Paediatric Eczema

Dr Manjeet JoshiConsultant Dermatologist

16th May 2012

Classification of the principal forms of eczema

EXOGENOUS

Irritant

Allergic contact

Photoallergic contact

Eczematous PLE

Infective dermatitis

Dermatophytide

Post traumatic

ENDOGENOUS

Atopic

Seborrhoeic Dermatitis

Asteatotic

Discoid

Pityriasis alba

Hand

Gravitational

Juvenile plantar dermatosis

Metabolic eczema or eczema associated with systemic disease

Eczematous drug eruptions

Atopic Eczema

Inflammatory skin reaction

Pathogenesis: Interaction of trigger factors, keratinocytes and T lymphocytes.

Clinical: redness, scaling, papulovesicles.

Prevalence: 5-30% schoolchildren

Pruritus, soreness, infection, sleep disturbance

Social/psychological impact on whole family

Considerable burden on primary and secondary care

Atopic dermatitis

NICE guidance (Dec 2007) Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years

Tacrolimus and pimecrolimus NICE Aug 2004

Topical steroids NICE August 2004

NICE eczema diagnosis

Itchy skin condition + 3 or more of:

Visible flexural dermatitis (or face/extensor areas if 18 mths or less)

Personal history of flexural dermatitis

Personal history of dry skin in last 12 months

Personal history of asthma/hayfever (or FHx of atopy in 1st deg rel)

Onset of S/S in under 2 yrs

(NB: coloured skin – extensor/discoid/follicular)

Pityriasis alba

Pattern of dermatitis with hypopigmentation being the main feature.

Children 3-16 years

Red or skin coloured plaque with branny scaling initially.

Erythema subsides to leave fine scaling and hypopigmentation. Patients usually present to Dr at this stage.

Course variable – takes time to repigment

Treatment:

Emollient, mild steroid. Tacrolimus and pimecrolimus.

Treatment - first line

Avoid irritants

EMOLLIENTS

TOPICAL STEROIDS

Sedative antihistamines

Antibiotics

Tar preparations (esp in lichenified eczema)

Emollients

Unperfumed, suited to child’s needs and preferences

Prescribe in large quantities (250-500g/week)

Soap substitute - soaps (incl. ‘moisturising soaps’) contain surfactants and solvents (SLS)

Used on whole body even when atopic eczema is clear

Show children/carer how to use treatment

Which emollient?

The best one is the one that your patient will use in an appropriate quantity

Aqueous cream is quite irritant and was designed as a soap substitute ie ‘wash off’ product

Cetraben / Doublebase / Epaderm used often

Dermol range/antibacterial esp when frequent infections

Aveeno esp if lighter moisturiser required

Steroids

Explain that benefits outweigh risks

Only apply to active eczema (may include broken skin) or (that which has been active in last 48 hrs), use od/bd

Don’t use potent on H+N

Don’t use potent in <1 yrs without specialist dermatological advice

Don’t use very potent without dermatology advice

Topical steroids

Gain control of eczema

Acute flare vs chronic disease

Mild - 1% hydrocortisone / fucidin H / daktacort

Moderate - eumovate / trimovate

Potent - betnovate / elocon / fucibet

Very potent – dermovate

Steroids

Label steroid container with potency (not outer packaging)

Consider treating problem areas for 2 consecutive days per week to prevent flares in children who have 2-3 flares per month. Review in 3-6 months

Consider different topical steroid of same potency if tachyphylaxis suspected instead of stepping up

Calcineurin inhibitors

Don’t use for mild eczema or as first line for eczema of any severity or under occlusion

Protopic for mod / severe eczema in >2

Elidel for mod eczema on H+N in 2-16 yrs

Only physicians with a special interest/experience in dermatology should start treatment, after discussing risk/benefit of all 2nd line options

Consider for facial eczema in children needing long- term or frequent use of mild steroid

Infected eczema in children

Flucloxacillin if non allergic

Erythromycin if penicillin allergic

Clarithromycin if unable to tolerate erythromycin

Recurrent infection: take swabs incl from family and consider skin sterilisation and nasal Staph eradication

Infection - HSV

Consider if fails to respond to AB or steroids

rapidly worsening painful eczema, fever, lethargy/distress, clustered blisters, punched out erosions

Needs immediate systemic aciclovir and same day referral (and to ophthal if around eye)

Start systemic AB if secondary bact infxn

Dermatophytide

Eczema can occur as an allergic response to dermatophyte infection elsewhere on the skin.

Id reaction

Vesicles on hands and feet common usually as a reaction to tinea pedis.

More likely to develop with inflammatory dermatophytes eg Trichophyton mentagrophytes of zoophilic type.

Erythroderma

Eczema

Psoriasis

Lymphoma and leukaemias

Drugs eg arsenic, gold, mercury, occasionally penicillin, barbiturates

Hereditary disorders eg icthyosiform erythroderma

PRP,LP, dermatomyositis, crusted scabies

Treatments - second line

Topical immunomodulators (>2y.o.)

Tacrolimus = Protopic 0.03% / 0.1% oint

Pimecrolimus = Elidel 1% cream

Phototherapy (UVB/PUVA)

Immunosuppressants

Oral steroids

Azathioprine

Ciclosporin

Mycophenolate mofetil

(methotrexate / alitretinoin)

Juvenile plantar dermatosis

Forefoot eczema, peridigital dermatosis, dermatitis plantaris sicca, atopic winter feet

Children aged 3-14 years

Shiny dry fissured dermatitis of plantar surface of forefoot. Striking symmetry.

? Secondary to changes in composition of shoes and socks in last 30 years

Treatment: Wear 100% cotton socks, stop wearing non porous footwear eg trainers. Urea preparations, lassars paste, WSP or tar.

Education

Discuss severity; explain usu improves, but can get worse in teens / adult life; link to A/H/Food allergy; post-inflammatory dyspigmentation; not clear re stress, humidity, temp extremes

Complementary Tx / food supplements not adequately assessed; caution if not labelled in English; steroids added to herbal products; liver toxicity with some Chinese products; inform you if using these

When to refer to dermatology

Diagnosis in doubt

Severe disease not responding to treatment

Secondary (or frequent) infection esp. Herpes simplex

Severe social/psychological problems /FTT

Treatment requiring excessive use of potent topical steroids

Suspected contact dermatitis (Type 4 allergy)(Type 1 food allergy suspected – refer to Dr Khakoo)

Thank you