The basics!!

Assessment Age of child – developmental & emotional Caregivers & environment Daily routine Skin condition of whole body Acute, chronic, atopic, contact dermatitis and /or seborrhoeic What could be irritants in regards to age & activities

Is to repair and maintain skin integrity and barrier function

Moist Wound Healing Provide moist environment Keep temperature close to body temperature Infrequent dressing changes Prevent or reduce scab formation

Practical Skin Care Emollients Topical Steroids Bacterial Management Wet Wraps / Dry wraps Identify irritants Behaviour modification

Management Practical tips on how to apply steroid and emollients – amount, how often, when, why Prophylactic as well symptomatic Bathing – with emollient and volume

Emollients Should be applied in a variety of ways including prophylactically Trouble shooting eg bacterial contamination Behaviour management

Demonstrated multiple effects of emollient on skin Decrease desquamation of the epidermis Improve skin barrier repair Decrease erythema and TEWL Increase SC hydration – Hydration persists with repeated application of emollient but effect is shorter in atopic skin compared to normal skin Decrease potency of topical corticosteroid required (steroid sparing)

Cork, M.J et al. (2003) Comparison of parent knowledge, therapy utilization and severity of atopic eczema before and after explanation and demonstration of topical therapies by a specialist dermatology nurse. British Journal of Dermatology, 149,

The clinical response observed in skin with effective emollient use Decrease in dryness and scaling Softening and increased elasticity Decrease in erythema Decrease in spongiosis Decrease in itch Decrease in Staph. Aureus (due to decrease in skin dryness) Decrease in pigmentation changes (over a period of weeks)

Topical Steroids When / how much to use The ‘step approach’ What about infection?

Classes of topical steroids 1: Very Potent ; up to 600 x hydrocortisone Dermal, Diprosone 2: Potent ; x Beta, Betnovate, Locoid, Elocon, Advantan 3: Moderate ; 2-25 x Aristocort, Eumovate 4: Mild hydrocortisone % ( DermNet NZ )

Precautions with: Children: higher absorption due to thin skin and larger surface area Occlusive dressings: nappies, wet wraps infection, weeping areas, pruritis etc Presence of excipients such as coal tar, urea Risk depends on: Steroid strength Length of application Site and type of skin problem For example, if using hydrocortisone(mild) would need to use 500g per week for adverse effect

Aim is use the least potent topical steroid that is effective Choice will be dependent on age of the child, severity & site For the older child/ young adult a moderately potent steroid may be used 1-2 x week for maintenance A step approach may be needed to effectively manage skin inflammation Topical steroid must be used in conjunction with emollients

Antihistamines Classified on their ability to block actions of histamine receptors in responsive tissue 1 st generation may help due to sedating effect Eczematous disease is T- cell mediated Histamine plays no significant role No evidence to show oral antihistamines decrease itch in eczema

Oilatum Plus/ QV Flare Up Bath additive : benzalkonium chloride 6%, triclosan 2%, light liquid paraffin For topical tx of eczema including eczema at risk from infection mls in infant bath, capfuls in bath Can be used on infants under 6 months If used daily for more than 5-7 days then step approach needs to be used when decreasing

‘Since focusing on her baths the change in her skin has been dramatic’ ‘I think if more parents with eczema kids knew about the importance of baths, we’d spare more kids (and their parents) a lot of misery’

Bleach in the Bath! Evidence based Drying of skin & difficult to use on daily basis Gentler antimicrobials can be used daily Cost factor Half a cup of bleach in full bath

Dry Wraps Use once appropriate use of emollients and topical steroids are in place (there are always exceptions) if overall eczema well managed but areas remain dry and /or excoriated Can introduce a family/individual to wrapping Provides protection of skin & hydration Tool in the ‘Tool Box’

20 Dry Wraps Advantages: Increased maintenance of skin hydration Decreases emollient application Protects skin Decreases itching Easy to use Disadvantages Drys out Requires regular emollient application initially Becomes itchy once emollient absorbed Not as effective as wetwraps

Wet Wraps Should be considered for - the severely affected child that is not well controlled despite adequate emollients and topical steroids being applied appropriately. the child who does not sleep well at night despite good skin management the child and /or family who have a good understanding of emollient therapy but cannot or are unwilling to apply the amounts required. Surprisingly, this is a good option for adolescents. Wet wrapping cannot be used when eczema is infected. The moisture will encourage bacteria growth

Wet Wraps Need to be taught, managed and supported by health professional who knows what they are doing Otherwise can be ineffective and a valuable management tool is lost If so can disappoint family and increase disillusionment 22