A case of atopic eczema: a guideline-based approach

Successful management of eczema in primary care depends on a number of factors, from recognition and diagnosis, to investigation for potential triggers, as well as appropriate treatment and not least, a holistic approach that considers parental anxiety and quality of life issues

THE CASE

Adam, an only child born after IVF, was seven months old when he developed a widespread itchy rash. His mother Jacqui brought him to the surgery, where he was seen initially by the practice nurse.

Adam's rash was widespread, red and dry, with particularly severe patches on his cheeks, the outside of his elbows and his knees. There were scratch marks on his arms and legs. His mother asked if Adam had slapped cheek disease.

The PN involved the GP and, although slapped cheek disease was a possibility, the widespread dryness and the pattern of marked areas on Adam's elbows led them to conclude this was eczema.

Jacqui was very distressed. She said she wondered if she had 'caused' Adam's eczema by not washing his clothes in the right washing powder. She was very concerned at the scratching.

DIAGNOSIS OF ECZEMA¹

Diagnose atopic eczema when a child has an itchy skin condition plus three or more of the following:

• Visible flexural dermatitis involving the skin creases (or visible dermatitis on the cheeks and/or extensor areas in children aged 18 months or under)
• Personal history of flexural dermatitis (or dermatitis on the cheeks and/or extensor areas in children aged 18 months or under)
• Personal history of dry skin in the last 12 months
• Personal history of asthma or allergic rhinitis (or history of atopic disease in a first-degree relative of children aged under 4 years)
• Onset of signs and symptoms under the age of 2 years (do not use this criterion in children under 4 years).

LOOKING FOR THE CAUSE

First assessment

Jacqui had not changed her washing powder recently. She had purchased a tub of E45 at a pharmacy on the day that the rash first appeared, but this appeared to cause Adam some distress and he screamed when it was applied. There was no family history of atopy.

Adam had been exclusively breast-fed until he was five and a half months old, when Jacqui had started to introduce baby rice as he seemed very hungry. She was concerned that she had done this too soon.

Adam had taken to the baby rice without ill effect and at six months Jacqui had started to introduce pureed vegetables and fruits, together with organic babyfood jars, mainly porridge and cereal. He had not had any nuts, dairy products or eggs.

First treatment

Jacqui was advised to discontinue the E45 and was given Cetraben to use repeatedly on the driest areas, together with a supply of steroid cream (hydrocortisone 1%) for the worst (red) areas. The PN explained how to use a step up, step down approach to managing the rash and arranged to review Adam after one week.

Second review

Jacqui returned one week later. Things were worse. Adam was still scratching. There was thickening of the skin on the outside of his elbows and knees. The most severely affected areas were worse than before, and the eczema more widespread.

Jacqui said she had been using Cetraben four times daily, and as a soap substitute for washing, together with bathtime emollients. She was worried about using steroids on Adam's skin but said she had been using them 'sparingly'. She said she felt people would think the eczema reflected badly on her as a mother.

HOLISTIC APPROACH¹

Assessment of severity, psychological and psychosocial wellbeing and quality of life

• Healthcare professionals should adopt a holistic approach when assessing a child's atopic eczema, taking into account
  • The severity of the atopic eczema, and
  • the child's quality of life, including everyday activities and sleep, and psychosocial wellbeing
• There is not necessarily a direct relationship between the severity of the atopic eczema and the impact of the atopic eczema on quality of life.

LOOKING FOR TRIGGERS

The practice nurse realised that Jacqui was highly anxious. She offered to go through the history again to look for trigger factors.

Jacqui had kept a food diary and stopped cooking food for her baby. Her confidence had fallen and she felt she had caused Adam's problems. She was now mainly feeding him commercial organic babyfood (organic porridge, rice, vegetables and fruit.)

She had changed her washing powder twice in a week.

Jacqui became very upset at being asked about pets. The family had a pet dog. She said that the dog had been in the family home since before Adam was born. The nurse agreed that the dog was unlikely to have caused the problems.

The practice nurse and Jacqui then looked together at NICE guidance on trigger factors and concluded that the most likely trigger factor was food.

ASSESSMENT FOR TRIGGER FACTORS¹

When assessing a child, identify potential trigger factors, including:

• Irritants (such as soap and detergents)
• Skin infections
• Contact allergens
• Food allergens
• Inhaled allergens.

Allergy

• Consider food allergy in:
  • Children who have reacted immediately to a food
  • Infants and young children with moderate or severe uncontrolled atopic eczema, particularly with gut dysmotility or failure to thrive.
• Consider inhalant allergy in children with:
  • Seasonal flares of atopic eczema
  • Associated asthma and rhinitis
  • Atopic eczema on the face (children over 3 years).
• Consider allergic contact dermatitis in children:
  • With an exacerbation of previously controlled atopic eczema
  • Who react to topical treatments.
• Reassure children with mild atopic eczema and their parents or carers that most children with mild atopic eczema do not need clinical testing for allergies.
• Advise children and their parents or carers not to have high street or internet allergy tests because there is no evidence of their value in the management of atopic eczema.

TREATMENT

Adam was then reviewed by the GP, who advised that Adam should use the Cetraben lavishly every two hours through the day.

She advised Jacqui on 'fingertip dosing' (squeezing a fingertip's length of cream from a tube to treat an area of skin the size of the palm).

She emphasized the need to 'get on top' of Adam's symptoms with the use of steroid creams, and said that in view of the skin thickening she would now step up and prescribe a moderately potent steroid cream, clobetasone (Eumovate), for use on thickened areas. She advised that a stronger cream was needed to penetrate the thicker skin but that it should not be used on his face or in his groin — in fact his napkin area was relatively spared. She arranged to see Adam with the practice nurse in a week's time.

The GP agreed that food still looked like a likely trigger but could see nothing obvious in the list of foods. She asked Jacqui to look at the jars of babyfood and write a list of all the ingredients. She also suggested reverting to the original washing powder so as not to confuse the issue. Jacqui left looking unhappy.

Compliance

Jacqui returned to see the practice nurse two days later and asking for a dermatology referral. On questioning she admitted that she had not used any of the steroids, and was now worried that she had done real harm by not complying with treatment.

The practice nurse involved the GP, who reassured Jacqui that no harm was done. She again emphasized the need to use steroids on the thickened areas of skin in order to break the itch-scratch-itch cycle. She agreed to refer Adam to a dermatologist but asked Jacqui to try the steroids for just a week while awaiting this and come back for review. She reassured her strongly that the steroids would not damage Adam's skin over this short time and showed her the NICE guidance.

TREATMENT OPTIONS1

• Offer a choice of unperfumed emollients
  
  
• Suited to the child's needs and preferences
• For everyday moisturising, washing and bathing.

Emollients should be:

• Used more often and in larger amounts than other treatments

• Used on the whole body even when atopic eczema is clear

• Used while using other treatments

• Used instead of soaps and detergent-based wash products

• Used instead of shampoos for children under 12 months

• Offered as a single product or a combination (offer alternatives if one emollient causes irritation or is not acceptable)

• Easily available to use at nursery, pre-school or school.

For children > 12 months, use shampoo labelled suitable for eczema Prescribe leave-on emollients in large quantities (250—500 g weekly) Show children and their parents or carers how to apply emollients. Where multiple topical products are used at the same time of day, children or parents/carers should apply them one at a time with several minutes between applications. Review repeat prescriptions with children and their parents or carers at least once a year.

Topical corticosteroids

• Explain that:
  • The benefits of topical corticosteroids outweigh the risks when applied correctly
  • Topical corticosteroids should only be applied to areas of active atopic eczema (or eczema that has been active in the past 48 hours).
• Do not use:
  • Potent topical corticosteroids on the face or neck
  • Potent topical corticosteroids in children under 12 months without specialist dermatological supervision
  • Very potent preparations without specialist dermatological advice.
• Prescribe topical corticosteroids for application only once or twice daily.
• Where more than one topical corticosteroid is appropriate within a potency class, prescribe the drug with the lowest acquisition cost, taking into account pack size and frequency of application.

DETECTIVE WORK

The practice nurse examined the ingredients list. She discovered that most of the ingredients in Adam's babyfood were very simple, but that the porridge contained whey protein.

Whey protein is a mixture of globular proteins isolated from whey, the liquid created as a by-product of cheese production. It is a dairy product.

The practice nurse suggested to Jacqui that, in addition to following the GP's advice, she stopped using commercial babyfood and returned to simple mashed vegatables and fruit of her own making, substituting an oat based cereal made up with expressed breast milk for the baby porridge.

TRANSFORMATION

For the following ten days Jacqui used emollients lavishly, used the clobetasone meticulously on thickened areas of skin on knees and elbows and stopped using the baby porridge. The effect was dramatic. When Adam returned for review his eczema had almost completely cleared.

Jacqui was enormously relieved. She cancelled the dermatology referral.

REFERRAL GUIDELINES¹

• Refer immediately for specialist dermatological advice if you suspect eczema herpeticum.
• Refer urgently (within 2 weeks) for specialist dermatological advice if:
  • The atopic eczema is severe and has not responded to topical therapy after 1 week
  • Treatment of bacterially infected atopic eczema has failed.
• Refer for specialist dermatological advice if:
  • The diagnosis is uncertain
  • The atopic eczema is not controlled based on a subjective assessment by the child, parent or carer
  • Atopic eczema on the face has not responded to appropriate treatment
  • You suspect contact allergic dermatitis
  • The atopic eczema is causing significant social or psychological problems
  • The atopic eczema is associated with severe and recurrent infections
  • The child (or parent or carer) might benefit from specialist advice on treatment application.
  • Refer for psychological advice children whose atopic eczema has responded to management but for whom impact on quality of life and psychosocial wellbeing has not improved
• Refer children with moderate or severe atopic eczema and suspected food allergy for specialist investigation and management
• Refer children with atopic eczema who fail to grow at the expected growth trajectory, as reflected by the UK growth charts, for specialist advice relating to growth.

FOLLOW-UP

Jacqui gradually weaned Adam off steroids and Cetraben. She kept him on a dairy-free diet until he was two years old. He needed occasional emollients during this time, particularly in cold weather, but only needed steroids once. At age two he was gradually introduced to diary products, with no adverse effects. The family dog continued to share the family home.

REFERENCE

1. NICE. Atopic eczema in children Management of atopic eczema in children from birth up to the age of 12 years. CG57, 2007. Available at: http://guidance.nice.org.uk/CG57/QuickRefGuide/pdf/English. Accessed February 2014