Paediatric Eczema Dr Manjeet Joshi Consultant Dermatologist 16 th May 2012
Classification of the principal forms of eczema EXOGENOUS ENDOGENOUS Irritant Allergic contact Photoallergic contact Eczematous PLE Infective dermatitis Dermatophytide Post traumatic 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 1 st 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 2 nd line options Consider for facial eczema in children needing longterm 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