Eczema School. Department of Dermatology, Aarhus Sygehus, Anne Braae Olesen, MD, Ph.D. or Mette Deleuran, Chairman, MD, DMSc.

Purpose/goal for the Eczema School. To educate the parents about the disease To treat the disease correctly. To accept the disease.

Different names for the disease Child eczema Asthma eczema Atopic dermatitis Atopic eczema Prurigo Besnier

Atopic eczema – how to describe the disease? Chronic skin disease that varies in intensity Dominated by severe itch and an increased tendency to itch Acute eczema: weeping? and often with infection. Chronic eczema: dry, infiltrated skin.

How common is the disease and courses for the disease? Affects 15-20 per cent of all Danish children Increased prevalens Genetic factors are involved Increased risk for the disease if the parents and siblings have the disease Environment and everyday life also have an impact on the disease.

Changes in the skin. The mechanical barrier is defect Decreased amount of fats in the skin Increased water loss from the skin Increased amount of inflammatory cells in the skin

Skin barrier function Altered composition of fatty acids in the strateum corneum Increased water loss LB

Skin dryness Krakeleret eksem Huden knastør og skællende

Atopic Eczema – itch The skin is leaking Evaporation – the skin gets dry The skin is itching and the child itches back ”Definition” af kløe (1600-tallet): en ubehagelig fornemmelse som medfører et ønske om at kradse sig Det er ikke nogen rationel refleks. Kløe og krads medfører yderligere hudirritation og likenisering samt eksem (Smerte er en anti-kløe tilstand) Tomgangsbevægelse Polerede negle Undgå bebrejdelser (operant betingning)

Do you think I sleep well at night?

Development of eczema disease 90 per cent develop the disease in the first three years of life Early debut can be predictive for severe disease 75-80 per cent are clear of symptoms in childhood In 10-20 per cent of the patients the disease comes back 25-50 per cent develop hand eczema later

Distribution of eczema Infants: especially the face, the scalp and the extensor sides of the extremities

Distribution of eczema Infants, especially the face, the scalp and the extensor sides of the extremities.

“Lick eczema” Cheilitis tørt fissureret eksem omkring mund og læber

Distribution of eczema. Children: flexural areas, head and neck, ankles and wrists.

Distribution of eczema. Adults: often face, neck and hands.

Complications Wound infections with staph. aureus: impetigo.

Complications Impetigo, oozing eczema.

Complications Herpes infections

Complications Molluscum.

Complications Warts and condyloma

Increased risks for other diseases Asthma (approximately 33 per cent) Hay fever (approximately 33 per cent) Food allergies (5-7 per cent) Food intolerance

Diet in children with eczema Nursing can postpone eczema debut Uncertain whether the eczema can be prevented Eczema patients on a diet are not free of symptoms Some children do get better on a diet A diagnosis of food allergy is based on history, prick/RAST-test and maybe provocation.

Dietary treatment in patients with eczema Many positive prick/RAST-tests concerning foods are not clinically relevant Some food allergies can disappear when the child grows older Dietary treatment do not always need to be life long It is important to consider the diet from time to time.

Dietary treatment in patients with eczema Avoid strict diets in children where you do not have specific suspicion on allergies. Malnutrition has been observed How severe the diet should be depends on the disease history.

Principles for treatment Avoid factors that irritate the skin

Principles for treatment Emmollient is basic treatment Control of dryness and itch

Steroid creams

Steroid creams Containing cortico-steroids Are divided into 4 groups Effect and side effect go hand in hand Diminish the inflammation in the skin Contract the block vessels and diminish erythema Diminish itch

Steroid creams Absorption of cream is greatest in areas with thin skin and intertriginous areas Face and genitals are especially sensitive Use milder steroid creams in these areas When you use the cream in the right way there are only few side effects

Steroid side effects Atrophy Skin bleedings Telangiectasiae Infections Acne Worsening of the disease when you stop the treatment

Treatment principles – steroid cream Only apply cream/ointment on active areas Apply in a thin layer: fingertip units Wash your hands after applying the cream or use gloves Use an effective cream to start with and reduce the strength when the skin gets better It is important to reduce gradually to prevent a flair of the disease

Treatment principles – steroid cream Used in the right way there are only few side effects Chronic untreated eczema harms the skin We see more under treated than over treated children It is important that the children get a normal life

Tar treatment of eczema Tar is a good treatment for eczema It is greasy and it smells Tar can sting on the skin if you have open wounds Can be used undiluted or diluted in creams Increases photo sensitivity

UV-treatment for eczema Sun light and UVB-treatment help most patients UV-treatment is best for bigger children PUVA-treatment for adults

Gamma-linolenic acid Unsaturated fatty acids It helps a few patients It is expensive You have to eat a lot of capsules every day It can be tried when you have severe eczema for a period Stop the treatment if it does not have any effect because the effect is not documented in larger groups

Alternative treatment Miralex cream

Treatment of eczema complicated with impetigo Wash with water and mild soap Sodium permanganate (red baths) Steroid creams with antibiotics Antibiotic creams and ointments Antibiotics as tablets or mixture

Newer treatments: Elidel and Protopic Elidel cream: 1 per cent Protopic ointment 0,03 per cent and 0,1 per cent Effective for treatment of atopic dermatitis Long term control of atopic dermatitis for around 80 per cent of the patients

Elidel and Protopic Advantages: Do not contain steroids Can be used in all skin areas Can be used for long term treatment Does not induce atrophy

Elidel treatment of atopic dermatitis Elidel må bruges efter 2 år Behnadlingsfri interval på 14 dage før vaccination (28 dage ved levende vaccination) Protopic 0,03 % må bruges hos børn over 2 år Protopic 0,1% hos børn over 16 år De samme regler for vaccination

Elidel and Protopic Side effects: Feeling hot on the skin after application Bacterial infections in the skin Herpes infections

Elidel and Protopic Do not use solarium or get UV-treatment when treated with Elidel and Protopic