Paediatric Acute care Guidelines PMH Emergency Department

Eczema is a dry itchy chronic inflammatory skin condition which typically begins in early childhood.

Background

  • Eczema affects approximately 30% of children 
  • Usually starts at less than 12 months of age
  • It follows a remitting and relapsing course
  • Eczema tends to resolve in most children by 5 years

Assessment

Diagnostic Criteria

  • Must have itchy skin condition plus three or more of the following:
    • Onset < 2 years (not diagnostic if child < 4 years)
    • History of flexural involvement (e.g. neck, popliteal fossa, antecubital fossa)
    • History of dry skin within the past year
    • History of atopic disease in patient or 1st degree relative 
    • Visual flexural dermatitis
  • In babies eczema can affect everywhere including the scalp, ears and face
  • In older children it tends to affect the elbows, knees and wrist

Examination

In order to evaluate the severity of eczema the European Taskforce on Atopic Dermatitis has developed a method allowing consistent assessment by means of a severity index called SCORAD.

Investigations

  • Skin swabs for bacterial or viral infections if required
  • Swabs of potential staphylococcal aureus carriage sites should be considered in patients with recurrent skin infection

Differential diagnoses

  • Psoriasis
  • Histiocytosis
  • Zinc deficiency (if perioral or perianal distribution)
  • Scabies
  • Malaria
  • Immunodeficiency

Management

  • Ensure the patient is provided with a Eczema Treatment Plan (complete utilising information as below)
    • All advice given is to be documented in the medical notes 

Everyday Management 

  • Avoid aggravating factors such as
    • Contact irritants (e.g. rough clothing (wool), fragranced soaps) 
    • Allergies (e.g. dust mites, pollens) 
    • Infections
    • Overheating 
 Bathing
  •  Daily bathing in lukewarm water with dispersible bath oil added to the bath
    • e.g. QV bath oil, Dermaveen bath oil, Hamilton dry skin bath oil
  • Soap and shampoo substitutes should be used
    • e.g. QV gentle wash, Dermeze soap free wash, Cetaphil restoraderm skin restoring body wash
 Moisturiser
  •  The drier the skin the thicker the emollient needs to be (e.g. ointment or thick cream) and the more frequent the application
  • Application of emollient immediately after bathing and twice daily is important to prevent dryness and itching
    • Ointments e.g. Dermeze ointment, QV intensive body moisturiser, QV kids balm
    • Creams e.g. Sorbolene with 10% Glycerin (tub container not pump), Dermeze thick cream, Cetaphil cream, QV cream

 

Active Eczema (red, itchy, rough areas)

Medicated creams/ointments
  • Topical corticosteroids are the mainstay of treatment
  • Use on all areas of inflammation, not just the worst areas, until complete clearance then stop
  • Ointment based treatments have an increased moisturising effect and are less likely to sting
  • Once daily application is usually sufficient 
  • Liberal application is often required
  • Authority Prescription is needed when prescribing more than 1 x 15g tube. The majority of children discharged from the ED will require more than a 15g tube (e.g. 4 tubes).
  • At PMH contact the ED Pharmacist for advice regarding prescribing ointments and emollients onto a hospital PBS prescription if required. 
The following suggestions are not proscriptive and are only a guide for short term use
Severity Scalp Face Body/Limbs
Very Mild 

Soap free shampoo
+/- Hydrocortisone ointment 1% daily

Hydrocortisone ointment 1% daily

Hydrocortisone ointment 1% daily
Mild 

 Advantan lotion or Desowen lotion
+/- Hydrocortisone ointment 1% daily

Hydrocortisone ointment 1% daily

Advantan Fatty Ointment daily
Moderate

 Elocon lotion daily

Advantan Fatty Ointment daily

Advantan Fatty Ointment or
Elocon Ointment daily
Severe Elocon lotion daily

Advantan Fatty Ointment daily 

Elocon Ointment daily or
Diprosone daily 

Advantan  = methylprednisolone aceponate 0.1%
Diprosone = betamethasone 0.05% dipropionate ointment
Desowen = desonide 0.05%
Elocon =  mometasone furoate 0.1%  

Wet Dressings
  • Recommended if the child is hot and itchy or waking at night with itch
  • Cool the skin and help to reduce the itch
  • Help with penetration of topical corticosteroids for severe inflammation or when the skin is thickened and lichenified
  • Cool compresses are used as wet dressings to the face
  • Consult with the Dermatology Department for guidance regarding application 
Antihistamines
  • Will not help with the itch caused by eczema as the itch is not histamine related
  • Not usually recommended
  • Sedating antihistamines may be given to improve the child’s sleep, but it is better to treat to eczema properly

 

Infected Eczema or Skin Prone to infection

Dilute Bleach Baths
  • Anti-infective treatment shown to reduce the incidence of recurrent staphylococcal aureus cutaneous superinfection
  • Improves the condition of the skin
  • Usually prescribed twice a week for three months. May be longer if the child has recurrent skin infections. 
  • Dilute bleach bath as per instructions on Fact Sheet: Diluted bleach baths for children with atopic dermatitis (eczema)
Antibiotics
  • Infected eczema
    • Flucloxacillin or Cephalexin orally for 10 days. See ED Guideline: Antibiotics 
  • Infected eczema with herpetic lesions
    •  Aciclovir orally for 5-7 days – See ED Guideline: Antibiotics
      • < 2 year old: 100mg five times a day
      • > 2 year old: 200mg five times a day
  • Localised staphylococcal skin infections
    • Mupirocin 2% ointment or cream topically to crusted areas, twice daily for 7 days
  • If the child has very severe infected eczema admit to hospital for intravenous antibiotics or Aciclovir

 

Admission Criteria

  • Infected eczema needing intravenous antibiotics or Aciclovir
  • Severe eczema requiring wet wraps

Referrals and Follow up

Dermatology:

  • If moderate to severe eczema for ongoing management

The Dermatology Department require the following referral information to assist with triaging referrals:

  • Severity of condition 
  • Duration of condition
  • Type of treatment used

 Immunology

  • If history of flare up associated with food
  • History of atopic disease (hay fever, asthma, food allergies)

Nursing

References

PMH ED Guideline: Eczema. Last Updated January 2015

  1. Therapeutic Guidelines Ltd. Atopic Dermatitis in Children (Revised February 2009). eTG complete. 2014  https://login.pklibresources.health.wa.gov.au/login?url=http://online.tg.org.au/ip/decktop/index.htm Accessed November 2014
  2. AMH Children’s Dosing Companion (online). Adelaide. Australian Medicines Handbook Pty Ltd; 2014 July. Available from: https://childrens.amh.net.au
  3. Guidelines for treatment of atopic eczema (atopic dermatitis) Part 1 (pages 1045-1060) Journal of European Academy of Dermatology 7 Venereology. Vol 26: 8 18/12/12 
  4. WA Health: CAHS PNMP 3.2.8 Atopic Dermatitis (Eczema) Management Guideline. Version 1. 2015

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