Paediatric Eczema - HIGP eczema.pdf · Juvenile plantar dermatosis Forefoot eczema, peridigital...
Transcript of Paediatric Eczema - HIGP eczema.pdf · Juvenile plantar dermatosis Forefoot eczema, peridigital...
Paediatric Eczema
Dr Manjeet JoshiConsultant Dermatologist
16th May 2012
Classification of the principal forms of eczema
EXOGENOUS
Irritant
Allergic contact
Photoallergic contact
Eczematous PLE
Infective dermatitis
Dermatophytide
Post traumatic
ENDOGENOUS
Atopic
Seborrhoeic Dermatitis
Asteatotic
Discoid
Pityriasis alba
Hand
Gravitational
Juvenile plantar dermatosis
Metabolic eczema or eczema associated with systemic disease
Eczematous drug eruptions
Atopic Eczema
Inflammatory skin reaction
Pathogenesis: Interaction of trigger factors, keratinocytes and T lymphocytes.
Clinical: redness, scaling, papulovesicles.
Prevalence: 5-30% schoolchildren
Pruritus, soreness, infection, sleep disturbance
Social/psychological impact on whole family
Considerable burden on primary and secondary care
Atopic dermatitis
NICE guidance (Dec 2007) Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years
Tacrolimus and pimecrolimus NICE Aug 2004
Topical steroids NICE August 2004
NICE eczema diagnosis
Itchy skin condition + 3 or more of:
Visible flexural dermatitis (or face/extensor areas if 18 mths or less)
Personal history of flexural dermatitis
Personal history of dry skin in last 12 months
Personal history of asthma/hayfever (or FHx of atopy in 1st deg rel)
Onset of S/S in under 2 yrs
(NB: coloured skin – extensor/discoid/follicular)
Pityriasis alba
Pattern of dermatitis with hypopigmentation being the main feature.
Children 3-16 years
Red or skin coloured plaque with branny scaling initially.
Erythema subsides to leave fine scaling and hypopigmentation. Patients usually present to Dr at this stage.
Course variable – takes time to repigment
Treatment:
Emollient, mild steroid. Tacrolimus and pimecrolimus.
Treatment - first line
Avoid irritants
EMOLLIENTS
TOPICAL STEROIDS
Sedative antihistamines
Antibiotics
Tar preparations (esp in lichenified eczema)
Emollients
Unperfumed, suited to child’s needs and preferences
Prescribe in large quantities (250-500g/week)
Soap substitute - soaps (incl. ‘moisturising soaps’) contain surfactants and solvents (SLS)
Used on whole body even when atopic eczema is clear
Show children/carer how to use treatment
Which emollient?
The best one is the one that your patient will use in an appropriate quantity
Aqueous cream is quite irritant and was designed as a soap substitute ie ‘wash off’ product
Cetraben / Doublebase / Epaderm used often
Dermol range/antibacterial esp when frequent infections
Aveeno esp if lighter moisturiser required
Steroids
Explain that benefits outweigh risks
Only apply to active eczema (may include broken skin) or (that which has been active in last 48 hrs), use od/bd
Don’t use potent on H+N
Don’t use potent in <1 yrs without specialist dermatological advice
Don’t use very potent without dermatology advice
Topical steroids
Gain control of eczema
Acute flare vs chronic disease
Mild - 1% hydrocortisone / fucidin H / daktacort
Moderate - eumovate / trimovate
Potent - betnovate / elocon / fucibet
Very potent – dermovate
Steroids
Label steroid container with potency (not outer packaging)
Consider treating problem areas for 2 consecutive days per week to prevent flares in children who have 2-3 flares per month. Review in 3-6 months
Consider different topical steroid of same potency if tachyphylaxis suspected instead of stepping up
Calcineurin inhibitors
Don’t use for mild eczema or as first line for eczema of any severity or under occlusion
Protopic for mod / severe eczema in >2
Elidel for mod eczema on H+N in 2-16 yrs
Only physicians with a special interest/experience in dermatology should start treatment, after discussing risk/benefit of all 2nd line options
Consider for facial eczema in children needing long- term or frequent use of mild steroid
Infected eczema in children
Flucloxacillin if non allergic
Erythromycin if penicillin allergic
Clarithromycin if unable to tolerate erythromycin
Recurrent infection: take swabs incl from family and consider skin sterilisation and nasal Staph eradication
Infection - HSV
Consider if fails to respond to AB or steroids
rapidly worsening painful eczema, fever, lethargy/distress, clustered blisters, punched out erosions
Needs immediate systemic aciclovir and same day referral (and to ophthal if around eye)
Start systemic AB if secondary bact infxn
Dermatophytide
Eczema can occur as an allergic response to dermatophyte infection elsewhere on the skin.
Id reaction
Vesicles on hands and feet common usually as a reaction to tinea pedis.
More likely to develop with inflammatory dermatophytes eg Trichophyton mentagrophytes of zoophilic type.
Erythroderma
Eczema
Psoriasis
Lymphoma and leukaemias
Drugs eg arsenic, gold, mercury, occasionally penicillin, barbiturates
Hereditary disorders eg icthyosiform erythroderma
PRP,LP, dermatomyositis, crusted scabies
Treatments - second line
Topical immunomodulators (>2y.o.)
Tacrolimus = Protopic 0.03% / 0.1% oint
Pimecrolimus = Elidel 1% cream
Phototherapy (UVB/PUVA)
Immunosuppressants
Oral steroids
Azathioprine
Ciclosporin
Mycophenolate mofetil
(methotrexate / alitretinoin)
Juvenile plantar dermatosis
Forefoot eczema, peridigital dermatosis, dermatitis plantaris sicca, atopic winter feet
Children aged 3-14 years
Shiny dry fissured dermatitis of plantar surface of forefoot. Striking symmetry.
? Secondary to changes in composition of shoes and socks in last 30 years
Treatment: Wear 100% cotton socks, stop wearing non porous footwear eg trainers. Urea preparations, lassars paste, WSP or tar.
Education
Discuss severity; explain usu improves, but can get worse in teens / adult life; link to A/H/Food allergy; post-inflammatory dyspigmentation; not clear re stress, humidity, temp extremes
Complementary Tx / food supplements not adequately assessed; caution if not labelled in English; steroids added to herbal products; liver toxicity with some Chinese products; inform you if using these
When to refer to dermatology
Diagnosis in doubt
Severe disease not responding to treatment
Secondary (or frequent) infection esp. Herpes simplex
Severe social/psychological problems /FTT
Treatment requiring excessive use of potent topical steroids
Suspected contact dermatitis (Type 4 allergy)(Type 1 food allergy suspected – refer to Dr Khakoo)
Thank you