RELEVANT DISCLOSURES MANAGING ECZEMA IN INFANTS AND CHILDREN Advisory board member - MEDA (Elidel), Speaking honoraria Bayer (Advantan) Advisory board, consultant, speaker: Pfizer, Abbvie, Janssen, Elli Lilly, Novartis Dr Jason Wu Dermatologist Princess Alexandra Hospital Toowong Dermatology ATOPIC DERMATITIS / ECZEMA Common- 10-30% of children Onset typically in early childhood, but can onset at any time, including in adulthood Q. Will my child grow out of it? https://oxforddermatology.com.au/skin-conditions/eczema/ https://www.dermnetnz.org/topics/atopic-dermatitis/ https://www.dermnetnz.org/imagedetail/6289 1
TODDLERS http://www.pcds.org.uk SCHOOL AGE COMPLICATIONS www.pcds.org.uk https://www.dermnetnz.org/topics/atopic-dermatitis-images/ https://www.dermnetnz.org/ 2
ECZEMA HERPETICUM https://www.dermnetnz.org/ WHAT IS MY CHILD ALLERGIC TO? PATHOGENESIS Complex interplay between genetics and environment Barrier defect & immune system dysfunction Can become self sustaining, exaggerating barrier defects, autoactivation of immune system, increase development of allergy to environment allergens. FACTORS Immaturity of the infant immune system Irritants soaps, detergents, scratching, rough fabrics climate Allergens house dust mite, dust, animal dander Microbiome, and Staph superantigens Stress physical (illness), new challenges (infection, new foods), psychological The Lancet. Volume 361, No. 9352, p151 160, 11 January 2003 3
WHAT IS MY CHILD ALLERGIC TO? ECZEMA AND FOOD ALLERGY Food allergy: Urticaria and/or angioedema (rarely anaphylaxis), or abdominal pain soon after eating offending food i.e. different to eczema Coexists in a third of moderate to severe eczema Cow's milk, hen's egg, peanut, wheat, soy, nuts, and fish are responsible for >90% of food allergy in children with AD. DETERIORATION OF ECZEMA WITH NEW FOODS ASSOCIATIONS Parents may commonly notice the eczema getting worse when new foods are introduced. only very rarely due to a true allergy. Eczema tends to deteriorate with stresses the body is facing, including any new challenge, such as the digestive system getting used to a new food Exposure of potential allergens through the skin favours development of allergy; Exposure to the digestive tract favours tolerance. Atopic march Asthma Hay fever Food allergy TREATMENT GENERAL Minimize barrier disruption Reduce exposure to environmental allergens Treat infection Treat inflammation 4
MINIMIZE BARRIER DISRUPTION Avoids skin contact with soaps Use soap-free wash Avoid bubble baths Emollients Which one? Can you prevent atopic dermatitis with regular emollient? Avoiding irritating fabrics Minimize scratching REDUCE EXPOSURE TO ENVIRONMENTAL ALLERGENS House dust mite protective linen and pillow case Avoid dust exposure Avoid grasses and pollens in those to are sensitive Avoid other sensitizing agents e.g. fragrance in creams Reduce Staphyloccus aureus causes a superantigen response BLEACH BATHS BLEACH BATHS 60mL 75L water http://markwardplayground.com/pool.html TREAT INFLAMMATION Mainstay is topical corticosteroids topical cortisones vs topical steroids 5
STEROIDS DIDN T WORK The steroids work, but it comes back I was advised to only use sparingly, so I didn t want to use it I was advised to only use the steroids for 1 week SIDE EFFECTS??? Don t steroids cause skin thinning? TOPICAL CORTICOSTEROIDS Face & Flexures Trunk and Limbs Lichen simplex chronicus Strength medication Brands Mild 1% hydrocortisone e.g. Sigmacort, Dermaid Moderate Betamethasone valerate 0.02% ~10x Triamcinolone acetonide 0.02% Triamcinolone acetonide 0.02% Methylprednisolone aceponate 0.1% Potent Mometasone furoate 0.1% Betamethasone diproprionate 0.05% ~50x Superpotent Betamethasone diproprionate 0.05% in optimized vehicle ~100x Clobetasol propionate 0.05% ointment e.g. Celestone M, e.g. Aristocort e.g. Tricortone e.g. Advantan e.g. Elocon, Zatamil e.g. Diprosone, Eleuphrat e.g. Diprosone OV e.g. Dermovate VEHICLES Ointment Creams Lotions Hydrogels Foams VEHICLE Less stinging especially acute disease Generally more effective, less sensitization, But greasy, so poorer compliance Better for acute disease Better tolerated for longer term use Better for scalps For scalp or body OCCLUSION WET WRAPS Acute therapeutic intervention for treatment of moderate to severe AD. Using clothing instead of bandages makes this intervention simpler, less time intensive, and less expensive https://basicmedicalkey.com/lichen-simplex-chronicus-2/ https://www.adrescuewear.com/effective-treatment-for-eczema/ 6
SOAK AND SMEAR QUANTITY?finger tip unit? apply sparingly vs apply sufficient to cover area Counting tubes used E.g. how long does a 15g tube last. REACTIVE TREATMENT Disease control IIIII IIIIIII IIII Treatment application PROACTIVE TREATMENT IIIII I I I I I I I I I I SOME KEY POINTS Most topical corticosteroids can be applied once daily The recommendation use sparingly is non-sensical What is commonly interpreted as skin-thinning by parents and non-dermatologists is usually a misinterpretation of active eczema When topical corticosteroids are used for treatment of eczema in children are stopped on resolution of the eczema, irreversible skin thinning does not occur Topical corticosteroids do not induce striae when used to treat eczema in children, unless used inappropriately or in overdose, and even then, on at certain sites (axillae/groin) Physiological HPA suppression can occur with very widespread and prolonger, or occlusive use of potent/superpotent topical corticosteroids. This recovers quickly Fine to use topical corticosteroid on excoriated or infected skin Topical corticosteroids should be first-line treatment for atopic dermatitis Hypopigmentation seen in patients treated with topical corticosteroids is due to the eczema, not the treatment 7
TOPICAL CALCINEURIN INHIBITORS PHOTOTHERAPY AND SYSTEMICS Elidel Tacrolimus ointment (compounded) TAKE HOME MESSAGES Give advice on general measures Topical corticosteroids are extremely safe in this age-group Don t unnecessarily contribute to topical corticosteroid phobia Discourage exhaustive searches for elusive allergens causing the eczema encourage parents to treat the disease properly. 8