Optimising eczema in children

GP Connect Clinical Feature by Jemma Weidinger, Dr Roland Brand, Sandra Vale, Maria Said, Dr Rachael Foster*

This article was originally published in June 2022, and has been revised and updated with new resources.

Atopic dermatitis, commonly referred to as eczema or atopic eczema, is a common chronic disease, and the leading cause of the global burden from skin disease.¹ While not life-threatening, eczema can have a significant psychosocial impact on the affected child and their family and can adversely affect growth and development, school performance, mental health, social life and general quality of life^2,3. Eczema is also associated with increased risk of other atopic diseases such as food allergy, asthma and allergic rhinitis.^1,4

Clinical experience in Australia indicates management of eczema may be more difficult in certain populations, including in children with skin of colour, who may show unique features such as post inflammatory dyspigmentation.

Recent research shows the altered skin barrier in people with eczema has a key role in the development of food allergy⁵ and suggests sensitisation to food allergens may occur through this impaired skin barrier.⁶ Current research also suggests introduction of common food allergens in the first year of life, including to infants considered at high risk (infants with moderate to severe eczema), may reduce the risk of food allergy development.⁷ Therefore, an urgency also exists to effectively manage eczema to potentially reduce the risk of food allergy development.

A paediatric eczema algorithm was developed by PCH to support GPs and other clinicians in optimising timely eczema management for children along with an eczema pre-referral guideline. Other recent new and updated resources include a toolkit for assessing and managing children with skin of colour, and A Practical Guide to Eczema Care, which helps health professionals provide consistent eczema education to parents of children with eczema. Key points from these resources are summarised below:

Key points when prescribing topical corticosteroids (TCS) for children with eczema:

• Ensure the appropriate TCS is used depending on skin site and eczema severity (e.g., Methylprednisolone aceponate 0.1% fatty ointment for face and Mometasone 0.1% ointment or betamethasone dipropionate 0.05% ointment for body).
• For children with skin of colour, advise parents that treatment induced hypopigmentation is common when using potent TCS, and self-resolves over weeks to months. Postinflammatory dyspigmentation may also be seen as the eczema resolves.
• Ensure the correct quantity of TCS is used for the specific surface area of eczema treated based on the fingertip unit measurement. For example, to cover total body surface area:
  • A two-year-old would require 7.5g (half a 15g tube) per application.
  • A child would require 15g (1 x 15g tube) per application.
  • An adult would require 30g (2 x 15gtubes) per application.

It is therefore important to prescribe multiple 15g tubes on streamlined authority scripts as clinically appropriate.

• Apply liberal amounts of TCS to cover all affected areas (not just the worst areas) every day until the eczema completely clears and skin feels smooth. For most children, acute eczema should clear within one-two weeks and chronic eczema should clear within four-six weeks.
• Re-start TCS as soon as the eczema flares again.

Key points for managing eczema well:

• Short daily bath with dispersible bath oil or soap-free wash or shower with soap-free wash.
• Apply TCS liberally once to twice daily as clinically indicated to all areas of active eczema until the eczema completely clears and skin feels smooth.
• Moisturise head to toe every day to improve and maintain the skin barrier, regardless of whether active eczema is present. Moisturising creams and ointments are preferred as they are more effective and longer lasting than lotions.
• Moisturisers and skin products containing food derived proteins such as nut oils or cow or goat milks, may play a role in the development of food allergies in babies and children with eczema, hence are not recommended.

Special considerations and second line treatment options for children with eczema:

• Persisting troublesome eczema despite optimal management with an appropriate moderate to potent TCS warrants dermatology specialist review. Consider immunology review if there is a history suspecting food allergy is contributing to eczema flares or a history of anaphylaxis.
• Second line treatment options including systemic immunosuppressant agents, narrowband UVB phototherapy or biologic agents may be considered where appropriate after dermatology specialist review. Clinical immunology/allergy specialists can also treat with biologic agents.

Resources for parents:

• Nip Allergies in the Bub – Eczema
• Allergy 250K for teens and young adults (website for young people living with severe allergies)
• ASCIA (Australasian Society of Clinical Immunology and Allergy (ASCIA)
• Allergy & Anaphylaxis Australia
  • Trained health educators answer 1300 728 000
  • People can be emailed an Eczema Starter Kit and placed on an eczema learning journey
• Operation Itch – Eczema video, Fiona Stanley Hospital Clinical Immunology
• Eczema information sheets for Aboriginal families – Perth Children’s Hospital
  • Eczema – Keeping our mob healthy
  • Caring for Eczema – Keeping our mob healthy

Resources for GPs:

• HealthPathways WA – Eczema in Children
• Perth Children’s Hospital:
  • Managing eczema in children: a guide for clinicians
  • Pre-referral guidelines: Eczema
  • Atopic dermatitis skin of colour clinician toolkit
• Nip allergies in the bub – Eczema training, plans and guides:
  • A health professionals guide to moisturisers and corticosteroids
  • A practical guide to eczema care – PCH currently have hard copies of the guide available for distribution to GPs and practice nurses. Please email Weidinger@health.wa.gov.au to request copies for your practice
• ASCIA:
  • Paediatric atopic dermatitis (eczema) e-training for health professionals
  • ASCIA Stepwise Management Plan for Eczema
• Rural Health West RACGP webinars presented by Dr Roland Brand, PCH Consultant Dermatologist, PCH Immunologist, A/Prof Richard Loh and Senior Allergy Dietitian, Ingrid Roche.
  • Part 1: Atopic dermatitis in children.
  • Part 2 Common conditions mistaken for atopic dermatitis and second line treatments for eczema.

*About the Authors:

• Jemma Weidinger, Eczema Nurse Practitioner, Perth Children’s Hospital.
• Dr Roland Brand, Consultant Dermatologist, Perth Children’s Hospital.
• Sandra Vale, Manager, National Allergy Strategy, PhD Candidate.
• Maria Said, Chief Executive Officer, Allergy & Anaphylaxis Australia.
• Dr. Rachael Foster, Consultant Dermatologist, Perth Children’s Hospital.

References:

1. Langan SM, Irvine AD, Weidinger S, 2020, ‘Atopic dermatitis’. Lancet, vol 396(10247), pp. 345-360. https://doi.org/10.1016/S0140-6736(20)31286-1. Erratum in: Lancet. 2020 Sep 12;396(10253):758. PMID: 32738956.
2. Carvalho D, Aguiar P, Mendes-Bastos P, Palma-Carlos A, Freitas J, Ferrinho P. 2020. Quality of life and characterization of patients with atopic dermatitis in Portugal: The QUADEP Study. J Investig Allergol Clin Immunol. 2020; 30(6):430-438. PMID: 31530518.
3. Lewis-Jones S. Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema. International Journal of Clinical Practice. Jul 2006; 60(8):984-992.
4. Martin PE, Koplin JJ, Eckert JK et al, 2013, ‘The prevalence and socio‐demographic risk factors of clinical eczema in infancy: a population‐based observational study. Clin. Exp. Allergy, vol 43(6), pp. 642–51. https://doi.org/10.1111/cea.12092.
5. Sugita k, Akdis CA, 2020, ‘Recent developments and advances in atopic dermatitis and food allergy’. Allergology International, vol 69(2), pp. 204–214. https://doi.org/10.1016/j.alit.2019.08.013.
6. Lack, G, 2011, ‘Early exposure hypothesis: where are we now?’ Clinical and Translational Allergy, vol. 1(S1), pp. S71–n/a. https://doi.org/10.1186/2045-7022-1-S1- S71.
7. Fleischer DM, Chan ES, Venter C et al, 2021, ‘A Consensus Approach to the Primary Prevention of Food Allergy Through Nutrition: Guidance from the American Academy of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; and the Canadian Society for Allergy and Clinical Immunology’. J Allergy Clin Immunol: In Practice, vol 9(1), pp. 22–43.e4. https://doi.org/10.1016/j.jaip.2020.11.002.