In this excerpt from the March/April 2012 edition of Journal of Family Health Care, Julie Van Onselen explains why redness and dry skin doesn't always equal eczema and also discusses how the pigmentation patterns of eczema appear on ethnic skin. To read the article in full,subscribe here.
Atopic eczema is a common childhood skin condition, which affects up to 20% of the UK children aged 3-11 years. The prevalence and incidence of atopic eczema in children continues to increase year-on-year and approximately 60% of infants develop atopic eczema in the first six months of life.
However, infants and children with or without an atopic tendency can also develop other inflammatory skin conditions, which may mimic eczema so are difficult to initially recognise. So when is a red and itchy skin condition atopic eczema and when should another diagnosis be considered? This article will describe and outline the recognition and diagnosis of atopic eczema, including different patterns of eczema.
Diagnostic criteria for atopic eczema
The terms "eczema" and "dermatitis" are often used interchangeably and are synonymous. The NICE Atopic Eczema Guidelines for children under 12 years old are extremely comprehensive providing an evidence based but practical approach to the management of atopic eczema. NICE gives the following diagnostic criteria for atopic eczema, which is defined as an itchy skin condition plus three of more of the following features:
● Visible flexural dermatitis involving skin creases (or visible dermatitis on the cheeks and/or extensor area in children 18 months or under)
● A personal history of flexural dermatitis (or dermatitis on the cheeks and/or extensor area in children 18 months or under)
● A personal history of dry skin in the last 12 months
● A personal history of asthma or allergic rhinitis (or history of atopic disease in a first degree relative of children under four years)
● Onset of signs and symptoms under the age of two years (do not use this criterion in children aged under
Natural history of atopic eczema
The natural history of atopic eczema, includes development of atopic eczema between three and six months of age and it may appear earlier or start later. Many children remit between the ages of two to five years and before adolescence. However, children with a history of atopic eczema are more susceptible to irritant and contact dermatitis and therefore have sensitive skin in teenage years/adulthood. Approximately, 20% children with atopic eczema will continue to be affected as adults, which at the most severe end of the spectrum can be a very distressing condition with many physical and psychological implications.
Signs and symptoms of atopic eczema
Atopic eczema has a variety of signs and symptoms; there can be quite a variation in the appearance between individuals. Eczema/dermatitis can be acute (rapidly evolving), subacute (in-between state) or chronic (longstanding irritable area) or both. Acute flares and infection cause inflamed, blistered and weepy skin. In the chronic phase, inflammation may subside and the skin will remain dry with thickened (lichenified) areas. Infants often have widely distributed eczema with faces affected, although the napkin area is frequently spared. Pre-school children tend to have more localised eczema in the extensor areas, particularly wrists, elbows, ankles and knees. School-aged children continue this pattern but also may develop facial and scalp eczema and a discoid pattern. Itch is often an unbearable symptom of eczema, causing the child to scratch often until they bleed; this becomes a vicious itch-scratch cycle and is often the most difficult aspect of eczema to manage.
Different presentations of atopic eczema
In children of Asian, black Caribbean and black African ethnic groups, pigmentary changes differ to white skin. Inflammatory changes are more subtle and the severity of atopic eczema can be underestimated; pigmentary changes cause hyperpigmentation, when eczema is flaring and hypopigmentation, in the chronic stages, which can last for months. Atopic eczema has a reverse pattern in skin of colour, affecting the extensor surfaces as well as flexures, lichenification (skin thickening) and discoid patterns are more common. Occasionally, the sole feature of atopic eczema in black African skin is multiple follicular papules with typical features such as lichenification, erythema, crusting and scale absent.
Discoid eczema is a manifestation of atopic eczema; it presents as round coin-shaped well-defined pink, red, or brown lesions. They have a dry cracked surface or a bumpy, blistered or crusted surface. Discoid eczema may be extremely itchy, and is often misdiagnosed as ringworm. The skin between the patches is usually normal, but may be dry and irritable. Infected eczema caused by bacteria and viruses can lead to different patterns of atopic eczema.
Bacterial eczema can cause atopic eczema to become widespread, with weepy, impetiginised lesions, staphylococcus aureus is classically characterised by weepy, golden crusts. Eczema herpeticum is a dermatology emergency; it is caused by the type 1 herpes simplex virus, develops down the nerve endings and on to the mucous membranes, multiplying and causing initial itching and burning sensations, with closely grouped vesicles developing on the base of erythema within hours.
Other types of childhood eczema/dermatitis
Seborrhoeic dermatitis, also known as "cradle cap" usually appears at four to six weeks of age, generally resolving by six months of age. It often appears on the scalp first, but the forehead, temples, eyebrows, back of neck, behind the ears and folds at the sides of the nose, nappy area and armpits are often also affected.
Dermatitis affecting the hands and feet
Junvenile plantar dermatosis is a type of foot dermatitis, thought to be caused by friction, sweating and footwear (as described since the advent of trainers in the 1970s). The feet are dry, fissured and shiny on the plantar surfaces, there is no association with atopic eczema and it occurs in children between 3-14 years old. Pompholyx, also known as dyshidrotic eczema, affects both the hands and feet. It causes crops of vesicles, which may convolute into blisters. Pompholyx commences with extreme itching, followed by blister formation, and then peeling and cracked skin in the resolution phase.
Tinea capitis is a fungal infection of the scalp, which is a differential diagnosis for atopic eczema in the scalp. Since the 1970's, in the UK, there have been reports of epidemics of tinea capitis, as it is highly infectious, particularly in black communities in South London However it is important to be clear that the infection can occur in any child irrespective of ethnic origin.
Tinea capitis is a childhood infection and the main signs are scaling and hair loss but acute inflammation with erythema and pustule formation (kerions) may occur. It can invade other areas of the body, the trunk, limbs and nails but rarely the groins or feet. Children and adults, who are carriers, have no signs or symptoms but the causative fungi is present in their scalp. Tinea corporis is a fungal infection on the body, which presents as ring-like (annular) lesions, which are pink and scaly and have central clearance. Tinea corporis is a differential diagnosis for discoid eczema. Tinea manum and tinea pedis affects the hands and feet, generally it is an asymmetrical condition, with on hand or foot affected but can be mistaken for hand/foot dermatitis or phomphylx. Tinea's are dermatophyte fungal infections, which are transmitted via human (anthropophilic) or animal (zoophilic) hosts.
Head lice and scabies are two infestations, which are common in childhood. Both infestations cause intense itch, which provokes an itch-scratch cycle leading to skin damage resulting in excoriations, like atopic eczema. When a child with eczema has intense itching of the scalp or body, infestation superimposed on atopic eczema should be considered.
Other skin conditions
Psoriasis in children is fairly rare, guttate psoriasis can occur, presenting as Small papules (often called raindrop psoriasis). Guttate psoriasis is usually acute; often initial presentation triggered by streptococcal throat infection, but it may develop into chronic plaque psoriasis or reoccur in teenage/young adulthood.10 Ichthoysis is a disorder of the kerinocytes, usually genetically determined, which is charcterised by excessively dry and scaly skin, on the extensor surfaces with little inflammation.3
Infants and children who develop atopic eczema or other skin conditions may present in a nurse or health visitor clinic. Atopic eczema patterns are not always classical, different presentations in ethnic/darker skin and other patterns of eczema need to be recognised. This knowledge can provide reassurance to the child and their parents. Children with atopic eczema may develop other skin conditions, which may superimpose and complicate eczema. Any doubt in changing atopic eczema symptoms or patterns, should be discussed with the child's GP and/or referred to a dermatology specialist.
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