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The basics!!
Assessment
 Age of child –
developmental &
emotional
 Caregivers & environment
 Daily routine
 Skin condition of whole
body
 Acute, chronic, atopic,
contact dermatitis and /or
seborrhoeic
 What could be irritants in
regards to age & activities
Is to repair and maintain skin integrity and barrier function
Moist Wound Healing
 Provide moist environment
 Keep temperature close to body temperature
 Infrequent dressing changes
 Prevent or reduce scab formation
Practical Skin Care
 Emollients
 Topical Steroids
 Bacterial Management
 Wet Wraps / Dry wraps
 Identify irritants
 Behaviour modification
Management
 Practical tips on how to apply steroid and
emollients – amount, how often, when, why
 Prophylactic as well symptomatic
 Bathing – with emollient and volume
Emollients
 Should be applied in a variety of ways
including prophylactically
 Trouble shooting eg bacterial
contamination
 Behaviour management
Demonstrated multiple effects of
emollient on skin
 Decrease desquamation of the epidermis
 Improve skin barrier repair
 Decrease erythema and TEWL
 Increase SC hydration –
 Hydration persists with repeated application of emollient
but effect is shorter in atopic skin compared to normal skin
 Decrease potency of topical corticosteroid required (steroid
sparing)
Cork, M.J et al. (2003) Comparison of parent knowledge, therapy utilization and severity of atopic
eczema before and after explanation and demonstration of topical therapies by a specialist
dermatology nurse. British Journal of Dermatology, 149, 582-589
The clinical response observed in skin
with effective emollient use
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Decrease in dryness and scaling
Softening and increased elasticity
Decrease in erythema
Decrease in spongiosis
Decrease in itch
Decrease in Staph. Aureus
(due to decrease in skin dryness)
 Decrease in pigmentation changes
(over a period of weeks)
Topical Steroids
 When / how much to use
 The ‘step approach’
 What about infection?
Classes of topical steroids
 1: Very Potent ; up to 600 x
hydrocortisone
Dermal, Diprosone
 2: Potent ; 150-100 x
Beta, Betnovate, Locoid,
Elocon, Advantan
 3: Moderate ; 2-25 x
Aristocort, Eumovate
 4: Mild
hydrocortisone
0.5 - 2.5%
( DermNet NZ )
Precautions with:
Risk depends on:
 Children: higher
 Steroid strength
absorption due to thin skin
and larger surface area
 Occlusive dressings:
nappies, wet wraps
 infection, weeping areas,
pruritis etc
 Presence of excipients such
as coal tar, urea
 Length of application
 Site and type of skin
problem
 For example, if using
hydrocortisone(mild)
would need to use 500g per
week for adverse effect
 Aim is use the least potent topical steroid that is effective
 Choice will be dependent on age of the child, severity & site
 For the older child/ young adult a moderately potent
steroid may be used 1-2 x week for maintenance
 A step approach may be needed to effectively manage skin
inflammation
 Topical steroid must be used in conjunction with
emollients
Antihistamines
 Classified on their ability to
block actions of histamine
receptors in responsive
tissue
 1st generation may help due
to sedating effect
 Eczematous disease is T- cell
mediated
 Histamine plays no significant
role
 No evidence to show oral
antihistamines decrease itch in
eczema
Oilatum Plus/ QV Flare Up
 Bath additive : benzalkonium chloride 6%,
triclosan 2%, light liquid paraffin
 For topical tx of eczema including eczema at risk from infection
 1 - 2 mls in infant bath, 4 - 8 capfuls in bath
 Can be used on infants under 6 months
 If used daily for more than 5-7 days then step approach needs to
be used when decreasing
‘Since focusing on her baths the change in her skin has
been dramatic’
‘I think if more parents with eczema kids knew about
the importance of baths, we’d spare more kids (and
their parents) a lot of misery’
Bleach in the Bath!
 Evidence based
 Drying of skin & difficult to use on daily basis
 Gentler antimicrobials can be used daily
 Cost factor
 Half a cup of bleach in full bath
Dry Wraps
 Use once appropriate use of emollients and topical steroids are
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in place (there are always exceptions)
if overall eczema well managed but areas remain dry and /or
excoriated
Can introduce a family/individual to wrapping
Provides protection of skin & hydration
Tool in the ‘Tool Box’
Dry Wraps
Advantages:
Disadvantages
 Increased maintenance
 Drys out
of skin hydration
 Decreases emollient
application
 Protects skin
 Decreases itching
 Easy to use
 Requires regular
emollient application
initially
 Becomes itchy once
emollient absorbed
 Not as effective as
wetwraps
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Wet Wraps
Should be considered for  the severely affected child that is not well controlled despite adequate
emollients and topical steroids being applied appropriately.
 the child who does not sleep well at night despite good skin
management
 the child and /or family who have a good understanding of emollient
therapy but cannot or are unwilling to apply the amounts required.
Surprisingly, this is a good option for adolescents.
 Wet wrapping cannot be used when eczema is infected. The moisture
will encourage bacteria growth
Wet Wraps
 Need to be taught, managed and supported by
health professional who knows what they are
doing
 Otherwise can be ineffective and a valuable
management tool is lost
 If so can disappoint family and increase
disillusionment
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