Learning Circle: Jan 26, 2011 Childhood Eczema
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1 Learning Circle: Jan 26, 2011 Childhood Eczema Wingfield Rehmus, MD MPH BC Children s Hospital Clinical Assistant Professor, UBC Department of Paediatrics Associate Member, UBC Department of Dermatology and Skin Science
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3 Eczema! Greek Ekzema: ek=out zein=to boil! Non-contagious inflammation of the skin, characterized chiefly by redness, itching, and the outbreak of lesions that may discharge serous matter and become encrusted and scaly.! Many forms: atopic dermatitis, seborrheic dermatitis, nummular dermatitis, winter eczema, statis dermatitis, contact dermatitis! Most common form in children is atopic dermatitis
4 BC Children s Hospital Approximate number of visits for the 10 most common diagnoses Atopic Dermatitis 1100 Acne 160 Hemangioma 150 Congenital Nevus 100 Warts 95 Molluscum Contagiosum 85 Psoriasis 80 Eczema, NEC 75 Vitiligo 60 Nevus 40
5 Atopic Dermatitis
6 Atopic Dermatitis: Infants
7 Atopic Dermatitis: Older children
8 Infections
9 What causes atopic dermatitis Genetics Skin itself Immune system Assoc. with hayfever, food allergies, asthma Poor handling of infections esp staph Skin_Cancer_(Non-Meloma)/The_Basics/Epidermis-dermis.jpg
10 Filaggrin and Atopic Dermatitis Filaggrin mutation Strongest risk factor for AD Patients with mutation! High rate of referral to dermatologist! Refractory to treatment! Increased risk of asthma! Dry skin! Hyperlinear palms _default.jpg
11 What makes it worse?! Dry skin! Contact with chemicals and fragrances Bubble bath Harsh soaps Perfume Fabric softener, dryer sheets! Contact with saliva, acidic foods! Contact with irritating fibers i.e. wool, tags in clothing! Infections
12 Impact on the family! Concern! Frustration comes and goes! Sleeplessness! Extra work, time! Cost! Changes in food prep/eating! Social concerns embarrassment, fear of contagion
13 What can be done to make it better?! There is NO cure! Fix the protective function Moisturize!!!!! Avoid contact with triggers No bubble bath, soap with fragrance Fragrance free laundry soap, no dryer sheets Cut tags out of clothing Rinse after swimming! Use medicine to calm the immune system Corticosteroids Steroid sparing agents! Prevent and treat infections
14 Atopic Dermatitis Home Care! Daily bath: warm not hot, 10 minutes! No scented products in bath! Wash with mild cleanser Dove Sensitive Skin, Cetaphil, Spectro, etc. No Ivory, Dial, Irish Spring, bath gels! Pat dry! Immediately apply medication! Seal medication in with plain moisturizer Ointment, cream! Use moisturizer several other times a day
15 Treatment! Corticosteroids ointments > creams > lotion Hydrocortisone 1%, 2.5% Betamethasone valerate 0.1% Mometasone 0.1%! Calcineurin inhibitors (tacrolimus, pimecrolimus)! Antihistamines Benadryl, Hydroxyzine! Systemic Therapy: NbUVB, MTX, CSA, Azathioprine
16 What else can parents/caregivers do?! Keep fingernails short! For babies, sleep with socks on hands! Cover areas frequently scratched after applying medicine! Consider impact of mold, dust mites, dander, pollens Mattress covers Avoid wall to wall carpets Dogs better than cats! Breastfeeding until 6 months, then introduce all foods
17 Eczema and food allergies! AD and food allergies are related! Children with AD have an increased risk of food allergy! Food allergies do not cause eczema! Occasionally withdrawing a food can make eczema better! Possibly food allergies occur due to contact between food and broken skin! Most common causes of food allergy in US Dairy, wheat, nuts, egg, shellfish, soy
18 Infections! Prevention Baths with!-!cup bleach per full tub If recurrent, consider staph carrier state! Impetigo! Treat both nares and perianal area with mupirocin BID for 3 weeks Culture Keflex, Erythromycin, Clindamycin! Eczema herpeticum IV acyclovir
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20 Differential Diagonsis: Could this be anything else?! Tinea Corporis Edges are more distinct Improves, then worsens with steroid use Raised border, often with scale Central plaques less scaly
21 Scabies! Scabies Itching out of proportion to findings Papules, nodules, pustules - esp hands, feet, axilla Other family members itchy Lack of typical eczema features
22 Nummular eczema! Localized! With or without history of atopic dermatitis! Often require stronger corticosteroids to treat! Often have a secondary infection associated
23 Seborrheic dermatitis! Generally more limited involvement - head and scalp plus folds! Yellow greasy scale compared to dryer appearance of AD scale Photos courtesy of DermAtlas.com
24 Atopic Dermatitis! Barrier inadequate -> water out and irritants in! Over-active immune response which worsens barrier! Treatment Emolliation Corticosteroids:! HC ointment to face and groin! Betamethasone valerate to moderate plaques or everywhere to calm a major flare! Mometasone to thicker, stubborn areas Calcineurin inhibitors! Around eyes, to groin, if concerned about atrophy! Perhaps as maintenance Newer moisturizers with ceramides etc. an alternative but pricey Avoid abrupt discontinuation of steroids, calm parents fears about steroid use,! Bleach baths! c bleach in tub for crusted, excoriated patients! Antihistamines if disrupting sleep! Antibiotics if clearly infected
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