THIS SITE IS INTENDED FOR HEALTH PROFESSIONALS ONLY

Ana  Also from Pulse

Search 

Your premium account expires in 17 days

  My modules  Key questions on eczema in children  Article module 

Key questions on eczema in children

Key questions on eczema in children

Key questions on eczema in children

Parents often ask us whether their child will grow out of eczema. What is the prognosis
for childhood eczema, and what are the pointers to a poorer prognosis?
Most children’s atopic dermatitis will gradually improve as they get older. Many children are better by
age three and 60-70% will grow out of their eczema by their teenage years, although they will always
have a tendency towards dry, sensitive skin. One study, however, claimed that symptoms may persist
2
until age 20. Persistence of eczema into adulthood is thought to be associated with early age of onset,
3
childhood allergic rhinitis and presence of hand eczema.

Which general self-help measures, such as wearing certain types of clothing, reducing
house dust and so on, have a real evidence base?
Daily liberal use of emollients is one of the most important things that patients can do to prevent ares
of eczema, and emerging data support the use of emollients from birth to prevent onset of atopic
4
dermatitis. Evidence for environmental modi cation is limited, and opinion is based on expert
recommendations. Recommendations are to avoid known chemical or physical irritants (such as wool, /
solvents and heat). Sensitisation to house dust mites is common in patients with eczema and exposure
5
may worsen asthma and allergic rhinitis. Evidence for dust mite avoidance is limited and normal
cleaning only marginally reduces allergen levels in the home. ‘Dust mite covers’ do show a reduction in
house dust mites and sensitisation, but the clinical relevance of this is questionable – and in clinical
6
studies this has not translated into an improvement of eczema in adults. One small study found that
covers improved eczema severity scores in children, with greater e ect seen in those with more severe
6
disease.

Avoiding irritating fabrics is encouraged, but evidence to support the use of silk fabrics (and their
associated high cost) has been mixed. A recent randomised, controlled, observer-blind trial of 282
children aged between one and 15 years concluded that silk clothing was unlikely to provide additional
7
bene t over standard care in children with moderate to severe eczema.

How should we respond to parents who ask for allergy tests for their child with eczema?
The impact of food exposure on the course of eczema remains unclear. If allergies are suspected of
8
triggering a child’s atopic dermatitis, recording a food diary may be helpful. GPs should consider food
allergy when children have had immediate reactions to food, or in children with moderate or severe
atopic dermatitis that is not controlled by optimal therapy, or when gastrointestinal symptoms are
present – particularly in those aged under ve. NICE suggests considering inhalant allergy in children
who have seasonal ares of their eczema, when eczema is associated with asthma or allergic rhinitis,
and in children aged over three years with atopic dermatitis on the face, particularly around the eyes.

Children and their families should be reassured that most children do not need allergy testing, and they
should be discouraged from seeking allergy testing from the internet or the high street as there is no
evidence of its value in the management of atopic eczema. Children should be referred for specialist
dietary advice following an eight-week trial of a cow’s milk-free diet when cow’s milk protein allergy is
suspected.

GPs often worry about what potency of steroid is safe on a child, how to adjust for
di erent areas and how long to use it for. Can you provide guidance?
Undertreatment is a common cause of low e cacy and parents report concern about over-using topical
steroids on their child’s skin. Side-e ects are of great concern to parents but the incidence of skin
thinning, striae and HPA axis suppression is low in clinical practice (particularly with mild-to-moderate
9
potency steroids used in primary care). Fingertip units (FTU) are a highly useful tool for educating
patients on how much topical steroid they should be applying. There are useful lea ets to help patients
understand how much cream to apply (for example, one adult FTU is su cient to cover the arm and
hand of a three-to-six-month-old baby).

Mildly to moderately potent topical steroids are generally safe to use in children for short durations and
for appropriate in ammatory conditions. Moderately potent steroids should not be used for more than
two weeks and children under 12 generally should not be prescribed potent or superpotent steroids

/
without specialist supervision. Moderately potent topical steroids should be used with caution on the
face and intertriginous zones.

NICE suggests:

Use mild potency for mild atopic eczema.

Use moderate potency for moderate atopic eczema.
Use potent for severe atopic eczema.
Use mild potency for the face and neck, except for short-term use (three to ve days) of moderate
potency for severe ares.
Use moderate or potent preparations for short periods only (seven to 14 days) for ares in vulnerable
sites such as axillae and groin.

Children generally require less steroid than adults because of their smaller body surface area. One
guideline suggests that infants be given one- fth of the adult dose, children be given two- fths and
10
adolescents be given two-thirds.

When should GPs suspect that cow’s milk protein intolerance might be playing a role in a
child’s eczema?
Cow’s milk protein allergy is estimated to have a prevalence of between 2% and 7.5% in formula or
mixed-fed infants, and 0.5% in exclusively breastfed infants. Symptoms may be immediate (IgE-
mediated) or delayed. Evaluation of an infant with suspected cow’s milk protein allergy should include a
thorough history, examination and family history. Although presentations may vary, children will typically
have gastrointestinal disturbance and atopic dermatitis, with up to 30% having upper respiratory tract
11
symptoms.

Allergen elimination diets are the gold-standard diagnostic test for suspected cow’s milk allergy. NICE
suggests that bottle-fed infants aged under six months with moderate or severe atopic eczema that has
not been controlled by optimal treatment with emollients and mild topical steroids should be o ered a
six-to-eight-week trial of an extensively hydrolysed protein formula or amino acid formula in place of
cow’s milk formula. If this brings no improvement, the infant should be referred to a specialist for
testing.

Under what circumstances should topical tacrolimus or pimecrolimus be considered?

Should these be initiated by specialists only, and how for long should they be used?
NICE recommends topical calcineurin inhibitors as second-line therapy in children over two with
moderate-to-severe atopic eczema that has not been controlled by topical steroids, or when the risks of
steroid use (such as skin atrophy) are unacceptably high. For this reason calcineurin inhibitors are often
used on the face and periorbital skin. Topical tacrolimus is licensed for use on the whole body in adults
and children over two, and topical pimecrolimus is licensed for use on the face and neck in children
aged two to 16. There is level 1a evidence to recommend o -label use of 0.03% tacrolimus or 1%
/
pimecrolimus ointment in patients with atopic dermatitis who are under two years of age with mild-to-
12
severe disease. Calcineurin inhibitors have a similar bene t to topical steroids, but are more expensive
and may cause burning and pruritus when applied (although this typically settles with repeated
13
application).

Topical calcineurin inhibitors may be prescribed in primary care by GPs with experience in treating
atopic dermatitis after careful discussion about potential risks and bene ts. The prescribing clinician
should be aware of the absence of long-term safety data. Despite an FDA black box warning, meta-
14
analyses have found no increased risk of malignancy.

Twice-daily application is most e ective in reducing in ammation and pruritus. After gaining control of
acute disease, application of topical tacrolimus (0.03% in children) two to three times per week to
recurrent sites of disease has been shown to be e ective in reducing relapses. This strategy has been
12
used for up to one year with no signi cant adverse events noted.

What measures should we suggest for disturbed sleep?

Disturbed sleep is common in children with atopic dermatitis and can have signi cant impact. Oral
antihistamines are not routinely recommended for use in atopic dermatitis, but NICE suggests a one-
month trial of a non-sedating antihistamine if there is severe itching or urticaria. During an acute are, if
sleep disturbance is major, a seven to 14-day trial of an appropriate sedating antihistamine should be
considered in children over six months.

There is a bewildering range of emollients available. Can you give guidance?

Healthcare professionals should o er a choice of unperfumed emollients to use every day for
moisturising, washing and bathing. This should be suited to the child’s needs and preferences, and may
include a combination of products or one product for all purposes. While ointments are the most
moisturising, their occlusiveness may not be tolerated. Leave-on emollients should be prescribed in
large quantities (250 to 500g weekly) and be easily available to use at nursery, preschool or school.
Local formularies will typically outline the emollients that should be chosen. Ointments such as
Hydromol and Epaderm are useful as soap substitutes, and the greasiest possible emollient should be
used for moisturising (ideally an ointment, but creams will often be more acceptable). E45 and aqueous
cream should be avoided. Dermol 500 may be useful as a soap substitute during acute ares, but it
should not be used as a leave-on emollient. Emollients should be applied around one hour before topical
steroids.

What are the key pointers to eczema being infected? Are swabs helpful in primary care?
Patients with eczema are more prone to infection, predominantly Staphylococcus aureus. Infection may
present with weeping, oozing or serous crust overlying the eczema. Infection should also be considered
in eczema failing to respond to therapy, or in rapidly worsening eczema. NICE discourages the use of
swabs unless other organisms are suspected or antimicrobial resistance may be relevant.
/
How common is eczema herpeticum, and how can we recognise and treat it?
Eczema herpeticum is estimated to have an incidence of four to seven per million children each year, but
15
is more common in those with non-white ethnicity. Eczema herpeticum typically appears as uniform
punched-out erosions or vesicles, but should also be considered in rapidly worsening eczema. If eczema
herpeticum is suspected, systemic aciclovir should be initiated immediately and the child should be
referred for immediate dermatological assessment. Secondary impetiginisation may occur, necessitating
the need for antibiotics, and topical steroids should be continued during an episode of eczema
herpeticum.

How should the GP manage a severe are of eczema in a child?

Children and parents should be educated to recognise acute ares and seek medical attention early.
Compliance with emollients should be checked. Topical steroids should be used once or twice daily until
lesions have settled. Moderate or potent topical steroids may need to be used on the body during severe
ares. Moderately potent topical steroids may be needed on the face during severe ares (for three to
ve days’ maximum duration). Patients should be reassessed at two to four weeks. Oral steroids are not
recommended in children and specialist advice should be sought. In children who do not respond to
treatment, bandaging and urgent referral to dermatology should be considered.

Can you explain what the ‘weekend regimen’ is for steroid cream treatment?
After gaining control of a are, the primary goal is to prolong the time until the next are. Recently, a
proactive approach has been adopted for patients experiencing repeated ares in the same area. The
‘weekend regimen’ describes prophylactic use of topical steroids or calcineurin inhibitors to problem
areas once or twice a week between ares. A number of clinical trials have shown a signi cant
reduction in the frequency of ares when the weekend regimen is used, and long-term studies have
4
shown this e ect to be preserved for 12 months.

Many dermatological diagnoses are more di cult in children with pigmented skin. Can
you give guidance on how we might recognise childhood eczema in these
circumstances?
Many dermatoses can appear di erent in skin of colour and it is important to be able to recognise these
to ensure appropriate treatment. It can be challenging to detect erythema in darkly pigmented skin, and
16
thus eczema may be under-diagnosed in these patients.

Eczema may look dark brown, purple or ashen in colour and xerosis and scaling may help with the
diagnosis. Patients with type VI (black) skin are also more likely to develop papular eczema. Eczematous
plaques may then fade to leave post-in ammatory hyperpigmentation, which can be more cosmetically
bothersome than the eczema itself. Multiple educational platforms are available for those wanting to

/
 learn more about recognising skin disease in ethnic minority populations. These include the Skin of
Color Society and the University of Nottingham
(http://www.nottingham.ac.uk/research/groups/cebd/resources/skin-of-colour/index.aspx)

Next page

FAQs | Site map | Contact us | Terms and conditions | Privacy policy | © Cogora Limited. All rights reserved

My account
Support
Contact us
NOTICE: We collect personal information on this site to improve your experience. To learn more about how we use your
information see our Privacy Policy.

Also CPD for nurses: