying out as dry skin will become itchy. Most children need to have it applied at least twice daily, but many will require applications four to five times daily (this will include during the day at school) and at night if they are awake and scratching. Small babies or children may need to use 250g of moisturiser per week. Moisturiser should be applied in a thin layer in the direction of hair growth to avoid the possibility of folliculitis, particular in older children, and allowed to soak in. It does not need to be rubbed in. All the skin should be treated, not just the eczematous areas (see Table 1).

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Note
Aqueous cream was originally designed as a wash product rather than as a leave-on moisturiser. A recent study showed that 50% of children prescribed it as a moisturiser developed stinging, itching, redness and burning.(6)

Topical steroids
Topical steroids or synthetic glucocorticoids have formed the mainstay of treatment for children with eczema for 50 years. They help to reduce inflammation by damping down the abnormal reactions occurring in eczema, control symptoms, such as itch, and improve the child's and family's life. Unfortunately there is a great deal of misinformation about steroids and many people and health professionals are very anxious about using them, so much so that there is a significant underuse of this very valuable therapy. Without a doubt when used properly they are extremely safe and the side-effects of atrophy or skin thinning, telangiectasia, local hair growth and striae are extremely rare.(1,3)
There are different strengths of steroid which vary hugely. Weaker strengths must be used on the face and neck (see Table 2).

[[nip33_table2_53]]

Use of topical steroids

  • Never use instead of moisturisers - use as well.
  • Use as secondline interventions after moisturisers and to control flare-ups.
  • Steroids should be applied to all areas of active eczema, ie, any reddened, thickened or excoriated or raw areas. Information in the packaging advises against the application to open areas, but this means to cuts and grazes rather than the open areas, which are part of the eczematous process.
  • Use only on eczematous areas and use lowest potency possible.
  • Do not use more than twice daily - some more modern steroids are designed for once daily use.
  • Apply sparingly, eg, "enough to make the skin look shiny".
  • Use ointment formulations rather than creams as they are greasier; the exception is very wet or weepy eczema where creams should be used.
  • Apply steroid 20-30 minutes after applying moisturiser to prevent dilution of steroid effect. For this reason mixtures of steroid and moisturiser are not recommended.
  • Parents and carers should wear gloves when applying steroids or wash their hands after doing so.

Diet
There is controversy about the effect of what children eat on their eczema. Many parents look to diet as a potential treatment for their child's eczema as a relatively easy thing to change, but the situation is not so simple. Eczema can be triggered or made worse by many things, such as house dust mite, grasses and pollens, temperature changes, stress and eating certain foods. It is thought that in about 30% of children food may be a trigger but only 10% will have food as their only trigger.(7)
Food allergies are more common in children with eczema and are usually immediate-type allergies. The most common foods to cause allergy are cows' milk, eggs, nuts, fish, soya and wheat. Food is most likely to be an important factor in causing eczema in only a small number of children under three years of age. Allergy tests are not always good at predicting whether diet is causing or exacerbating eczema. Often the best way is to eliminate a certain food for six to eight weeks. This usually requires dietetic supervision in children. This means that only a small number of children will be helped by changes in diet and even those who are will still need to maintain a good skincare routine.

Bandaging
The use of bandages may be helpful, but should not be used without ongoing support and education from health professionals trained in their use.

Wet wraps
These involve the use of a double layer of tubular cotton dressing or a premade garment over a topical steroid or moisturiser. The bottom layer is soaked in warm water and then wrung out before application. Wet wraps take time to apply and help to keep the skin moisturised for longer while soothing the skin and increasing absorption of the products. They are not firstline treatments and are suitable for short-term use. They should not be used on infected eczema.

Occlusive paste bandages
These are messy and time-consuming to apply, but are helpful for treating lichenified eczema. Impregnated paste bandages are applied in a pleating fashion to the limbs only over topical steroid and a second layer of adhesive bandage is applied to keep the lower layer in place. This is not a firstline treatment.
 
Topical immunomodulators
Since 2002 immunomodulators have been licensed to treat atopic eczema. They are not steroids but work by affecting the function of the protein called calcineurin. They are used as secondline treatments:

  • Tacrolimus (Protopic; Astellas) ointment comes in two strengths. Protopic 0.03% is licensed to treat children over the age of two years with moderately severe or severe atopic eczema.
  • Pimecrolimus (Elidel; Novartis) cream comes in one strength. It is licensed for use in children aged two to 16 years with moderately severe atopic eczema of the face and neck where appropriate topical steroids have not worked.

Other measures

  • Antihistamines are often prescribed, but there is little evidence that they actually reduce itching. Modern antihistamines are nonsedating so not usually helpful. Old-fashioned sedating antihistamines are more helpful and can be used at night to help children sleep. They are suitable for short term use.
  • Cotton clothing - avoid wool or manmade fibres which can be irritants.
  • Keep nails short to reduce damage whenscratching.
  • Avoid fabric conditioners when washing clothing. There is no evidence to suggest nonbiological washing powders are any better than biological but rinsing clothes well is probably important.
  • Keep house cool.

Indications for medical/specialist referral

  • Doubt about diagnosis.
  • Erythoderma (where a large area of the child's body is abnormally red indicating widespread inflammation).
  • Suspected bacterial infection - weeping crusted eczema often yellow or golden coloured.
  • Suspected eczema herpetic due to infection with herpes simplex. Should be considered if child with eczema is suddenly unwell and pyrexial with vesicular lesions at very early stages or "punched out" lesions, often around eyes.
  • Children where firstline treatment has failed despite adequate explanation and delivery of skincare.

Secondline treatments requiring dermatologist supervision

  • Phototherapy: ultraviolet light can be used to treat various inflammatory conditions including eczema. Artificial forms of both ultraviolet A (UVA) and ultraviolet B (UVB) are used.
  • Systemic treatments: prednisolone, ciclosporin and azathioprine may all be used to treat children with severe atopic eczema.

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Resources

National Eczema Society
T: 0207 281 3553
W: www.excema.org

British Association of Dermatologists
W: www.bad.org.uk

National Institute for Health and Clinical Excellence (NICE)
W: www.nice.org.uk

References

  1. Charman C, Lawton S. Eczema. The treatments and therapies that really work. London: Robinson; 2006.
  2. Lawton S. Eczema. In: Hughes E, Van Onselen J, editors. Dermatology nursing. Churchill Livingstone; 2001.
  3. Mitchell T, Paige D, Spowart K. Eczema and your child: a parent's guide. London: Class; 1998.
  4. McHenry PM, Williams H, Bingham EA. Management of atopic eczema. BMJ 1995; 310:843-7..
  5. Robinson J. Atopic eczema. In: Barnes K, editor. Paediatrics: a clinical guide for nurse practitioners. London: Butterworth Heinemann; 2003.
  6. Cork MJ, Timmins J, Holden C, et al. An audit of adverse drug reactions to aqueous cream in children with atopic eczema. Pharm J 2003;271:747-8.
  7. National Eczema Society. Diet and eczema in children. London: NES; 2003.