The effects of childhood atopic eczema can be distressing for the entire family, not just the individual sufferer.Julie Van Onselenoffers some treatment advice and moral support
Childhood atopic eczema is a very common condition, with a lifetime prevalence of up to 20 per cent of children aged three to 11 years1.
Children are at increased risk of developing atopic eczema, as well as closely linked conditions such as asthma, allergic rhinitis (hay fever) and if a parent or grandparent has an "atopic tendency", meaning they have one or more of these conditions2. In essence atopic conditions are immunological. There is a genetic predisposition stimulated by a multitude of environmental factors, which can be very individual.
What is atopic eczema?
In atopic eczema the skin barrier is defective and the skin is excessively dry. The reasons for this include genetic changes in structural proteins, filaggrin and protease inhibitors. Decreased levels of natural moisturising factors (NMFs) in the skin lead to a reduction in the water retaining capacity of the skin, and breakdown of lipid lamellae from the corneocytes in the stratum cornum, which can all cause skin barrier breakdown. As the corneocytes lose their water retaining capacity, they shrink and open cracks, permitting the penetration of irritants and allergies. Cytokines are also released which cause the inflammation6.
Impact on family life
Atopic eczema can have a huge impact on family life and school. Caring for a child with eczema is time consuming, while the effects of sleep deprivation following disturbed nights can be very draining and may affect a parent's ability to hold down a job. Children can feel ashamed, embarrassed and even angry about their eczema; and not surprisingly some feel upset about being unable to join in some activities with their peers, and can be the target of school bullies3.
Is eczema a lifelong affliction?
Although atopic eczema can be seen in newborns the condition typically develops between three and six months of age (approximately 60 per cent of infants develop atopic eczema in the first six months of life1) and can continue to increase year-on-year. The condition is largely managed in primary care, with 97 per cent of children with eczema treated there1.
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 dermatitis4 and therefore suffer with more sensitive skin in adulthood. Some children will continue to suffer from atopic eczema in adulthood, and for some it can be a very distressing condition with many physical and psychological implications. It is useful to note that the terms "eczema" and "dermatitis" are often used interchangeably and are synonymous terms.
Atopic eczema has a variety of signs and symptoms and 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 both2. Acute flares cause inflamed, blistered and weepy skin, in subacute and chronic eczema the inflammation may subside and the skin will remain dry with thickened (lichenified) areas. Infants often have widely distributed eczema with faces affected; 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 pattern2. Itchiness 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.
Making an initial assessment
The nursing assessment of an infant or child with atopic eczema should be holistic and include: family and personal history of eczema; distribution (including evidence of any skin infection) and onset; aggravating factors (triggers); sleep disturbance, dietary restrictions; impact on quality of life, present and previous treatments and treatment expectations7. NICE guidelines also advise that a detailed history should be recorded. It is important to take into account the severity of the atopic eczema and the impact on a child's quality of life, including everyday activities, sleep, and psychological well-being.
Physical and psychological assessment
NICE5 have developed a practical assessment tool, useful for primary care settings, as it outlines a simple physical (skin) and psychological assessment. The physical and psychological assessment is graded as clear, mild, moderate or severe. There is not necessarily a direct relationship between the severity of eczema and its impact on quality of life5. When assessing past and present treatments, it is helpful to ask the parents to bring all topical treatments and any other medications to the appointment. Questions to ask around treatments may include: When do they use the treatments (child's daily skin routine)? Where do they use them? How much do they apply? What size are the packs? Which treatments are effective/have helped? Which treatments have not helped? Are there any specific concerns with treatments (e.g. topical corticosteroids)?8
Primary care management for infants and children with atopic eczema needs to focus around parent and child education and psychological support. Time should be allowed for providing adequate explanation, which can be supplemented by good patient information and support. Trigger factors for eczema need to be identified and if possible avoided. Topical treatment is crucial, as the skin barrier defect needs daily and liberal emollient therapy. Topical corticosteroids should be the first line of defence for acute flares. Recognising and treating infection (bacterial, fungal and viral) is very important, especially if the eczema is not responding to topical corticosteroids.
NICE5 advocates a stepped approach to management, with the treatment tailored to the severity of the eczema. Emollients should form the basis of management and used even when eczema is clear. Other treatments should be stepped up and down including topical corticosteroids, topical calcineurin inhibitors, bandages and phototherapy and systemic treatments. Patients should be offered information on how to recognise when their child's skin is starting to flare, with clear instructions on how to manage flare-ups, according to a stepped care plan5.
The most important treatments for atopic eczema are emollients, because they restore the skin barrier. In addition to emollient therapy, products that irritate or lead to skin breakdown (soaps, shampoos and perfumed products) should be avoided. An essential emollient therapy package for infants/children includes topical "leave-on" emollient/s and emollient wash products.
Remember that more than one product may be required and emollient bath oils and wash products will cleanse the skin and reduce staphylococcus aureus.5 Emollient therapy works by providing a surface film of lipids restoring some barrier ration of environmental agents/triggers. The occlusive effects of lipids trap water within the stratum corneum and reduce epidermal water loss9. This effect may last for a few hours with emollient creams or longer with grease-based emollients. Humectant emollient creams contain NMFs and can produce similar rehydration as grease-based emollients with a higher degree of cosmetic acceptability6. An individual (child/parent) should be provided with a choice of products. For washing, soap substitutes should be used to cleanse the skin; further moisturising effects may be achieved by adding a bath additive to washing water. Leave-on emollients (moisturisers) should be applied after washing, prior to bedtime and regularly to keep skin well hydrated. They should be smoothed into skin, not rubbed, in a downwards motion following the direction of hair growth. Children require at least 250 g per week to be prescribed and applied. Topical treatment should be applied to well moisturised skin (leaving a gap between applications)10.
Topical corticosteroids Topical corticosteroids are effective in reducing symptoms of inflammation and a first-line treatment for atopic eczema flares. Topical corticosteroids are categorised in the UK in four potency groups: mild, moderate, potent and very potent. Following the NICE5 stepped approach, the most effective preparation should be chosen for the severity of eczema, and dilution avoided. For example, a mild topical corticosteroid should be used for treating infants under one year and facial eczema in children; however as a child gets older a moderate or potent topical steroid may be required for short-term treatment on the torso and limbs. Parents are frequently concerned about the potential risks from side effects of topical corticosteroids; they can cause systemic and local side effects but only if used incorrectly or excessively.
Education and information on therapeutic and correct application amounts can be given by advising on the finger tip unt (FTU) measure of application. One fingertip equates to the amount of cream or ointment expelled from a tube with a 5mm diameter nozzle, applied from the distal skin crease to the tip of the index finger12. Recommended guides for the number of FTUs according to the age of the child and body area can be found within the patient information leaflet contained in every pack of topical corticosteroid.
Topical calcineurin inhibitors When atopic eczema is more severe and not controlled by topical corticosteroids, topical calcineurin inhibitors (TCIs) can be considered as second-line treatment.
Topical calcineurin inhibitors are immunomodulators, which suppress this over-activity of the immune system, helping the eczema to clear. There are two preparations available, Tacrolimus is recommended within its licensing indications as an option for the second-line treatment for moderate-severe atopic eczema, aged two and over and Pimecrolimus is recommended within its licensing indications as an option for the second-line treatment for moderate atopic eczema on the face and neck of children, aged 2-16 years5. TCIs do not cause thinning and can be used safely on delicate areas such as the face, neck, eyelids and skin folds but they should not be used on infected skin. It is important that TCIs are not applied to sun-exposed areas and sun protection measures should be taken.
Atopic eczema is frequently bacterially infected with staphylococcus aureus, due to atopic skin having higher colonies of staphylococcus aureus compared to non atopic skin. It is helpful for parents to learn how to recognise infected eczema, which will generally be wet and weepy with golden crusts and unresponsive to treatments with plain topical corticosteroids. Swabbing is only required if micro-organisms other than staphylococcus aureus are suspected. Antiseptics (bath oils and emollients) are a helpful adjunct for decreasing bacterial load, in cases of recurrent infected eczema, however, long-term use should be avoided. NICE5 recommends that eczema infected with staphylocoocus aureus should be treated with one two-week course of systemic antibiotics. Localised areas of bacterial infection can be treated with topical antibiotics, including those combined with topical steroids for a maximum of 14 days.
Viral infection in atopic eczema includes herpes simplex, which can be complicated by eczema herpeticum, varicella (chickenpox) and molluscum. Herpes simplex infections should be treated with topical acyclovir. If eczema herpeticum occurs, this will be seen as a rapid development of cherry red vesicles, in cropped groups, affecting the whole body and often commencing on the face. If ecezmaherpeticum is suspected, emergency treatment is required with systemic aciclovir and referral to the dermatology department for same day advice (and urgent ophthalmic referral if skin around eyes is involved)5. Children and infants will inevitability be exposed to and catch the varicella virus resulting in chickenpox, which is the only way to develop life-long immunity. If a child with atopic eczema develops chickenpox while taking oral corticosteroids or immunosuppressants, urgent medical help must be sought13.
Other treatment options
Other treatment options may include adjuvant bandages, wet and dry wraps and therapeutic clothing. Referral to a dermatology specialist within intermeadiate or secondary care should happen as recommended by the NICE guidelines.5
A holistic family-orientated approach is essential in caring for infants and children with atopic eczema.
Primary care health professionals will often need to provide support to the child and their family over a long period of time. It is very important for primary health care professionals to keep updating their skills in providing eczema care. Accurate information sources should be recommended to supplement the health care professional's advice and provide parental knowledge enabling them to cope more effectively in managing their child's long term and distressing condition. The child should also be involved in their own self management from an early age. Children respond very well to sticker reward charts, which are an ideal way of teaching them to apply their own emollients. Nursery and school staff will also need support on understanding the needs of the infant/child with eczema and should be involved in their care.
Case study 1
Jamal, a six-month-old baby, attends baby clinic with his parents. His GP has recently diagnosed atopic eczema and prescribed 1% Hydrocortisone cream for his face.
He has very dry skin and an inflamed face and scalp, which is affecting his sleep because of the urge to scratch all the time. His parents,Mohammed and Sabeena, have two older children aged four and two years, who don't suffer from eczema and although Sabeena has mild rhinitis,Mohammed has no history of atopy.Their distress and confusion has largely arisen from friends and family giving them lots of "well-meaning"advice. Following this advice they bathe Jamal on a weekly basis and apply baby oil to his body, instead of the 1% Hydrocortisone cream prescribed.
The health visitor firstly undresses Jamal and examines his skin. She gives his parents information on atopic eczema, with advice and support on how to manage Jamal's skin, improve the itching and restore sleep. On this visit the health visitor focuses on the importance of emollients and encourages Jamal's parents to bathe him once a day using emollients as bath oils, soap substitutes and leave-on emollients. She also encourages Jamal's parents to moisturise his skin at each nappy change, explaining that by keeping his skin well moisturised, the itch will reduce.At night, she recommends cotton or silk baby grows with built in mittens, which will help prevent nighttime scratching and advises them to keep his bedroom cool.
The health visitor also reassures Mohammed and Sabeena on the safe and correct use of topical corticosteroids, which are needed for his face. She supplements all her advice and support with information booklets and factsheets from The National Eczema Society (NES). One month later at the next baby clinic, Jamal's skin is well moisturised, he is not scratching much and sleeping well; the 1% Hydrocortisone cream has reduced his facial inflammation and his parents are much happier.
Case study 2
Eight-year-old Alice has asthma, which is now well controlled. She recently developed acute eczema, on her face, limbs and hands, which was wet and weepy, with some yellow crusting.Alice and her mother, distressed by this sudden appearance, made an appointment with the practice nurse.Alice told her that her skin was often "dry and very itchy" and her school friends keep teasing her as she is always scratching at school.
Alice also experienced mild eczema as a three-month-old baby, but this was the worst her skin has been and it was affecting her sleep as well.The practice nurse explained that Alice had an acute infected flare of her eczema.The yellow crusting areas are staphylococcus aureus; a commonly infected eczematous skin.
She advised Alice to use emollients with added antimicrobials and referred her to the GP for a course of oral antibiotics. Alice returned to the nurse two weeks later and her eczema had cleared, but she still had very dry skin, which was starting to itch again.The practice nurse emphasised the importance of a daily emollient routine and said Alice should replace all soap with emollient washes and apply leave-on emollient at least twice a day.The practice nurse also advised Alice to take a small pot of emollient into school, to use at lunchtime. Alice's mother agreed and said she would talk to her teacher so Alice could be given privacy and space to apply the emollient at school.The practice nurse gave Alice and her mother additional information from the National Eczema Society, which could be taken into her school and directed them to the NES web site.
1. Schofield JK, Grindlay D, Williams HC. Skin Conditions in the UK: A Health Care Needs Assessment. Nottingham: Centre of Evidence Based Dermatology, University of Nottingham, UK; 2009. pp. 85-95
2. DermNetNZ. Atopic eczema. [Online]. Available from: http://www.dermnetnz.org/dermatitis [Accessed 13 December 2010]
3. All Party Parliamentary Group on Skin. Report on the enquiry into the impact of skin diseases on people's lives. London: APPGS; 2003.
4. MacKie RM. Clinical Dermatology.Oxford: Oxford University Press; 1997. pp 78-9. NICE
5. National Institute for Health and Clinical Excellence. CG 57 Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years - Full Guidance. [Online]. Available from http://www.nice.org.uk/CG57 [Accessed 7 April 2010]
6. Cork MJ, Danby S. Skin barrier breakdown: a renaissance in emollient therapy. Br J Nurs 2009; 18: 872-877
7. Primary Care Dermatology Society & British Association of Dermatologists. Guidelines for the management of atopic eczema. Guidelines 2006; 20: 361-365
8. Van Onselen J. Recognising and assessing eczema. Independent Nurse 2010; 9: 39- 40
9. Cork MJ.The Importance of Skin Barrier Function. J Dermatolog Treat 1997; 8: S7
10. Ersser S,Maguire S, Nicol N, et al. Best practice in emollient therapy: a statement for healthcare professionals.Dermatol Nurs 2007; 6: S2-S19
11. National Prescribing Centre. Using topical corticosteroids in general practice. MeReC Bull 1999; 10(6): 21-24
12. Long CC, Finlay AY.The finger-tip unit - a new practical measure. Clin Exp Dermatol 1991; 16: 444-447
13. Charman C, Lawton S. Eczema: What Really Works (the treatments and therapies that really work). London: Constable and Robinson Ltd; 2006
Further information www.eczema.orgThe National Eczema Society has two principal aims: first, to provide people with independent and practical advice about treating and managing eczema; secondly, to raise awareness of the needs of those with eczema with healthcare professionals, teachers and the government.
Factsheet and bookets: Covering all aspects of childhood atopic eczema and treatment. Free access to all publications is avaiable for health care professioanls registering on the HCP area at www.eczema.org
Exchange Magazine: the National Eczema Society's quarterly magazine is produced to keep members up-to-date with the management and treatment of eczema and to provide a forum for an exchange of news, ideas and information
Support for Health Care Professionals: Help and support specifically for health care professionals is provided by a dedicated telephone (0207 501 8230) and email helpline (professional @eczema.org) and a programme of study days (delegate rate £10 per day, call or email for details)
Patient helpline: An eczema helpline operates 8.00-20.00hrs on 0800 089 1122 and is the first point of contact for anyone affected by eczema. It provides support and guidance on eczema management and treatment.
Julie Van Onselen JVO Consultancy-education in dermatology Dermatology Nurse, Oxfordshire PCT