Managing paediatric eczema in primary care

There is a high burden of paediatric eczema in the primary care setting. Dr Liew Hui Min, a consultant dermatologist from SOG-HM Liew Skin & Laser Clinic at Gleneagles Hospital, Singapore, shares her insights with Pearl Toh on how to manage paediatric eczema in the primary care setting.

Diagnosing paediatric eczema

Itch and painful skin are two main symptoms of paediatric eczema, similar to those seen in adults. Often, these can lead to disrupted sleep and lower productivity in daily activities of children such as schooling.

One of the root causes of paediatric eczema may be traced back to a genetic predisposition to atopic diseases, for instance, allergic rhinitis, asthma, and allergic keratoconjunctivitis. Other risk factors predisposing a child to developing eczema include weather, humidity leads to sweating, house dust mites, pets, skin infection, flu symptoms, stress, and food.

On the other hand, other underlying disorders, such as zinc deficiency, hyper-immunoglobulin E syndrome, and Netherton’s syndrome (a genetic condition), can also manifest in eczema-like skin conditions. Nonetheless, these conditions are rare.

For diagnosis, the Hanifin and Rajka criteria is well established — those who satisfied three major and three minor criteria listed in the Table below is considered to have eczema. [Acta Derm Venereol Suppl (Stockh) 1980;92:44-47]

Another allergic skin condition known as urticaria (or hives) is also characterized by itch. Hives usually manifests as fleeting itchy rash with sudden onset. It usually lasts for minutes to hours, often less than a day, although it may recur on a daily basis.  Often, it is self-limiting in nature, but it may also last for months or even years in the case of chronic hives.

While hives presents as raised erythematous wheals with severe itching; eczema is characterized by skin lesions which are reddish, dry, itchy, crusting, or even blistering, cracking, or bleeding.

It is not uncommon for eczema and urticaria to present at the same time — further worsening the eczema condition.  If urticaria is suspected, it is important to treat the child with oral anti-histamines.

If eczema is left undiagnosed, it can lead to long-term impairment of quality of life, such as disruption of sleep (which can affect the child’s growth and development) and hindered social interactions with their peers due to inability to participate in activities, particularly outdoor activities.

Poorly controlled eczema can lead to skin infections, or worse, it can even lead to systemic infections such as cellulitis or infective endocarditis in some circumstances. Infected eczema usually manifests as weepy inflamed skin, with sensation of pain at the same time. 

In diagnosing paediatric eczema, GPs need to obtain a thorough history of how eczema has affected the child. Therefore, it is important that time is devoted in history taking and understanding the challenges faced by the parents or carers of the child.

In particular, things to take note of during history taking include age of eczema onset, triggers, family history of atopy, and impact on quality of life (sleep disturbance, school attendance, poor concentration).

Treating paediatric eczema

The key aims for managing paediatric eczema is to alleviate itch and address the patient’s concerns.

In general, liberal use of emollient is crucial to prevent eczema from flaring up. Therefore, doctors should take note to include emollient as part of the treatment plan — which often gets omitted.  

To manage acute flares, a topical steroid is usually recommended. Being aware of the different potency of topical corticosteroids is important — young children may not require very potent steroid, because children’s skin is usually thinner compared to that of an adult. 

Doctors should be aware of what treatment has the child received before, based on history taking. The potency of topical steroids used can be increased if the severity of eczema has worsened despite previous treatment with steroids.

Adequate amount of topical steroids should be used to avoid undertreating the eczema flare. Normally, the amount of topical steroid used should span one fingertip unit (FTU), ie, the length of an index finger distal phalanx to cover the surface areas of two palm size of an adult hand. [Image] Also, doctors should avoid using the word “thinly” to prevent inadequate application.

It is important to ensure that topical steroid is applied until the eczema rash has settled. GPs may need to arrange an early review in 2 weeks to check on response to treatment.

Oral corticosteroid should be avoided when treating an eczema flare in a young child, as it may affect their growth. If doctors are considering oral corticosteroid use, the child may require a referral to the specialist.

In particular, referral to a specialist should be considered when:

·           there is a recurrent flare of eczema, requiring potent topical steroid,

·           the child and family are affected by eczema, eg, lack of sleep, developmental delay in the child and poor weight gain,

·           the child requires 2^nd or 3^rd line of treatment such as phototherapy and immunosuppressants (these treatments should be introduced by specialists as it requires meticulous monitoring and also special training of healthcare professionals to carry out certain treatments)

Challenges

One main challenge that GPs face during treatment is fear of steroids among parents (or sometimes, even healthcare professionals). Consequently, this can lead to poor compliance to treatment because the parents are worried that the steroid cream will harm their children.

As a result, recurrence of flare becomes frequent. In fact, topical steroid is still safer than oral steroid.

To compound the issue, there are too many alternative medicines available. Most of these are not medically proven and may even cause harms if used inappropriately.

Hence, listening to and understanding concerns and beliefs of the parents/carers is important in the course of management. This is because parents can be fixated on their beliefs about causes/triggers of eczema, which can impede the appropriate medical intervention required for the child.

Conclusion

Doctors should be mindful of the parents’ concerns. Not addressing their concerns may impede the treatment plan.  Also, doctors need to counsel parents on the safe use of topical corticosteroid and remind them to use emollient daily.