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Atopic dermatitis ( eczema ) in children

Common condition -most common chronic inflammatory skin disorder of childhood AD affects 5 % to 20 % of children & it’s incidence is increasing Most cases are seen during the 1st five years of life It has a significant impact on QoL of the children ( frequent applications of topical creams which can be complex and uncomfortable ) and their care-givers AD can lead to sleep loss , irritability , anxiety , lowered self esteem and psychological impairment 

History-when did this start , pattern and severity what treatment has been tried and response any trigger factors ( particularly for irritant & allergic dermatitis ) how does the condition impact -the child / carers ask about dietary history & any dietary manipulations is the child growing / developing normally have other members suffered 

from atopic diseases

flexural dermatitis – that involves the skin creases or visible dermatitis on cheeks and / or extensor areas in children 18 months or under, personal h/o flexural dermatitis , personal h/o dry skin in the preceding 12 months , personal h/o asthma or allergic rhinitis or a h/o atopic disease in a 1st degree relative of children under 4 yrs , onset of signs symptoms under age 2 ( NICE adds that this criterion should not be used in children < 4 yrs ) Citing differences in presentation the guidance adds that Asian , black and Caribbean & black African children- AD may affect extensor surfaces and discoid or follicular patterns may be more common.’

Also note that the child may have areas of differing severity -ie they can co-exist and in such cases each area should be treated independently additional validated tools as VAS , Patient Oriented Eczema Measure ( POEM ) , Children’s Dermatology Life Quality Index ( CDLQI ) , Infants Dermatitis Quality Life Index ( IDQoL ) or Dermatitis Family Impact ( DFI ) could be used to assess the impact of the condition 

potential triggers -irritants -for e,g soaps , detergents , shampoos , bubble baths , shower gels , washing up liquids ( if a clear precipitant is identified -avoiding them may resolve the issue ) skin infections contact allergens food allergens inhalent allergens

any previous reaction to food with immediate symptoms in moderate to severe cases optimum management is not effective ? any associated gut dysmotility symptoms as colic , vomiting , altered bowel habit or failure to thrive ?

is the child presenting with seasonal flare ups ? atopic eczema + asthma / allergic rhinitis children aged 3 and over with atopic eczema on face -particularly around eyes Risk factors for inhalant allergies in children include a 1st degree relative with allergies , food allergy in infancy and atopic dermatitis ( James W Mims et al 2011 )

Reaction to topical treatments in children with exacerbation of previously controlled atopic eczema

Bottle fed infants < 6 months with moderate to severe AE – offer 6-8 weeks trial of extensively hydrolysed protein formula or amino acid formula in place of cow’s milk formula ( if optimum treatment with emollients and mild topical corticosteroids has not worked ) refer for specialist dietary service if more than 8 weeks has passed since the commencement of cow milk free diet

mild AD – allergy tests are not needed advise against high street or internet allergy testing diet based on umodified proteins of other species as goat , sheep milk or partially hydrolysed formulas should not be used soya protein can be offered to children > 6 months with specialist dietary advice women who are breastfeeding children with atopic eczema ○ tell we do not know if altering her diet can help ○ if food allergy is strongly suspected- a trial of allergen specific exclusion diet can be considered under dietary supervision parents may ask about factors as stress , humidity or extremes of temp and NICE suggests that their role is unclear and these factors should be avoided where possible 

choice of unperfumed emollients for moisturising , washing and bathing can include a combination or one product for all purposes inform to smooth emollients rather than rubbig them in prescribe enough for e.g 250 g to 500g / weekly and advise to use in large amounts and more than other treatments they should be used on whole body -even when the atopic eczema is clear and while using other treatments advise to use emollients and / or emollients wash products instead of soaps and detergent based wash products children < 12-advise to avoid shampoo and use emollients and/ or emollient wash products ( if a shampoo is used in older children -it should be unperfumed ) washing the hair in bath water should be avoided

discuss benefits /harms and that benefits outweigh harms when applied correctly prescribe for application once or twice daily decide potency based on severity which may vary according to body site use mild potency on face/ neck ( moderate potency can be used short term 3-5 days in severe flare ups ) moderate or potent agents can be used short term ie 7-14 days for flares in vulnerable sites as axilla and groin advise to apply over areas of active atopic eczema which may include areas of broken skin if no response is seen within 7-14 days of using moderate / potent agents -exclude secondary bacterial or viral infection potent steroids should not be used in primary care in children under 12 potent steroids- in children over 12 can be used for short time ( no longer than 14 days ) but not on face or neck 

Topical calcineurin inhibitors not recommended as 1st line for mild atopic eczema or as 1st line treatment for atopic eczema of any severity discussed on a separate chart

not to be used routinely offer a 1 month trial of non-sedating antihistamine in children with severe itching or urticaria -cont is beneficial & review every 3 months children 6 months or over -offer trial of 7-14 days during acute flare ups if sleep disturbance has a significant impact on child / carers

advise on how to recognise symptoms signs of bacterial infections (weeping , pustules , crusts , treatment not working, rapid worsening , fever , malaise ) to obtain new eczema medications after treatment as products in open containers can get contaminated and act as source of infection consider if the infection may be due to herpes simplex ( cold sore ) and treat with oral acyclovir even if the infection is localised 

Eczema herpeticum is a disseminated cutaneous infection with herpes simplex in patients with atopic dermatitis may present with sudden onset of eruption of monomorphic vesicles, punched out erosions with haemorrhagic crusts over areas of eczema ○ areas of rapidly worsening painful eczema ○ clustered blisters which appear like early stage cold sore ○fever , lethargy or malaise medical emergency and it can lead to death if untreated due to bacterial superinfection and bacteremia if suspected start systemic aciclovir immediately and refer for same day assessment , also start antibiotic if secondary bacterial infection is suspected if it involves the skin around the eyes -start systemic aciclovir immediately and refer same day for eye/ skin specialist advise

severe atopic eczema that has not responded to optimum topical therapy after 1 week treatment of bacterially infected atopic eczema has failed

diagnostic uncertainty inadequate control based on subjective assessment or in cases of frequent flare ups ( 1-2 / week ) or the child is reacting adversely to many emollients stubborn facial eczema which does not respond to appropriate treatment clinical presentation raises suspicion of contact allergic dermatitis ( for e,g persistent atopic eczema or facial , eyelid or hand atopic eczema ) condition has significant impact on the social / psychological well being of the child /carers as sleep disturbance / school attendance it is associated with recurrent infections particularly deep infections as abscesses or pneumonia suspected food allergy failure to grow at the expected growth trajectory

REFERENCES

  1. *Atopic eczema in under 12s: diagnosis and management (nice.org.uk)
  2. Gür Çetinkaya, Pınar, and Ümit Murat Şahiner. “Childhood atopic dermatitis: current developments, treatment approaches, and future expectations.” Turkish journal of medical sciences vol. 49,4 963-984. 8 Aug. 2019, doi:10.3906/sag-1810-105
  3. Liaw, Fang-Yih et al. “Eczema herpeticum: a medical emergency.” Canadian family physician Medecin de famille canadien vol. 58,12 (2012): 1358-61.
  4. Xiao A, Tsuchiya A. Eczema Herpeticum. [Updated 2021 Aug 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560781

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