Download Management of atopic eczema in children

PRESCRIBING IN CHILDREN n
Management of atopic eczema
in children
REBECCA PHILLIPS, HYWEL WILLIAMS and JANE RAVENSCROFT
Atopic eczema is a
common condition,
affecting about a fifth of
children in the UK.
Although the severity
varies, it can cause great
distress to a child and
their family. This article
discusses the evidencebased management of
atopic eczema in children.
A
topic eczema, or atopic dermatitis, is
a very common chronic inflammatory
skin condition with a genetic tendency
that is influenced by environmental factors. Around 20 per cent of UK children
are affected, with most presenting in
infancy. The symptoms can cause a great
deal of distress to both a child and their
family. Up to 60 per cent of children will
grow out of the condition by early adolescence although many will have future
relapses. While the severity of the condition varies greatly, most children will suffer with mild disease and the majority of
these patients rely on primary care input.
Atopic eczema is characterised by skin
dryness, itching, redness, vesicles and
crusting in the acute stage, and lichenification in the chronic phase. The clinical
presentation of eczema varies depending
on the age of the child affected; infants
under the age of one year usually present with eczema on the cheeks and scalp,
whereas in those older than one year,
eczema often extends to affect the extensor surfaces. In older children, eczema
may become more widespread and typically involves the flexural surfaces (see
Figure 1). Simple validated diagnostic criteria have been developed that may assist
in diagnosis (see Table 1).1
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Figure 1. Moderate-to-severe eczema in a
9-year-old girl
This article focuses on the management of atopic eczema in children. It presents the evidence supporting current
interventions and proposes treatment
approaches for example cases.
Aim of management
The aim of the management in atopic
eczema is first, to get control of skin
inflammation and second, to then
maintain control while at the same
time enhancing the skin hydration and
barrier through emollient use. This
management approach first involves
identifying and minimising potential
trigger factors. Once allergic or irritant
factors are identified and dealt with,
Prescriber January 2016 z 33
n PRESCRIBING IN CHILDREN l Eczema
Must have:
An itchy skin condition in the last 12 months
Plus three or more of:
i. Onset below age two years*
ii. History of flexural involvement
iii. History of a generally dry skin
iv. Personal history of other atopic disease**
v. visible flexural dermatitis as per photographic
protocol
* not used in children under four years
** in children aged under four years, history of atopic
disease in a first-degree relative may be included
Table 1. UK diagnostic criteria for atopic eczema1
the key is then to control skin inflammation.
The NICE guideline presents a stepwise management approach to eczema
depending on the severity, as shown in
Table 2. Patient and family education,
along with a clear written care plan, are
vital to ensure a good understanding of
the condition, compliance and effective
management of future flares. This is particularly important, as topical treatments
can be time-consuming and messy. It is
also imperative to address any potential
fears regarding side-effects of medications, such as topical steroids, which
may hinder adequate treatment.
Table 3 outlines the factors to consider when managing a child with atopic
eczema and Table 4 summarises the
treatment approaches in mild-to-moderate and moderate-to-severe eczema
flares.
Management of mild-tomoderate eczema
Emollients
Liberal use of emollient therapy in managing eczema is currently recommended
but should be tailored according to the
individual patient and degree of skin
dryness. Even though the evidence for
using these products is limited, recent
studies have highlighted the steroid-sparing effects of emollient therapy and
their ability to prevent eczema flares.2,3
Emollients are safe to use and have few
adverse effects, which are usually mild
and include transient burning and poor
cosmetic acceptability. However, some
emollients such as the aqueous cream
have actually been shown to cause
harm.4 Because emollients need to be
applied daily and lifelong, patients should
be given a choice of emollients and more
than one may need to be prescribed, for
example, a different emollient for the
face and body.
Topical corticosteroids
Topical corticosteroids have been shown
to be significantly more effective at
treating patients with atopic eczema in
the short-term compared with placebo.5
Intermittent treatment with fluticasone
propionate using various regimens
has been shown to significantly reduce
relapse rates of eczema.6 Such intermittent use (also known as “weekend
therapy” as it refers to application at previously active sites on two to three days a
week) is perhaps one of the most useful
Mild atopic eczema
Moderate atopic eczema
Severe atopic eczema
Emollients
Emollients
Emollients
Mild-potency topical
corticosteroids
Moderate-potency topical
corticosteroids used
proactively
Potent topical
corticosteroids
Topical calcineurin
inhibitors
Topical calcineurin
inhibitors
Bandages
Bandages
Phototherapy
Systemic therapy
Table 2. NICE guideline: a stepwise approach to the management of atopic eczema13
34 z Prescriber January 2016
evidence-based treatment approaches to
emerge for those with chronic or relapsing eczema.
All patients should be started on
once daily treatments as twice daily
applications have shown no additional
benefits.6 Pulsed treatment has also not
shown any benefit over continuous treatment, and there is no good evidence to
support dilution of preparations. Shortterm treatment is not associated with
any serious systemic effects or skin atrophy.6 It should be stressed that side-effects of topical corticosteroids rarely
occur when they are used appropriately
and it is important to dispel any anxieties surrounding their use. The largest
eczema trial ever conducted showed that
mild or moderate topical corticosteroids
are extremely safe when used as needed
over a five-year period; just one case of
clinical skin thinning out of 1213 children
(0.1 per cent) was noted.7
Bandaging
Application of wet-wrap bandaging over
emollients or topical steroids may be of
some benefit to certain patients. Studies
have shown that bandaging can significantly reduce the severity of the condition; however, other studies have found
no benefit.8-10
Oral antihistamines
There seems to be no clear benefit of
administering oral antihistamines and
these are not recommended. However,
the sedative effect may be of some benefit in individual cases.6
Topical tacrolimus and pimecrolimus
Topical tacrolimus (Elidel) and pimecrolimus (Protopic 0.03% and 0.1%) are
immunosuppressive agents. Both have
been shown to be more effective than
placebo. Topical tacrolimus is more
effective than topical pimecrolimus
and of similar efficacy to mild or moderate corticosteroids in the treatment
of eczema.11,12 Topical pimecrolimus is
aimed at milder atopic eczema where
its main claimed advantage is absence
of skin thinning, yet a direct comparison
of topical pimecrolimus against mild or
moderate topical corticosteroids did not
show any significant skin thinning in the
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Eczema
corticosteroid group.7 NICE recommends
both topical tacrolimus and pimecrolimus
as second-line therapy in moderately
severe and severe eczema.13
Various safety studies have demonstrated that shor t-term use of tacrolimus is safe and there is no clear
evidence of increased risk of skin
malignancy. 6 The precise role of topical pimecrolimus for mild eczema is
unclear, although it appears to be safe
over a five-year period. Higher potency
0.1% tacrolimus is more likely to cause
local skin burning and irritation than
0.03% tacrolimus or moderate potency
topical corticosteroids.11
In clinical practice, topical tacrolimus may be useful as an alternative for
patients requiring almost continuous topical preparations or in those with resistant facial eczema. Lower potency 0.03%
tacrolimus is licensed for use in children
from the age of two years, while 0.1% tacrolimus is licensed only for children aged
16 years and above. They should be used
once or twice daily until symptoms have
resolved or can be used intermittently to
prevent flares. These medications should
usually be initiated under the guidance
of a GP with a special interest (GPSI) in
dermatology or a dermatologist.
Allergens
Sensitisation to aeroallergens and food
allergens is present in 70–80 per cent
of children with moderate-to-severe
eczema, but this does not imply clinical
allergy, which is best assessed through
thorough questioning.14 Common food
allergens in young children include cow’s
milk, egg, peanuts, soya and tree nuts,
while allergies to fish, tree nuts and
peanuts are more frequent in older children. Many children will grow out of milk
and egg allergies by the age of about
three years.14 A food allergy should be
considered in children with a history of
a reaction to certain foods, those with
moderate-to-severe eczema who have not
responded to usual treatment, those with
early-onset eczema in infancy and those
with associated gut symptoms.
There is no evidence that exclusion diets have a beneficial impact
on eczema in unselected patients. 15
However, in infants with a suspected
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l PRESCRIBING IN CHILDREN n
Factor
Comment
Age of child
Severity of eczema
Pattern of eczema
•S
ide-effects are more common in young infants
• Important to prescribe a steroid of adequate potency
• Discoid and extensor eczema are often more stubborn
and require longer or more aggressive treatment with
topical agents
• To guide emollient use
• To guide future treatment
Skin dryness
Previous treatments and
their effect
Possible trigger factors,
eg irritants, allergens,
stress, infections
Compliance/attitudes
Psychosocial impact
Growth and development
Sleep disturbance
Personal history of
atopic disease
•D
iscuss avoidance of triggers and consider referral for
allergy assessment if indicated
•P
arents may have preconceived ideas about eczema or
treatments
• The psychosocial impact on the child and family should
be explored. Consider involving school nurses
• Severe eczema may affect the growth of a child
• Poor sleep can have a negative psychological impact
• Consider and treat co-morbidities in children with atopic
disease
Table 3. Factors to consider when managing a child with atopic eczema
allergy to egg and a positive specific IgE
test, exclusion diets may help.6 Children
with suspected food allergies should be
referred for specialist assessment and
advice, which may include skin prick
tests and specific IgE tests. A six-toeight week trial of hypoallergenic bottle
formula may also be tried in babies with
moderate-to-severe eczema younger
than six months old.14
Allergy to environmental aeroallergens such as house dust mites, pets
and pollens, and to contact allergens
such as fragrances and preservatives, is
more common in older children. It may
be suspected in those with a seasonal or
environmental variation in their eczema
and those with a particular distribution
of eczema. Response to these allergens
may also be investigated by skin prick
tests, specific IgE or patch testing if
indicated, which can help guide advice
on allergen avoidance. Evidence for the
efficacy of house dust mite reduction
methods is limited and of low quality.16
They are generally not recommended as
they are time consuming and probably
not beneficial.13
Washing and bathing routines
There is no randomised controlled trial
(RCT) evidence on the effects of bathing frequency, showers versus baths or
water temperature.6 Bath additives may
appear to be a useful way to use emollients but there is no clear evidence to
support their use over and above direct
topical application. In practice, patients
are advised to avoid soaps and bubble
bath and instead to use emollients exclusively to moisturise and wash.
Washing powders and clothing
There is no evidence to suggest that biological washing powders provoke worsening of eczema compared to nonbiological
products.6 Synthetic fibres and rough
textiles in clothing may be irritating and
should be avoided.
Psychological interventions
Some psychological interventions may
be useful as an adjunct in managing
eczema, such as cognitive behavioural
therapy (CBT), habit reversal and hypnotherapy.17-19
Severe eczema
Systemic therapy and ultraviolet light
Systemic immunosuppressive therapy,
including ciclosporin, methotrexate,
azathioprine, and phototherapy, can be
used to gain control of severe atopic
eczema. Despite not being licensed for
use in children, there is reasonable evidence to suggest that these agents are
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n PRESCRIBING IN CHILDREN l Eczema
Case
Example of treatment approach
Mild-to-moderate
eczema flare
•L
iberal use of emollients and soap substitutes tailored to
skin dryness. These should be prescribed regularly and
used even when the eczema is not active
• Consider infection and triggers
• Short bursts (3–7 days) of a mild topical steroid such as
hydrocortisone 1% once daily to control flares. If this is
not adequate, a moderately potent topical steroid such as
clobetasone butyrate 0.05% ointment can be tried using
such a reactive approach
Moderate-to-severe
eczema flare
•L
iberal use of emollients and soap substitutes as above
• Consider infection and triggers
• Potent topical corticosteroid such as betnovate valerate
0.1% ointment once daily to eczematous areas of the body
for 1–3 weeks until clear, followed by an emollient-only
period. Any future flares should be treated with short bursts
of the same potent steroid
• Areas on the face, axillae and groin should be treated with
a moderately potent steroid such as clobetasone butyrate
0.05% ointment to avoid side-effects
• In the case of frequent flares, once the initial 1–3 week
treatment has been completed, a topical corticosteroid can
be continued as weekend therapy (Sat/Sun) to maintain
control of the eczema and prevent relapses. Alternatively,
Protopic ointment may be used intermittently, eg twice
weekly Mon/Thur, to keep control of flares in the same way
Antiseptics
Antiseptics preparations can be used in
patients who suffer with recurrent clinical
skin infections but their long-term regular use is not supported by any studies.
The use of bleach baths appears to have
some benefit in children with moderate-to-severe eczema who have recurrent
significant skin infections. 6 One study
has recommended that 250ml Milton
Sterilising Fluid (containing 2% sodium
hypochlorite) is added to a full bath tub
(about 120 litres). The patient should
soak in the water for 5–10 minutes
before rinsing thoroughly, once or twice
weekly.24
Aciclovir
If a child with eczema is suspected
to have a localised herpes simplex
infection, oral aciclovir should be commenced.13 Eczema herpeticum presents
with widespread, rapidly worsening and
painful eczema, clustered vesicles and
punched-out lesions. If this is suspected,
systemic aciclovir should be started
immediately and the patient must be
referred for urgent specialist advice.13
Table 4. Treatment approaches in mild-to-moderate and moderate-to-severe eczema
References
effective. They should be initiated and
monitored in a secondary care setting.
Short-term (five to seven days) oral
prednisolone may be useful in a crisis,
but this is not recommended longer
term due to rebound.20 Ultraviolet light
in the form of narrow-band UVB is commonly used in a hospital setting for
those with more severe eczema with
inadequate responses to topical therapies.
1. Williams HC. UK diagnostic criteria for
atopic dermatitis. Centre of Evidence Based
Dermatology, Nottingham (cited 2015).
Available at: http://www.nottingham.ac.uk/
research/groups/cebd/resources/ukdiagnostic-criteria-for-atopic-dermatitis.aspx.
2. Grimalt R, et al. The steroid-sparing effect
of an emollient therapy in infants with atopic
dermatitis: a randomized controlled study.
Dermatology 2007;214(1):61–7.
3. Wiren K, et al. Treatment with a barrier-strengthening moisturizing cream delays
relapse of atopic dermatitis: a prospective and
randomized controlled clinical trial. J Eur Acad
Dermatol Venereol 2009;23(11):1267–72.
4. Cork MJ, Danby S. Aqueous cream
damages the skin barrier. Br J Dermatol
2011;164(6):1179–80.
5. Hoare C, et al. Systematic review of treatments for atopic eczema. Health Technol
Assess 2000;4(37):1–191.
6. Williams HC, Bigby ME. Evidence-based
Dermatology. 3rd edn. Chichester, West
Sussex: John Wiley & Sons, Ltd, 2014.
7. Sigurgeirsson B, et al. Safety and efficacy of pimecrolimus in atopic dermatitis: a 5-year randomized trial. Pediatrics
2015;135(4):597–606.
Infected eczema
Systemic antibiotics
Clinically infected eczema has been
shown to respond to systemic anti­
b i o t i c s , s u c h a s f l u c l o x a c i l l i n . 21
However, there is no benefit for their
use in clinically uninfected eczema.22
Patients should continue to use topical corticosteroids and emollients to
treat the underlying eczema, although
it is reasonable to delay the use of
topical corticosteroids by 24–48 hours
in cases of widespread or severe
infection.
Patients with atopic eczema are more
prone to acquiring bacterial, viral and
fungal skin infections. Infection might
present with weeping, oozing and serous
crusting overlying the eczematous
lesions. Staphylococcus aureus is the
most commonly implicated organism,
which is found in around 80 per cent of
people with atopic eczema even in the
absence of clinical infection. Other organisms include β-haemolytic streptococci,
herpes simplex and the yeast Malassezia
furfur.
Topical antibiotics
NICE recommends that topical antibiotics, including those in combination with
topical steroids, should only be used
for short periods (less than 14 days) in
cases of clinically infected eczema.13
However, there is no clear evidence that
the addition of antibiotics to topical corticosteroids offers any advantage over
topical corticosteroids alone, and they
are not recommended in noninfected
eczema.6,23
36 z Prescriber January 2016
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Eczema
8. Pei AY, et al. The effectiveness of wet wrap
dressings using 0.1% mometasone furoate
and 0.005% fluticasone proprionate ointments in the treatment of moderate to severe
atopic dermatitis in children. Pediatr Dermatol
2001;18(4):343–8.
9. Hindley D, et al. A randomised study
of “wet wraps” versus conventional treatment for atopic eczema. Arch Dis Child
2006;91(2):164–8.
10. Beattie PE, Lewis-Jones MS. A pilot
study on the use of wet wraps in infants with
moderate atopic eczema. Clin Exp Dermatol
2004;29(4):348–53.
11. Svensson A, et al. A systematic review of
tacrolimus ointment compared with corticosteroids in the treatment of atopic dermatitis.
Curr Med Res Opin 2011;27(7):1395–406.
12. Cury Martins J, et al. Topical tacrolimus for
atopic dermatitis. Cochrane Database Syst Rev
2015;7:CD009864.
13. NICE. Atopic eczema in children: management of atopic eczema in children from birth
up to age of 12 years. CG57. December 2007.
https://www.nice.org.uk/guidance/CG57
14. Harper J, et al. Textbook of Pediatric
Dermatology. 3rd edn. Oxford: Blackwell
Publishing, 2012.
15. Bath-Hextall F, et al. Dietary exclusions
for established atopic eczema. Cochrane
Database Syst Rev 2008;1:CD005203.
16. Nankervis H, et al. House dust mite
reduction and avoidance measures for treat-
ing eczema. Cochrane Database Syst Rev
2015;1:CD008426.
17. Melin L, et al. Behavioural treatment of
scratching in patients with atopic dermatitis.
Br J Dermatol 1986;115(4):467–74.
18. Noren P, Melin L. The effect of combined
topical steroids and habit-reversal treatment in patients with atopic dermatitis. Br J
Dermatol 1989;121(3):359–66.
19. Sokel B, et al. The development of a
hypnotherapy service for children. Child Care
Health Dev 1990;16(4):227–33.
20. Schmitt J, et al. Prednisolone vs.
ciclosporin for severe adult eczema. An
investigator-initiated double-blind placebo-controlled multicentre trial. Br J Dermatol
2010;162(3):661–8.
21. Salo OP, et al. Efficacy and tolerability
of erythromycin acistrate and erythromycin
stearate in acute skin infections of patients
with atopic eczema. J Antimicrob Chemother
1988;21(Suppl. D):101–6.
22. Ewing CI, et al. Flucloxacillin in the treatment of atopic dermatitis. Br J Dermatol
1998;138(6):1022–9.
23. Birnie AJ, et al. Interventions to reduce
Staphylococcus aureus in the management of
atopic eczema. Cochrane Database Syst Rev
2008;3:CD003871.
24. Vlachou C, et al. Bleach baths using
Milton Sterilising Fluid for recurrent infected
atopic dermatitis. Am J Acad Dermatol 2010;
63(Suppl. 1):126.
l PRESCRIBING IN CHILDREN n
Further reading
NICE. Eczema - atopic. Clinical Knowledge
Summaries. July 2015. http://cks.nice.org.
uk/eczema-atopic
University of Nottingham. The Global Resource
for Eczema Trials. December 2014. http://
www.greatdatabase.org.uk/GD4/Home/
Index.php
University of Nottingham Centre of EvidenceBased Dermatology. Maps of systematic
reviews on atopic eczema. May 2014.
http://www.nottingham.ac.uk/research/
groups/cebd/documents/methodologicalresources/maponaewebsite.pdf
Declaration of interests
None to declare.
Dr Phillips is a clinical fellow in paediatric
dermatology at Nottingham University
Hospital/Nottingham Children’s Hospital,
Dr Ravenscroft is a consultant
dermatologist at Nottingham University
Hospital/Nottingham Children’s Hospital
and Professor Williams is professor of
dermato-epidemiology and
co-director of the Centre of EvidenceBased Dermatology, Nottingham
University Hospitals NHS Trust
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