Eczema Management

Early diagnosis (Pediatrics 2008)

Can influence child’s overall physical and social well-being

Can effect family dynamics – physical, emotional and functional

Significance of early and effective management (Pediatrics 2008)

Early diagnosis of eczema and early appropriate treatments implemented may decrease a number of preventable problems

Treatments initiated immediately on onset can decrease severity of the skin barrier issues

Early diagnosis can be made with identifying at risk babies, ie. family history, sibling with eczema

Diagnosis and control may influence development of asthma and allergic rhinitis (Hanifin et al,poster presentation Am Ac Derm, 2007)

Key points to managementAssess severity and child’s/family QolIdentity potential triggersConsider food allergy

Reacted to a food with immediate symptomsHave moderate to severe uncontrolled eczema

despite optimum topical managementGut dysmotility (colic, vomiting, altered bowel

habits)Most children with eczema do not need to

have tests for allergies

Key points continued

Do not undergo high street or internet allergy tests – no evidence

Altering diet of breast feeding mothers may not be helpful or appropriate

Any exclusion diet in child or breast feeding mother should be under the care of a dietitian

Topical treatment

Emollients – no different from older child but more acceptance of greasier consistencies

Topical steroids – always use the lowest strength that worksFirst 2 classes generally usedOccasionally stronger classes are required for

severe flares

Steroids available in New Zealand (July 2007)Mild Moderately Potent Potent Very Potent

Hydrocortisone 0.5-2.5%

DermAid

DP Lotion-HC

Skincalm 1%

Lemnis Fatty Cream HC

Pimafucort

2-25 times as potent as 1% hydrocortisone

Eumovate

Aristocort

Viaderm KC

Kenacomb

I00-150 times as potent as 1% hydrocortisone

Beta, Betnovate, Daivobet 50/500

Fucicort

Nerisone Hydrocortisone 17-butyrate

Locoid Cream/Crelo Emulsion/Lipocream/Ointment/Scalp Lotion

Elocon C/Lotion/Oint

Advantan Cr/Oint

Up to 600 times as potent as 1% hydrocortisone

Clobetasol propionate

Dermol C/Ointment

Betamethasone dipropionate

Diprosone OV Cream/Ointment

Case oneCurrent history

6 month old boySevere, generalized eczemaWeeping, crusted lesionsNo feverStill exclusively breast fedNo solids introducedNo improvement

Daily applications of steroid creams

Several exacerbations of eczema during breast feedingIrritableDisrupted sleepFailing to thrive

Past history

Born full termUnremarkable pregnancyNormal weight and lengthMother has asthma and hayfever

Diagnosis and treatments

Severe infected atopic eczema

Allergy tests were performed

RAST, specific immunoglobulin E (IgE)

and Skin Prick Test, SPT

Positive to milk, wheat, egg, kiwifruit and peanut

Exclusion diet by the mother for 4 weeks, supervised by a

paediatric dietitian.

Exclusion diet led to clear improvement in the child’s eczema

Foods that account for more than 90% of food allergies - by age

Infant Children(2-10 years)

Older children

Cow milk Cow milk Peanut

Eggs Eggs Tree Nuts

Wheat Peanut Fish

Soy Tree Nuts Shell fish

Fish Sesame

Shell fish Pollen-associated foods

Sesame

Kiwifruit

Does food allergy resolve ?…

cow’s milkhen’s eggpeanuts, fish, seafood, …

prevalence

age3 yrs 5 yrs6 months

Case two3 year old boyMild eczemaOn a highly restricted dietDeveloped severe eczema at 2 months of age when breastfeeding was stopped

Eczema had been diffuse and resistant to topical treatments

He had an assessment by an allergistSPT showed strong positive results to milk and eggHis diet excluded egg and milk and he had an amino

acid formula (Neocate)By age 2 years his eczema was mild and he tolerated egg in baking.At that point he was seen by a general practitioner who suggested RAST testing

Case 2 continued....The results showed

Decrease in egg Sensitisation to other food allergens; soy, wheat,

fish and beefAdvised that exclusions of these other foods

would lead to further reduction in his already ‘mild’ eczema

However.......There was no reduction in the eczemaWeight dropped from 50th centile to 25th centileDeveloped significant behavioural issues

Case 2 continued....Referred back to allergy clinic

Retested and found to have outgrown both egg and milk allergies

Diet was completely liberalisedResidual eczema managed with topical

steroidsAchieved appropriate weight gainBehavioural problems improved

DiscussionDiet manipulation more pronounced under the age of 2 years with severe, early onset of eczemaCaution with allergy tests interpretation without clinical history

Over interpretation of the resultsIrrelevant sensitisation to foods rather than true allergy Stress of adhering to unnecessary food exclusionsNutritional compromiseCareful history, 4-6 week exclusion trial, then

reintroductionSupervised by a dietitian

Take home messagesBasic management principles apply across

the ages especially when severe, exacerbated or poorly controlled eczema

In the younger child help and support is required to maintain self care

Allergies may play a role but skin management is always the most important intervention