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The effective management of atopic dermatitis in school-age children

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VOL: 100, ISSUE: 32, PAGE NO: 55

Sue Ward is information and education manager, National Eczema Society, London

Sue Ward is information and education manager, National Eczema Society, London

The terms atopic eczema and atopic dermatitis (AD) are synonymous. In this article, the latter term is used. AD can affect all age groups but is most commonly associated with children. It is a dry-skin condition, the severity of which can vary from person to person. It is not contagious. In mild forms of the condition the skin is dry, hot and itchy, while in more severe cases the skin can be broken, raw and bleeding, or produce vesicles and papules that may become eroded.

School-age children who have had AD for a long time may have skin that has become thickened, dry and scaly, referred to as lichenification. The course of the condition is remitting and the patient will have flares followed by partial or full remission.

AD is a growing problem that now affects five to 15 per cent of children by the age of seven, and 15-20 per cent of all school-age children in the UK (Williams, 1997). It has increased three-fold over the past 30 years (Emerson et al, 1998).

AD is intensely itchy and this is often the symptom that is most distressing for the patient. The itch leads to a vicious itch-scratch cycle.

The child's natural reaction to the itch is to scratch, which exacerbates the problem and increases the risk of infection. Breaking this cycle is vital.

The main treatments are emollients (moisturisers) to rehydrate the skin, and topical corticosteroids to control inflammation.

Causes of AD
It is thought to be a hereditary condition (Leung and Bieber, 2003) but many dermatologists now believe that environmental factors may also play an important part in the development of AD (McNally et al, 2001).

Patients with AD are thought to be sensitive to allergens in the environment that are harmless to others (Turner et al, 1991). In atopy there is an excessive reaction by the immune system, which produces inflamed, irritated, and sore skin.

Psychological factors
These are important in AD (Linnet and Jemec, 1999). Although much of the research has focused on adults, it is clear that AD can generate considerable emotional problems for children.

For those over five years of age, problems can include time off school and impaired performance due to lack of sleep. AD may be associated with poor self-image and a lack of self-confidence that can interfere with social development (Absolon et al, 1997).

Children may also learn that they can punish or manipulate parents and carers into getting their own way by scratching. For some children with AD, bullying may be a problem (Titman, 2003).

In 1997, a study was carried out at the dermatology outpatient departments of three inner London hospitals to establish the rate of psychological disorder in children between the ages of five and 15 who had AD. Thirty children with AD and 30 children for comparison were enrolled onto the study.

The comparison group consisted of children aged five to 15 years who were attending the same clinics with minor skin problems such as viral warts, molluscum contagiosum (a disease of the skin and mucous membranes caused by a poxvirus), and benign melanocytic naevi (moles).

The results found twice the rate of psychological disturbance in children in the AD group compared with the control group. The findings indicate that school-age children with moderate or severe AD are at a high risk of developing psychological difficulties that may have implications for their academic and social development (Absolon et al, 1997).

Having AD can be particularly devastating for teenagers because body image becomes important to children once they reach adolescence (Teare, 2003). Fears about finding a partner, and limitations on the type of clothes and make-up they can wear may cause them a great deal of distress. Stress itself can be an aggravating factor that can make the AD worse (Gil et al, 1987). A negative cycle can then ensue where stress causes a flare up which leads to more stress.

However, it is not clear whether psychological factors such as stress, anxiety, and depression are a result of AD or vice versa (Hoare et al, 2000).

School and atopic dermatitis
School is a major part of any child's life and even for children not affected by AD, it can be difficult at times. Children with AD may sometimes feel different, self-conscious or anxious about fitting in at school.

They may have to cope with teasing or bullying, experience difficulty in making new friends or find other children are reluctant to touch them because they have AD (Roberts, 2001).

It is useful if nurses can encourage parents and carers to provide the school with details of situations to avoid, as well as methods that are effective in helping a child to calm down or stop scratching.

Some basic guidelines to help children with AD in school are given in Box 1. Children who have this condition will benefit from a consistent, calm, and consultative approach.

Basic treatments
These will almost certainly need to be carried out during the school day to keep the child's AD under control. All children with AD should be using emollients and a soap substitute.

Emollients

Emollients keep dry skin moisturised and are essential to minimise itchiness. Ideally, a supply of the cream, ointment, or lotion used by the child should be kept at the school.

However, the child should also be encouraged to carry a small pot of the emollient at all times. Many emollients can be decanted into small colourful pots, which children may find less noticeable.

Emollients may need to be applied two or three times during the school day in order to ensure that the skin does not dry out. A young child will need to use a minimum of 500g of emollient every two weeks, while an older child or teenager will need to use 500g a week (Kerrigan et al, 2001).

Soap degreases the skin and should be avoided by children with AD. Schools should be encouraged to have a soap substitute available in washrooms that can be used by children with skin conditions.

Topical corticosteroids

These are applied to the skin to reduce the inflammation associated with AD. In most children, AD can be controlled either by the use of emollients alone, or by a combination of emollients and a mild topical corticosteroid such as hydrocortisone cream.

However, in those children who have moderate to severe AD, a moderate or potent topical steroid may be prescribed.

Topical corticosteroids are usually applied once or twice a day, so it is unlikely that children will have to have their steroid applied during the school day, as the topical corticosteroid should have been applied first thing in the morning after bathing.

Antihistamines

The intense itching caused by AD can make it very difficult to sleep, so children may be prescribed antihistamines to take at night. These can leave a residual drowsiness the following morning, which may affect concentration at school.

Educating teachers and pupils about atopic dermatitis
The National Eczema Society has launched the first-ever charity initiative to educate children about AD, following concerns raised by carers regarding lack of knowledge in schools about AD and its effect on children.

Designed for children from three different age groups (Foundation to Year Three, Year Four to Year Seven, and Year Eight to Year Eleven), the information packs provide guidelines for teachers.

Articles and activities in lesson-plan format help them to learn about AD and bring the issues into the classroom in a challenging and interesting way that also links into the national curriculum.

The enormously positive response to date suggests that this pack will prove to be a successful method of promoting information about AD as well as encouraging empathy towards those who have the condition (Ward, 2003). See Box 2 for details.

Conclusion
With proper information and education the majority of cases of AD can be well managed, allowing most children to lead a normal, active and fulfiling school and social life.

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