case study atopic eczema. james is 18m old. he has an itchy rash on his flexural creases of his...
TRANSCRIPT
• James is 18m old. He has an itchy rash on his flexural creases of his elbows, knees and wrists
• His skin is generally dry with red patches and itchiness on cheeks and neck
• His mother had eczema since being a child. Her hands and wrists show lichenification. She also has mild asthma and his father has hayfever
• Diagnose atopic eczema when a child up to the age of 12 has an itchy skin condition plus 3 of the following:– Visible flexural dermatitis involving skin creases (elbows, knees) or
visible dermatitis on cheeks &/or extensor areas in children ≤18m– Personal history of flexural dermatitis or dermatitis on cheeks &/or
extensor areas in children ≤18m– Personal history of dry skin in last 12m– Personal history of asthma or allergic rhinitis (or history of atopy in 1st
degree relative of children < 4 years– Onset of signs or symptoms < 2 years
• In Asians, black Caribbean or African children the extensor surfaces may be affected and discoid (circular) or follicular (around hair follicles) patterns may be more common
• Severity of the eczema
• Effects on quality of life – sleep, everyday activities, psychosocial wellbeing
• Personal history of atopy and eczema
• Family history of atopy and eczema
• Examination – Extent, location, severity and infective elements
• Avoid soaps and detergents– Use emollient soap substitute– Use gloves– Reapply emollients after wetting skin
• Avoid temperature extremes– Humidity
• Avoid abrasive clothing– Use cotton fabrics
• Diet is a significant trigger in <10%• Common triggers include cows’ milk, eggs, soya, wheat, fish
and nuts• Consider if:– Child has previously reacted to a food with immediate
symptoms– Infants and young children with moderate or severe
eczema not controlled with optimum management, particularly if gut motility is affected
– Symptoms are associated with failure to thrive
• Measures often time consuming, difficult and costly with limited benefits
• Consider inhalant allergy if :– Seasonal flares– Children with atopic eczema associated with asthma or
allergic rhinitis– Children ≥ 3 years with atopic eczema on the face
particularly around the eyes
• Use even when skin is clear
• Aim is to retain the skin’s barrier function and to prevent painful cracking
• The drier the skin, the more has to be applied. Greasier products have a better emollient effect
• Can also use bath products
• Optimum time to apply is after a bath
• Depends of the state of the skin
• Only use intermittently and for short periods (1-2 weeks)
• Tailor potency to severity
• Do not use very potent products in children without specialist advice
• Efforts to reduce dryness and inflammation should be promoted ahead of antihistamines
• Offer 1 month trial of non-sedating antihistamine to those with severe atopic eczema or those with mild or moderate eczema with severe itching or urticaria
• Review Rx every 3 months
• Use 7-14 days of a sedating antihistamine if sleep disturbance is significant
• James manages for a considerable period of time but when aged 4 he returns with a significant flare. Some patches look moist and inflamed and some have a golden yellow crust. He also has a mild pyrexia
• The skin is colonised with S.aureus in 90% of affected areas. If there are clinical signs of widespread infection, oral antibiotics are recommended
• Topical antibiotics should be reserved for cases of clinical infection in localised areas and use for no more than 2 weeks
• Punched out erosion, vesicles or infected skin lesions failing to respond to oral antibiotics should raise suspicion
• If a severe infection is suspected start immediate treatment with systemic aciclovir and refer for same day specialist advice