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Childhood atopic dermatitis: 2

Linda Moffat, RGN, SCM, Cert Health Ed.

Sister, Dermatology and Medical Procedure Unit, Cumberland Infirmary, Carlisle, Cumbria

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Part 1 of this Factfile on AD appeared in the September 2003 issue of Professional Nurse

The management of children with atopic dermatitis (AD) must involve assessment not only of the child's condition but also of the effect AD has on the rest of the family. It must involve providing the family and child with information on coping with the condition and ensuring the family has adequate health care and financial support.

Treatment plan - First-line treatment
Basic skin care and regular use of emollients are crucial to managing AD, and patients must be advised of the importance of bathing and using emollients. The Dermatology Care Working Group Report (2001) found major shortcomings in the UK's dermatology service and highlighted the need for improvements in prescribing practices with regard to emollients. In response to this, Holden et al (2002) proposed a set of simple guidelines for emollient therapy (see overleaf).

Topical corticosteroids
These are the mainstay of therapy to control acute flares of AD in children (Lane, 1997). In general, the least potent corticosteroid that controls the child's symptoms should be used to avoid side-effects. Children are especially prone to systemic adverse effects of topical corticosteroids because compared with adults their skin surface area is larger in proportion to their bodyweight.

It is important to note that topical corticosteroids do not address infection with Staphylococcus aureus, the presence of which often results in children failing to respond to treatment. Combination steroids with antibiotic/antiseptic properties can be used short term to treat local areas of infected AD, while systemic antibiotics should be prescribed for more widespread skin infection. Less often, skin may be infected with streptococcal organisms and should be treated with systemic antibiotics. Exposure to the Herpes simplex virus can provoke potentially serious infection (eczema herpeticum) in a child with AD and should be treated promptly with systemic antivirals.

Occlusive bandage techniques
The most distressing feature of AD is pruritus and compulsive scratching, which exacerbates AD. Occlusive techniques include the use of ichthammol and tar-impregnated bandages or wet-wrap dressings. Parents require training and practice in applying these before using such treatments at home.

The advantages of occlusion techniques are that they:

- Are an effective barrier against scratching

- Reduce irritation and associated problems, for example, sleep disturbance, pain and discomfort

- Have a cooling effect that provides relief when skin is inflamed

- Provide a moist environment that encourages healing and relieves dryness

- Increase efficacy of topical steroids

- Enable bandages to be left in place for up to three days, reducing use of topical steroids.

Oral antihistamines
Antihistamines of the sedating type offer the most benefit to children; however, most are contraindicated for infants under the age of 12 months.

Antihistamines tend to be less effective if used long term and so should be restricted to intermittent use. They should also be discontinued temporarily if skin-prick testing, the radioallergosorbent test (RAST) or contact allergy testing is to be carried out, as they will interfere with the results.

Second-line treatment
Diet restriction The association between AD and food allergy is complex, although children with severe AD will usually have food allergies. Probably less than 10% of all children with AD have IgE-mediated food allergy with angioedema and urticaria (Barneston and Rogers, 2002). Diagnosis will be obvious from the immediate reaction to a particular food, which can then be avoided. However, what is not so clear is the role of late-phase food reactions, which exacerbate AD without immediate symptoms, an area that is receiving increasing attention (Barneston and Rogers, 2002).

Almost any food can provoke AD, but eggs and milk have a statistically higher chance of doing so (Atherton, 1995). Such foods have high nutritional value and should not be removed from a child's diet unless there is clear evidence that it exacerbates AD. A dietitian should supervise exclusion diets.

Phototherapy
Phothotherapy involves exposing the child's skin to ultraviolet radiation, namely, UVA and UVB. Treatment should be prescribed by a dermatologist and administered in dermatology departments only, as it requires specialist equipment and specialist nurses. UV radiation carries some risks, the most significant being sunburn (erythema). Sunburn in childhood appears to be the main predisposing factor to developing malignant melanoma in later life (Atherton, 1995), so phothotherapy should be considered only if AD is severe and unresponsive to first-line treatments.

Topical immunosuppressive therapy
A topical preparation of tacrolimus can be used to treat moderate to severe AD in children aged over two years who have not responded to first-line treatments. Two studies specifically related to childhood AD have confirmed its efficacy (Boguniewicz et al, 1998; Kang et al, 2001).

Topical tacrolimus avoids the need to use topical corticosteroids and can be applied to all body sites (with the exception of eyes and mucous membrane); however, it should not be used with infected skin or under occlusion. Exposure to sunlight and UV radiation must be minimised, and advice regarding sun protection must be given.

The effect of treatment with topical tacrolimus on the developing immune system of children has not yet been established, so this should be taken into account when prescribing treatment.

Third-line treatment - Oral immunosuppressive drugs
Systemic immunosuppressive drugs modify the activity of the immunological system and prevent over-reaction to certain triggers. Oral corticosteroids are occasionally required for patients with a severe exacerbation of AD, but should not be prescribed routinely. This is because there is often a 'rebound' effect when they are withdrawn. The side-effects of systemic corticosteroids are well documented but the main concern in children is that of growth retardation if these are prescribed regularly.

Azathioprine is a cytotoxic drug used to achieve immunosuppression. Before it is prescribed, it is essential to measure the enzyme thiopurine methyltransferase (TPMT), as this metabolises azathioprine, which could lead children with low activity of this enzyme to experience severe myelosuppression (Murphy and Atherton, 2001). Hepatotoxicity is also a well-recognised complication.

Another potent immunosuppressant that is less toxic to bone marrow is cyclosporin, however it is nephrotoxic. Studies carried out by Berth-Jones et al (1996) and Harper et al (2001) have confirmed its efficacy in childhood AD, but improvement is generally not maintained once the drug is withdrawn.

Treating AD in preschool children may be costing the UK as much as £47 million a year (Dobson, 2001), with families carrying more than one-third of the burden. Severe forms of AD can have a major impact on a child's development and quality of life, and will have personal, social and financial repercussions for the whole family. Primary and secondary care services can do much to minimise the effects of AD on sufferers and families by improving the service we offer.

FACTFILE - ASSESSMENT
The assessment of a child with atopic dermatitis must include questions regarding family history, what makes the condition worse, how it affects sleep, schooling, hobbies, its effects on the family, previously tried treatments and present therapy. It should also include a thorough skin examination.

EDUCATION
This must include an explanation and allow time for parents to ask questions. Parents need to be taught how to minimise the effects of AD, so they need to be informed of potential environmental triggers and how to avoid identified triggers. They must be advised on the correct and appropriate use of prescribed treatment and its function, which should be supported by a practical demonstration and supervised application of the topical treatment. All the above should be supported by clear and concise literature.

SUPPORT
Support systems must be in place from early diagnosis. Parents must have easy access to primary carers and hospital dermatology units. They must be informed of local support groups and the National Eczema Society. The family may require financial support, and parents should be made aware that they may be eligible for benefits. Parents and children may also require the support of dietitians and a child psychologist. Cooperation of the child's nursery/school should be encouraged.

NATIONAL ECZEMA SOCIETY
Hill House, Highgate Hill, London N19 5NA. Information line: 0870-241 3604; website: www.eczema.org

FACTFILE - PRINCIPLES OF EMOLLIENT USE
- Health professionals involved in caring for patients with eczema and dry skin conditions should understand the basic principles of emollient use

- Patients with eczema and other dry skin conditions should avoid soap and use an emollient soap substitute for washing, bathing and showering

- A daily emollient routine is an important part of managing patients with eczema and other dry skin conditions, even when the skin is under control. Emollients should be applied at least twice a day so it is important to supply them in adequate quantities (500g or more a week)

- It is important that patients understand the relative benefits of steroid creams (to reduce inflammation) and emollients (to combat dry skin). (Controversy has surrounded the use of corticosteroids in the past decade, so the nurse involved in the child's eczema management must have good knowledge of topical steroids to educate and inform the child's parents.)

- Emollients come in a variety of forms but greasier preparations often work better and last longer in babies and young children

Source: Holden et al, 2002.

Atherton, D.J. (1995)Eczema in Childhood: The Facts. New York, NY: Oxford University Press.

Barneston, R., Rodgers, M. (2002)Childhood atopic eczema. British Medical Journal 324: 1376-1379.

Berth-Jones, J., Finlay, A.Y., Zaki, I. et al. (1996)Cyclosporine in severe atopic dermatitis: a multicenter study. Journal of the American Academy of Dermatology 34: 1016-1021.

Boguniewicz, M., Fiedler, V.C., Raimer, S. et al. (1998)A randomised, vehicle-controlled trial of tacrolimus ointment for the treatment of atopic dermatitis in children. Journal of Allergy and Clinical Immunology 102: 637-644.

Dermatology Care Working Group. (2001)Assessment of Best Practice for Dermatology Services in Primary Care. London: Ash Communications Healthcare.

Dobson, R. (2001)Atopic dermatitis in children costs £47m each year (News). British Medical Journal 322: 884. Available at: bmj.com/cgi/reprint/322/7291/884/a.pdf

Harper, J.I., Berth-Jones, J., Camp, R.D.R. et al. (2001)Cyclosporin for atopic dermatitis in children. Dermatology 203: 3-6.

Holden, C., English, J., Hoare, C. et al. (2002)Advised best practice for the use of emollients in eczema and other dry skin conditions. Journal of Dermatology Treatment 13: 103-106.

Kang, S., Lucky, A.W., Pariser, D. et al. (2001)Long-term safety and efficacy of tacrolimus ointment for the treatment of atopic dermatitis in children. Journal of the American Academy of Dermatology 44 (suppl 1): S58-S64.

Lane, A.T. (1997)Efficacy and safety of topical steroids in paediatric atopic dermatitis. Journal of the European Academy of Dermatology and Venereology 8 (suppl 1): S24-S27.

Murphy, L.A., Atherton, D.J. (2001)Azathioprine in severe childhood eczema: value of TPMT as a predictor of outcome and safety in treatment. British Journal of Dermatology 144: 927.

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