Childhood Atopic Dermatitis 2

* VERY! 10-20% of children in developed countries (Harper et al,2000) * Incidence has trebled over the last 30 years (Harper et al, 2000) * Positive correlations of eczema with higher social classes and airpollution has been confirmed (Simpson, Hanifin, 2005) * 80% of children will develop eczema in 1st year * 50% of children will clear by 2 years of age * 85% of children will clear by 5 years of age * About 5% of children with eczema will continue into adulthood How common is Atopic Eczema ? 3

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 Increased IgE production  Specific IgE to multiple antigens  Increased basophil spontaneous histamine release  Decreased CD8 suppressor/cytotoxic number and function  Increased expression of CD 23 on mononuclear cells  macrophage activation with increased secretion of GM- CSF(IL-5), PGE 2 and IL-10  Decreased numbers of IFN-gamma-secreting from Th 1-like cells 6

First appointment is important in managing the eczema effectively and gain the trust of the patient and family * Family history * Coexisting atopic disease * Immunization * Allergies, tests, diet manipulation and adequacy * Growth * Previous treatments used and outcomes * Most distressing element * Sleep disturbance * Environmental aggravators, assess heat/prickle/dryness * Effect on family life, school * Parents expectations from treatment * YOUR expectation from treatment Taking a good history 7

Infantile stage: ( 0-2 years ) tends to start around 3-6 months.Usually affects the face, wrists,nappy area and when severe every part of the body.Often gets infected. Childhood stage:( 2-12 years ) the skin starts to become dry cracked and thickened.Usually affects the elbows,back of knees,ankles and back of ears.Severe thickening of the skin is very common in Afro-Caribbeans and Asians. Adolescent and adult phase: (puberty onwards ) lichenification of the skin is very prominent now.Affects the elbows,knees, neck and bottom of the eyes. STAGES of Atopic Eczema PHASES 8

Serum IgE levels Skin prick tests(Allergy test) Skin patch tests RAST(checks to see if the body is producing antibodies against common things like house dustmite,pollens,cat and dog hair and food substances) Skin biopsy INVESTIGATIONS 9

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Must have:Major Features  itchy skin  family history of atopy  typical picture,( facial, flexures, lichenification) Plus three or more of the following:Minor Features  Xerosis/ichthyosis/hyper linear palms, keratosis pilaris  periaricular fissures,dennie-morgan lines  chronic scalp scaling,pityriasis alba,cataract Diagnostic criteria 14

 Pityriasis alba 15

 Xerosis 16

 Keratosis Pilaris 17

 Ichthyosis 18

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* Heat * Dry skin and environment * Prickle * Allergies * Irritants * Infection * Saliva * Water What aggravates Atopic Eczema? 21

* Too many clothes * Hot baths >29 degrees * Too many blankets * Sport/running around * Hot cars * Heaters * Hot school classrooms What makes eczema hot and itchy? 22

* Soap, use bath oils or washes * Air blowing heaters * Swimming pools * Australia!!!! * Therefore apply moisturiser from top to toe regularly and more often when flaring What makes eczema dry and itchy? 23

This depends on  Disease severity  Age  Compliance  Efficacy  Safety data  Treatment costs 24

Every day * avoid aggravators * moisturiser * bath oil Eczema Treatments Topical Treatments Flaring Treatments * every day treatments + * steroid ointments * wet dressings * cool compresses * antibiotics 25

* Phototherapy(using ultraviolet rays UVA,nUVB) * Immunity suppressing drugs(e.g.oral steroids,azathioprine,ciclosporin,tacrolimus) * Diet and nutrition (food allergy) * Alternative therapies (Chinese medicine herbalism) Second line treatment(severe cases): All these require specialist treatment in the Hospital. 26

 Identify trigger factors ◦ Irritants – soaps and detergents ◦ Contact allergens ◦ Food allergens ◦ Inhalant allergens ◦ Skin infections  Refer for specialist advice when necessary 27

 Tailor treatment to severity ◦ Start with emollients – should be used even when skin clear ◦ Mild disease – emollients + mild steroid creams 1% hydrocortisone ◦ Moderate disease – emollients + moderate steroid creams. Topical calcineurin inhibitors, bandages. ◦ Severe disease – potent steroid creams (short periods only) topical calcineurin inhibitors, bandages, phototherapy, systemic therapy 28

 Use topical antibiotics + steroid for localised infection for no longer than 2 weeks  Non-sedating antihistamines if eczema is severe or severe itching or urticaria  Sedating antihistamines children aged > 6/12 during acute flares if sleep disturbance for child or carers.  Recognise indications for referral 29

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 Treat the AD!  Oral antibiotics ◦ Cephalexin (50 mg/kg divided BID-TID) ◦ Dicloxacillin ◦ Septra, clindamycin, doxycycline if concerned about MRSA 31

 Dilute bleach ◦ ¼ cup household bleach in half-full bathtub once to twice weekly ◦ Dilute bleach + intranasal mupirocin improved AD severity over 3 month study period  Swimming in chlorinated pool may have similar effect 32

 Immediate (same day) ◦ if eczema herpeticum suspected  Urgent (within 2 weeks) ◦ If severe and not responded to optimal treatment for 1 week ◦ Treatment of bacterial infected eczema has failed 33

 Routine referral  Diagnosis uncertain  Eczema on face not responded  Eczema is associated with sever recurrent infections  Contact allergic eczema suspected  Causing serious social or psychological problems for child or carers  Eczema not controlled to the satisfaction of carers or child 34

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