Paediatrics: Atopic eczema/dermatitis

Atopic eczema/dermatitis

The terms atopic eczema and atopic dermatitis are used interchangeably.

•   One of the most common skin diseases affecting children, with a prevalence of 5–15% in developed countries.

•   The age of onset is less than 6mths in 75%.

•   Flare-ups are commonly due to dry skin, irritants, infection, sweating/ heat, emotional stress, and occasionally allergies.

Aetiology

•   Genetic susceptibility.

•   Impaired epidermal barrier function.

•   Immune dysregulation.

•   Allergen (food and airborne) sensitization and infection play a lesser role.

Presentation

See Plate 1.

•   Acute eczema may be erythematous and weeping.

•   Chronic eczema may be lichenified and dry.

•   There are often s changes of excoriation, post-inflammatory hypo/ hyperpigmentation and infection.

•   Infant eczema often affects cheeks, elbows, and knees with crawling.

•   Childhood eczema is often flexural; also affects the wrists and ankles.

•   Adolescent and adult eczema is also flexural, but may also affect the head and neck, nipples, palms, and soles.

Treatment

•   General measures: soap avoidance, e.g. soap free bath oil or wash. Limit showers/baths to 5–10min in lukewarm water. Moisturize immediately after showering. Wear loose fitting cotton undergarments. Avoid over heating. Keep finger nails short.

•   Specific measures: use topical corticosteroids daily until the eczema is clear, then taper off on alternate days for 1wk and then twice weekly before stopping. If the eczema returns resume once daily application until clear and then recommence taper.

•   ointments are generally better than creams;

•   wet dressings improve efficacy and can be done at home;

•   swab suspected infection (viral PCR, immunofluorescence or culture and bacterial cuture);

•   treat promptly with antibiotics or antivirals after this;

•   sedative antihistamines may improve sleep at night for those older than 2yrs.

•   In those not improving, review the causes for flare-ups (see b ‘Presentation’, above). They may need admission to hospital for intensive wet dressings or referral to a dermatologist for consideration of phototherapy or systemic therapy.

For mild eczema: a mild potency topical corticosteroid ointment, e.g. 1% hydrocortisone, is appropriate daily for anywhere on the body.

• For mild to moderate eczema, a moderate potency topical corticosteroid ointment: e.g. clobetasone butyrate 0.05%, is appropriate and safe for daily use on the face and body, but not the groin.

• For moderate to severe eczema, a potent topical corticosteroid ointment, e.g. mometasone furoate, is appropriate daily for the body, but not the face or groin.

Complications

• Sleep disturbance.

• Emotional upset.

• Family dysfunction.

• Eczema herpeticum (HSV)

• Staphylococcus aureus infection

• Growth delay.

• Atopic cataracts.

Prognosis

The natural history tends towards resolution with age. Predicting this is dif-ficult, however, early onset severe disease with associated atopy (hayfever and asthma), and elevated IgE may be associated with a worse prognosis.