Eczema

  • Background

    The onset of eczema is usually before 12 months. Infants initially develop facial eczema; flexures are affected later. Eczema is a remitting and relapsing condition. 85% of children will "grow out of" eczema before age 5.

    Eczema is aggravated by heat, prickle (wool, nylon, seams, labels), and dryness. Eczematous skin is prone to secondary bacterial and viral infection. Infection should be considered when eczema flares or fails to respond to treatment.

    Assessment


    Characteristic clinical features:

    • onset during the first year
    • distribution on face, scalp and trunk in infancy, and flexures in childhood
    • itch
    • family history of atopy

    Bacterial infection is suggested by flare of eczema, particularly with crusts, weeping, erythema and increased itch. The usual organism is Staphlyococcus aureus.

    Herpes infection is characterised by vesicles (grouped), satellite lesions, pustules, and erosions. It is often tender and not especially itchy.

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    Differential diagnoses include miliaria, scabies, psoriasis or occasionally zinc deficiency or histiocytosis. Consider immunodeficiency if there is associated failure to thrive, persistent diarrhoea or repeated infection.

    Management

    Give a parent information leaflet and complete a written management plan.

    Steroids (to involved areas)

    • Face/ nappy areas: Hydrocortisone ointment 1% bd
    • Body:Betamethasone Valerate 0.02%(Celestone M) bd, or mometasone furoate 0.1% (Elocon) daily

    Ointments are preferred because they have emolient effects and are less irritating. They should be applied thinly and not rubbed in vigorously. Families should be reassured about the safety and efficacy of topical steroids.

    Moisturisers

    4-6 times per day eg. 50% soft, 50% liquid paraffin (Dermeze). It should be stored in the fridge and applied over steroid creams. Sorbolene may cause irritation. Care should be taken to avoid contaminating cream remaining in the jar.

    Avoid Irritants

    • overheating: wear light loose clothing to bed; luke warm baths
    • soap: do not use soap
    • excessive soaking: limit baths to 5 minutes maximum; add 1 capful of bath oil; apply moisturisers after baths
    • scratchy clothing and sheets: wear cotton, cotton/polyester, care with labels etc,
    • scratching: keep fingernails short; mittens; if severe consider splints at night for facial eczema
    • consider other irritants such as sand, chlorinated water

    Cold compresses and wet dressings:

    These rehydrate, reduce heat and itch, and protect from trauma and friction. They should always be used if the child is not sleeping well because of itch.

    Antihistamines

    A short period of antihistamine treatment is sometimes useful to prevent itch.

    Diet

    • Infants with eczema should be breast fed as long as possible.
    • Parents may notice that certain foods are associated with a flare up of eczema. Common associations are artificial colours/preservatives, shellfish, oranges, tomatoes, eggs and nuts. In such circumstances it is sensible to avoid these foods but more extensive elimination diets should be avoided without discussion with dietician, immunologist.

    Topical antibacterial treatment

    If there is recurrent infection, consider nasal swabs and elimination of nasal carriage with mupirocin ointment (Bactroban). Skin carriage can be reduced with antiseptic preparations such as benzalkonium chloride/triclosan/paraffin (Oilatum bath oil) or triclosan cream (Microshield-T)

    Disposition

    Refer children with troublesome eczema to medical outpatients for follow-up.

    Resources