Management of atopic eczema in children should include assessment of psychosocial factors and avoidance of irritants and triggers, says Dr Nigel Stollery

Atopic eczema is a common, chronic inflammatory skin condition that usually starts in early childhood—12%–15% of infants are affected usually within the first 6 months of life. In 75% of patients, remission occurs by the age of 15 years although some will relapse in later life.1 As there are no definitive tests or diagnostic markers for the condition, diagnosis can be difficult because of variability in distribution and morphology.

Diagnosis of atopic eczema

To help with diagnosis, a set of clinical/diagnostic markers have been determined, the first of which were published by Hanifin and Rajka in 1980.2 These markers were updated in 1994 by a UK Working Party,3 which reduced them to just six based on Hanifin and Rajka’s original list. The criteria consist of:3

  • one major criterion:
    • history of a pruritic skin condition
  • minor criteria:
    • history of flexural dermatitis (or cheeks and extensor surfaces in children under the age of 18 months)
    • history of dry skin in the preceding 12 months
    • onset under the age of 2 years
    • personal history of asthma, allergic rhinitis (or family history in a first-degree relative of children under the age of 4 years)
    • visible flexural dermatitis (antecubital and popliteal fossae).

In Asian, black Caribbean, and black African children, the extensor surfaces may be affected more than the flexures, and discoid or follicular patterns may be more common.4,5

These criteria are well established and were thoroughly validated prior to their publication in 1994. The NICE guideline endorses these criteria in that it recommends that for a diagnosis of atopic eczema to be likely, the patient should have an itchy skin condition plus at least three of the factors listed as minor criteria.4,5

A key principle when considering a diagnosis of atopic eczema is the taking of a detailed history, which as well as the above major and minor criteria, ideally should include the following topics:4,5

  • Time of onset, pattern, and severity of the atopic eczema
  • Any history of triggers, including dietary ones
  • Any past or present treatments both prescribed and purchased over the counter
  • The impact the condition has on the family (parents/carers and siblings)
  • Personal and family history of other atopic conditions (asthma, hay fever, rhinitis)
  • Growth and development.

The features of eczema will vary depending on the duration of the condition. In the acute stages, eczema is characterised by erythema, oedema, oozing/crusting, vesiculation, and excoriations; whereas once chronic, the following features are more likely: lichenification, dryness, scaling, cracking/fissuring, post-inflammatory hyper- and hypopigmentation.

When assessing a patient with atopic eczema it may be useful to use a scoring tool to document the severity of the condition. For example, the SCORing of Atopic Dermatitis (SCORAD) index,6 which takes into account the extent of the condition and six clinical signs of disease intensity (i.e. erythema, oedema, oozing, excoriation, lichenification, and xerosis). Other tools are simpler and may be more appropriate given the time limitations of consultation in general practice (e.g. three-item severity [TIS] score and a simplified version of SCORAD).7,8

Differential diagnoses

Although in most cases the diagnosis of atopic eczema is straightforward, other conditions can sometimes mimic it, such as those described below.

Scabies
As with eczema, the pruritis associated with scabies is usually the most significant symptom. Scabies, which is caused by a mite infestation, may mimic or co-exist with eczema. Clues include spread of the infection to other family members, papules on the genitals, and excoriations in the finger webs and umbilicus.9

Tinea infection
Unlike eczema, which is usually distributed symmetrically, tinea usually affects a localised area, the annular appearance of which may be mistaken for the discoid form of eczema. Steroids may alter the appearance of the rash (tinea incognito), but will not improve it. If there is doubt, skin scrapings should be taken.10

Seborrhoeic dermatitis
This may start very early in life with dry skin, but unlike atopic eczema, it often involves the scalp (cradle cap), extending down around the ears and eyebrows, the neck, and the axillae, as well as the groin (nappy area), which is not usually affected by eczema. In dermatitis, there is usually little irritation and in most cases it will settle before the child’s first birthday.11

Atopic eczema can usually be diagnosed by taking a careful and thorough history and examination of the child. There is little need for tests and investigations; however, in some cases, the investigations below may be useful.

Skin swabs
If secondary infection is suspected, it is useful to take a skin swab to confirm this and to determine antibiotic sensitivities. Antibiotics can be started without the results of the swab, which can be reviewed in retrospect if treatment failure occurs.

When a child has been in contact with varicella, and eczema herpeticum is suspected, a viral swab can be useful.4,5 Further information about bacterial and viral infection is below.

Immunoglobulin E testing (blood and skin prick tests)
Testing for immunoglobulin E (IgE) is not usually required or undertaken in the diagnosis of atopy in young children. The absence of a specific IgE can be useful in excluding a particular allergen, but a raised level does not always implicate it in the disease as this may be due to respiratory disease (e.g. pollens and house dust mite).

General principles of management

Education
Around 70% of patients with atopic eczema will develop the condition in the first 5 years of life,12 hence the majority will present accompanied by their parents or carers. In some cases a family history will mean that parents will already have a good understanding of the condition and its management, for others there will be many questions and misconceptions regarding the condition. At the time of diagnosis or soon after, education of both patients and parents/carers will be required. The importance of education must never be underestimated. The full NICE guideline on the management of atopic eczema contains a section on education, which includes three randomised controlled trials (RCTs) and two case series.5

The largest of the RCTs was undertaken in Germany and held by a multi-professional team. It involved 2-hour sessions once weekly covering medical, nutritional, and psychological issues, and the outcome was assessed after 1 year using SCORAD. The results confirmed that the children who received the education programme experienced improvements in the severity of eczema that were significantly better than in the control group.5

The second RCT evaluated a nurse-led educational programme for parents of children with varying degree of eczema. This consisted of a 2-hour session covering treatments and how to use them, the importance of maintenance therapy, practical advice on self management, environmental control, and general information about the condition and treatment expectations. Again there was a significant improvement in the intervention group after 4 months.5

Avoidance of irritants and triggers
Simple lifestyle advice should be given to patients and parents/carers on how to avoid potential irritants and triggers such as those shown in Box 1 (see below). Children should keep their nails short to reduce the impact of scratching and it is worth demonstrating the use of soap substitutes.4,13

Box 1: Potential triggers and factors that affect eczema4,14
  • Irritants—wool or synthetic clothing, soaps, detergents, perspiration, disinfectants, topical antimicrobials, and many chemical reagents
  • Contact allergens—preservatives in topical medications, perfume-based products, metals, and latex
  • Inhaled allergens (aeroallergens)—house dust mites (Dermatophagoides pteronyssinus and farinae), animal dander, cockroach, tree and grass pollens, and moulds
  • Foods/dietary factors—cow’s milk, eggs, peanuts, tree nuts, wheat, soya, fish, shellfish, and (rarely) others such as sesame, kiwi, and legumes
  • Microbial colonisation and/or infectionStaphylococcus aureus, streptococcus species, Candida albicans, Pityrosporum yeasts, herpes simplex virus
  • Climate—extremes of temperature and humidity, and seasonal variation in the pattern of atopic eczema
  • Environmental factors—hard water, cooking with gas, proximity to road traffic, and background tobacco smoke
  • Familial factors—genetics, family size, and sibling order
  • Social class—higher incidence in more affluent social classes
  • Concurrent illness and disruption to family life—teething, psychological stress, and lack of sleep

Emollients
The regular application of emollients is essential in the management of atopic eczema. Choice of emollient will depend on personal preference and a variety of types should be made available by the practice for patients to try. Starter size samples can be very useful and are usually available to GPs from pharmaceutical companies.

Emollients can take different forms including ointments, bath additives, and soap substitutes.4,5 Emollients may harbour infection especially where fingers are placed into tubs of cream. Pump dispensers will reduce the risk of this, and decanting portions of cream into smaller containers can help. In general, the quantities of emollients prescribed are often too low. Parents need to be reassured that asking for too much emollient is not a problem. The British National Formulary (BNF) provides advice on emollient quantities to be used on specific sites of the body although these quantities relate to adults only.14

The full NICE guideline on the management of atopic eczema in children includes a number of studies relating to the different types of emollients.5 None of these studies looked at the quantity or frequency of emollient use and no evidence was found for most of those listed in the BNF for children.15 One study found an immediate cutaneous reaction (defined as one or more of burning, stinging, itching, and redness developing within 20 minutes of application) in 56% of applications of aqueous cream.5

Topical corticosteroids
Along with emollients, topical corticosteroids are the mainstay of treatments for atopic dermatitis. These agents have been used for many years, but care is required especially when stronger strengths are used as side-effects can occur. The NICE guideline advises using the lowest potency of corticosteroid to control symptoms, with regular review, and stepping down treatment once control is achieved.4,5

Mild topical corticosteroids should be the first-line treatment in infants as well as for the face and flexures in children of all ages. Moderate potency steroids can be used second line for eczema that is not responding to mild strengths, but care is required. Potent strength corticosteroids can be used in short bursts in infants and children (e.g. 3 days) in those not responding to weaker strengths. In children with chronic lichenified eczema, longer bursts can be used (e.g. 1–2 weeks under supervision), but use on the face and flexures should be avoided. Treatment with potent corticosteroids should only be initiated by specialists.

Clear guidance (written if possible) should be given regarding the use of corticosteroids. Care should also be taken when considering putting potent corticosteroids on repeat prescription. Regular monitoring should be undertaken to check for side-effects; this should include use of growth charts.4,5

Topical immunomodulators
Topical tacrolimus and pimecrolimus are not recommended for the treatment of mild atopic eczema or as first-line treatments for atopic eczema of any severity. Tacrolimus is recommended as an option for the second-line treatment of moderate to severe atopic eczema in adults and children. Pimecrolimus is a second-line treatment option for moderate atopic eczema on the face and neck.4,5 The NICE guideline suggests that they should only be used if the patient has failed to respond to topical corticosteroids or is intolerant to them. The use of these agents should be avoided in areas where there is infection, especially herpetic infection. Long-term side-effects are unknown. The NICE guideline recommends that the use of these therapies should only be initiated in secondary care or by a GP with a specific interest in dermatology.4,5

Infection

In one study, 40% of 190 children had 164 episodes of exacerbation of eczema due to bacterial infection over a 13-month period of observation. Of these 164 episodes, 25 required hospital admission. Swabs revealed the presence of Staphylococcus aureus in 97% of cases and in combination with ?-haemolytic streptococci in 62% of cases.16 Secondary viral infection is less common but in the case of varicella, which can cause eczema herpeticum, it requires early treatment with intravenous aciclovir so any cases will require hospital admission.

Impact of atopic eczema

Atopic eczema can have a significant impact on the lives of both patients and their families/carers and psychosocial issues relating to the condition should be explored (see Box 2). When quality-of-life measures specific for dermatology have been used with patients with eczema, scores higher than for any other skin conditions have been recorded. When questioned, the predominant symptom is chronic pruritis (scratch–itch cycle). In addition to eczema impacting on daytime activities, 60% of patients report sleep disturbance, which in turn affects education, social interactions, and behaviour.17 Severe eczema has been shown to lead to increased clinginess, dependency, and fear in younger children,18 which not only affects the patient, but can also have an impact on the lives of other siblings.

The stigma associated with eczema can also affect participation in leisure and sporting activities, particularly swimming. In school leavers, eczema may influence career choices and opportunities. For example, at job interviews, visible eczema may influence an applicant’s chances of being chosen. In sales careers where appearance is important, visible eczema on hands and the face may affect success. More specifically irritants and specific products may impact on an affected patient’s ability to work as a hairdresser or in the beauty trade. Atopic eczema can also result in an increase in stress-related illness, exhaustion, disruption of family life,19 and financial implications for the family of the affected child.

Box 2: Psychosocial factors to consider in patients with atopic eczema, and their families
  • Sleep disturbance (leading to tiredness, and education and behaviour problems)
  • Low self-esteem (bullying and teasing at school)
  • Increased clinginess, fear, and parental dependency
  • Sport activity disruption (especially swimming)
  • Effects of the daily routine of application of treatments, particularly the time and commitment required by patients and parents to treat properly
  • Effects on the family unit with disruption of siblings’ and parents’ lives
  • Parental/carer stress and exhaustion

When to refer

One study in Nottingham showed that overall, 6% of children with atopic dermatitis, aged 1–5 years were referred to secondary care over a 12-month period. Referral to secondary care was positively related to disease severity, with referral occurring in:20

  • 43% of severe cases
  • 15% for moderate cases
  • 3% of mild cases.

The NICE guideline makes a number of recommendations regarding the referral of children. These are detailed below:4,5

  • Urgent/immediate referral if eczema herpeticum is suspected
  • Refer within 2 weeks if:
    • severe atopic eczema has not responded to optimum topical therapy after 1 week
    • treatment failure of bacterially infected atopic eczema has occured
  • Routine referral if
    • there is diagnostic uncertainty
    • management has not satisfactorily controlled the atopic eczema based on a subjective assessment by the child, parent, or carer (e.g. the child is having 1–2 weeks of flares per month or is reacting adversely to many emollients)
    • facial atopic eczema has not responded to appropriate treatment
    • the child or parent/carer may benefit from specialist advice on treatment application (e.g. bandaging techniques)
    • contact allergic dermatitis is suspected (e.g. persistent atopic eczema or facial, eyelid, or hand atopic eczema)
    • significant social or psychological problems for the child or parent/carer are occurring (e.g. sleep disturbance, poor school attendance)
    • there are severe and recurrent infections, especially deep abscesses or pneumonia.

Additional guidance

The British Association of Dermatologists and the Primary Care Dermatology Society issued a joint guideline in 2005 on atopic eczema in children and adults.21 This offers a good, summary of all aspects of care and can be accessed online. The guideline also gives details of the National Eczema Society, which is based in London, and includes its eczema helpline number from which extra advice can be sought.

Implementation

Although the management of atopic eczema in children is generally straightforward, it does take time to educate patients and their carers. This is often a limiting factor in general practice where appointments are limited and time a significant constraining factor—nurses with an interest in dermatology can provide vital support.

Financial pressures may also affect care with inadequate amounts of emollients being prescribed and patients not feeling comfortable asking for more—again patient education is very important in trying to overcome this. Moreover, pressure to use cheaper and unsuitable creams as emollients rather than as soap substitutes (e.g. aqueous cream) can not only lead to side-effects, but affect compliance as young children may refuse to use them.

Conclusion

Childhood eczema is a common condition, which will be seen regularly in day-to-day general practice. Management in most cases follows basic principles that can make significant differences to the lives of both patients and their carers. The NICE guideline is a useful document that covers this in detail and provides evidence-based answers to questions faced by GPs. This guidance is due for review in December 2010.

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