Features

The management of eczema in children

07 July 2017

Jean Robinson looks at the community pracitioner's role in treating eczema.

Eczema treatment

Jean Robinson SRN, RSCN, CCN, BSC, MA
Clinical Nurse Specialist, Paediatric Dermatology

Abstract

Eczema is very common in children and impacts significantly on the quality of life of children and their families and carers. Poor adherence remains the main cause of treatment failure. Rigorous and consistent use of treatments is key to relieving symptoms, but many parents experience significant barriers to application. Community practitioners are ideally placed to educate parents in the use of emollients, and where necessary topical corticosteroids, identify and discuss problems and help parents to develop strategies to overcome difficulties. Food allergy is associated with eczema, particularly in infants and the risk increases with severity. Community practitioners need to be confident
in its recognition and management.

Key words: Eczema, management strategies, emollients, topical corticosteroids, food allergies


Eczema 

Atopic eczema (synonym atopic dermatitis) is a chronic inflammatory, itchy skin condition characterised by exacerbations and remissions (NICE 2007), which affects 20 per cent of children in the UK (Williams et al 1999). It commonly starts in the under-fives and clears in most children by teenage years (NICE 2007). Most have mild disease but about 15 per cent of sufferers will have moderately severe or severe disease (Emerson et Williams 1998). Severity ranges from mild where there are areas of dry skin with infrequent itching, with or without small areas of redness, through moderate where there is dry skin with frequent itching and redness with or without excoriation and localised thickening, to severe where there is widespread dryness, incessant itching, redness with or without excoriation, extensive skin thickening, bleeding, oozing and cracking and pigmentary changes (NICE 2007). Itchy children can be very miserable, irritable and fail to thrive. Interrupted sleep causes problems for the child and the whole family (NICE 2007). Children may also suffer at school due to bullying, absences, poor self-esteem and poor performance (Santer et al 2012). Eczema may be triggered by soap and detergents, infections and food and inhalant allergens (NICE 2007).

In healthy skin the stratum corneum (the outer level of the epidermis) is a strong barrier that controls transepidermal water loss and stops the influx of allergens and irritants like infection. The stratum corneum has been described as a ‘brick wall’ (Cork and Danby 2009 p872-877) where the ‘bricks’ are corneocytes. Normally these contain high levels of natural moisturising factor (NMF), which attracts water leading to swelling and a smooth physical barrier. These ‘bricks’ are surrounded by a ‘mortar’ made up of a lipid mix. In eczema, changes in one or a number of genes that determine the structural integrity of the stratum corneum skin barrier e.g. filaggrin results in barrier breakdown allowing transepidermal water loss and the entry of allergens and irritants like infection. It is thought that the interplay of these factors with environmental exposures (soaps, detergents) combine to increase skin barrier breakdown (Cork and Danby 2009).


Treatment and the community practitioner's role

NICE (2007) and RCPCH (2011) guidelines offer clear guidance on how to manage childhood eczema with core components being emollients and, for many children, the use of topical corticosteroids (TCS) combined with a strong focus on the educational needs of children and their parents and carers. It is widely recognised that non adherence to treatments is the main cause of treatment failure (Bewley et al 2008; NICE 2007; Santer et al 2013; Sokolova and Smith 2015). Factors that have been identified are: lack of knowledge, complicated treatment regimes, poor quality of life, dissatisfaction with treatment strategies, infrequent follow up, steroid phobia and the use of complementary therapies (Sokolova and Smith 2015) as well as the time consuming nature of applying topical treatments and child resistance to treatment (Santer et al 2013).

Much has been written about the physical and emotional burden of caring for a child with eczema; (Elliott and Luker 1997; Santer et al 2012; 2013). Some parents report feeling exhausted and stressed and find it hard to find the time to carry out the care. Many report child resistance to treatment to some degree with a smaller number reporting significant problems - the so called ‘cream wars’ In a study by Santer et al (2012;2013) parents reported various strategies to overcome child resistance such as games, rewards and distraction, explaining and involving the child in the treatment and trying to establish a daily routine. Other less positive strategies included disguising treatments eg putting bath additives in different bottles or applying treatments when the child was asleep, restraining the child or reducing frequency of applications altogether.

Unfortunately, many carers feel unsupported by health professionals who are seen as being dismissive while offering conflicting advice (Santer et al 2012). Some parents also struggle to accept the medical model of ‘control rather than cure’ (Smith et al 2010 and Santer et al 2013). Community practitioners can help by:

  • Offering parents and carers balanced and consistent information about treatment plans (Santer et al 2013) verbally, via demonstration and in writing, which can be reiterated at further consultations.
  • Acknowledging parents’ diffculties and recognising the work they put in to caring for their child.
  • Engaging with carers’ beliefs eg worries about steroid use, and their belief that this is not a long-term problem (Santer et al 2014).
  • Offering practical advice- demonstrations of how to apply treatments might be the most effective way of reducing psychological stress (Titman 2001).
  • Helping parents work out how they can develop an achievable routine that does offer some flexibility.
  • Optimising child/parent/professional relationship with good verbal and nonverbal communication, effective listening and developing a shared understanding of treatment goals with parents (it has been shown that a strong relationship with a health provider leads to improved adherence) (Smith et al 2010; Santer et al 2013; Sokolova et al 2015).
  • Routinely asking how parents are managing treatment plans (Edwards and Titman 2010).
  • Considering referral to community children’s nursing teams for further nurse-led education.

Emollients

Emollients are the mainstay of managing eczema but are often underused. Some parents feel they don’t work and many have no knowledge of their use in helping to prevent flares (Santer et al 2012). The terms emollient and moisturiser are often used interchangeably. Emollients soften while moisturisers add moisture (Lawton 2009) and work to increase the hydration of the stratum corneum by occluding the skin’s surface so that water is not lost. Emollients are available as bath oils, soap substitutes and leave on emollients or moisturisers. Children and their parents and carers should be involved in the choice of moisturisers but need advice so they are able to make informed choices (Carr 2009).

Currently, NICE (2007) suggests first line therapy for eczema must include the intensive use of emollients including soaps and oils. Bathing and cleansing the skin is an integral part of the emollient regime.

Daily baths or showers of no more than 20 minutes with added emollients (plain water has a drying effect on skin) will help hydrate the skin (Lawton 2009). Water softeners do not reduce eczema severity (Thomas et al 2011).


Leave on emollients or moisturisers

These are available in lotion, cream, gel, spray or ointment formulations. Ointments are occlusive and greasy and more effective for very dry fissured skin but some families will find these cosmetically unacceptable and will prefer to use cream formulations (Lawton 2009). Aqueous cream was originally designed as an emollient wash product but is often advised as a leave on emollient. Danby et al (2011) showed that its use as a leave on emollient in people with eczema leads to worsening skin barrier function as it contains sodium lauryl sulphate (SLS), which probably leads to corneocyte swelling, elevation of pH and changes in lipid synthesis. The use of aqueous cream should therefore be avoided.

Practical demonstration and discussion of their use is very helpful and should include:

  • Apply in the direction of hair growth
  • Apply 2-4 times daily depending on severity of eczema
  • Apply enough - children should use at least 250g per week (NICE 2007)
  • Routines need to be sensible and achievable (Lawton 2013)
  • If using tubs of ointment rather than creams or lotions from pump dispensers there is increased risk of infection from contamination - advise decanting from the pot with a spatula or clean spoon for each application (Lawton 2014). If the child’s skin is very dry then the use of an ointment will be optimal
  • Children need access to emollients (and an appropriate place and help to use them) at nursery and school and school nurses should be involved in the writing of healthcare plans for children with eczema in schools.

Natural oils

Many health professionals recommend the use of natural oils (most frequently olive oil) for the management of cradle cap, dry skin and eczema. However, it was found in 2012 that olive oil applied topically caused a significant reduction in stratum corneum integrity and induced mild erythema in people with and without a history of eczema (Danby et al 2012). Its use should therefore be discouraged in the treatment of dry skin and infant massage, and paraffn-based mineral oils used instead. The use of sunflower seed oil is not recommended until further research has been undertaken as it is not clear if it is harmful to the infant skin barrier’s differing lipid composition. Massage in babies and young children with eczema who have broken and inflamed skin is not recommended because of the risk of spreading infection and the likelihood of worsening inflammation (National Eczema Society 2015). There is debate about the use of peanut or arachis oil and although refined peanut oil may be considered safe, people with nut allergies are advised to avoid any products eg shampoo or some moisturisers that contain it (National Eczema Society 2015).


Topical Corticosteroids

Topical corticosteroids (TCS) are very important in the management of many children’s eczema and when used appropriately are safe and effective with rare side effects (Bewley 2008; Mooney et al 2015). However, children’s eczema is often undertreated due to steroid phobia (mainly related to beliefs about irreversible skin thinning), which results in unnecessary suffering for children and their families (Bewley et al 2008, Aubert-Wastiaux et al 2011; Mooney et al 2015). Mooney et al (2015) note many parents and non- dermatologists erroneously ascribe the changes in active eczema to ‘skin thinning’. ‘Steroid phobia’ is generated by health professionals, close acquaintances and information from the internet (Smith et al 2010) and community practitioners must be able to offer practical demonstration along with consistent and well informed advice about potencies, their possible side effects and the use of TCS without encouraging their indiscriminate application. When used to treat active eczema and only stopped once the active inflammation has resolved, adverse effects are minimal (Mooney et al 2015) and children achieve maximum clinical benefit.

The instruction to ‘use sparingly’ should be avoided because it suggests that TCS are inherently dangerous and is likely to encourage their underuse (Bewley et al 2008, Mooney et al 2015). Carr (2009) suggests that parents often find the fingertip unit of application complicated and the instruction to apply TCS to affected areas of skin (i.e. red, thickened and open areas of eczema), avoiding healthy skin, in a suffcient amount to produce a shine, is clearer and easier to follow. This should be left to soak in rather than being rubbed in as this can result in irritation.


Complementary treatments

Many parents are keen to use complementary therapies that cover a range of approaches and while some may be helpful it is generally advisable that parents discuss this with a health professional in order to avoid any adverse eff ects or interactions with current treatments (National Eczema Society 2015). Herbal medicines are often mistakenly viewed as a non-steroidal alternative treatment but some eg Wau Wa cream, Abido and OSAS (available over the internet or from market stalls) have been found to contain potent or super potent TCS (National Eczema Society 2015). The use of these should be strongly discouraged. Homeopathy is frequently advocated and used for the treatment of eczema but the evidence resulting from a systematic review of controlled clinical trials failed to show it is an eff cacious treatment for eczema (Ernst 2012). While there is some evidence that probiotics may reduce the risk of eczema they seem to have little eff ect in established eczema (Osborn and Sinn 2009). There is no convincing evidence of any benefi t from dietary supplements e.g. evening primrose oil, borage or fi sh oil (Bath-Hextall et al 2012).


Food allergies 

Food allergy is an immune-mediated hypersensitivity reaction to food and can be divided into Immunoglobulin E (IgE)- mediated (immediate onset) reactions and non- IgE- mediated (delayed onset reactions aff ecting respiratory, cutaneous and gastrointestinal systems (RCPCH 2011B). The prevalence of food allergy in infants with eczema is estimated at around 40 per cent (Rancé 2008) and the relative risk increases with the eczema’s severity. Cows’ milk, hens’ eggs, soya and wheat account for more than 90 per cent of food allergies in infants. Community practitioners need to be particularly alert to symptoms in babies with moderate or severe eczema of non-mediated reactions eg gastro-oesophageal refl ux, loose or frequent stools, blood or mucus in stools, colic, poor feeding and faltering growth in conjunction with one or more gastrointestinal symptom. Management involves allergyspecifi c advice with prevention or treatment of further reactions and good dietetic support for specifi c allergen avoidance and monitoring (RCPCH 2011B, NICE 2011.) There is a high level of parental anxiety about food allergy and its possible curative role in children’s eczema although parents perceived health professionals as uninterested in this (Santer et al 2012). Community practitioners need to be confi dent about recognising and assessing for food allergy and referring appropriately. It is important to be sure that only foods that are relevant to the causality of eczema are removed to avoid the risk of unnecessary nutritional compromise (Rancé 2008).


Immunisations

Children with eczema and egg allergy can receive standard immunisations including MMR routinely (Clark et al 2010). The MMR vaccine is cultured in fi broblasts derived from chick embryos and not egg so the amount of egg protein is negligible. Children who have documented anaphylaxis to vaccines need to be assessed by an allergist.


Conclusion

Eczema remains a signifi cant problem for many children and their families. Confi dent, well informed community practitioners could have a very positive impact on the control of children’s eczema and the support provided to them and their parents and carers.


References

Aubert-Wastiaux H, Moret L et al (2011) Topical corticosteroid phobia in atopic dermatitis: a study of its nature, origins and frequency. British Journal of Dermatology 165 808-814

Bath-Hextall F J, Jenkinson C et al (2012) Dietary supplements for established eczema. Cochrane Data Systematic review 15 (2) CD005205

Bewley A (2008) Expert consensus: time for a change in the way we advise our patients to use topical steroids. British Journal of Dermatology 158 917-920

Carr J. (2009) Evidence- based management of atopic eczema. British Journal of Nursing 18 10 603-610

Clark A T, Skypala S C et al (2010) British Society for Allergy and Clinical Immunology guidelines for the management of egg allergy. Clinical and Experimental Allergy 40 1116-1129

Cork M, Danby S (2009) Skin barrier breakdown: a renaissance in emollient therapy. British Journal of Nursing 18 (14) 872-877

 

Picture credit: Shutterstock

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