Eczema Management

Early diagnosis (Pediatrics 2008) Can influence child’s overall physical and social well- being Can effect family dynamics – physical, emotional and functional

Significance of early and effective management (Pediatrics 2008) Early diagnosis of eczema and early appropriate treatments implemented may decrease a number of preventable problems Treatments initiated immediately on onset can decrease severity of the skin barrier issues Early diagnosis can be made with identifying at risk babies, ie. family history, sibling with eczema Diagnosis and control may influence development of asthma and allergic rhinitis (Hanifin et al,poster presentation Am Ac Derm, 2007)

Key points to management Assess severity and child’s/family Qol Identity potential triggers Consider food allergy Reacted to a food with immediate symptoms Have moderate to severe uncontrolled eczema despite optimum topical management Gut dysmotility (colic, vomiting, altered bowel habits) Most children with eczema do not need to have tests for allergies

Key points continued Do not undergo high street or internet allergy tests – no evidence Altering diet of breast feeding mothers may not be helpful or appropriate Any exclusion diet in child or breast feeding mother should be under the care of a dietitian

Topical treatment Emollients – no different from older child but more acceptance of greasier consistencies Topical steroids – always use the lowest strength that works First 2 classes generally used Occasionally stronger classes are required for severe flares

Steroids available in New Zealand (July 2007) MildModerately PotentPotentVery Potent Hydrocortisone % DermAid DP Lotion-HC Skincalm 1% Lemnis Fatty Cream HC Pimafucort 2-25 times as potent as 1% hydrocortisone Eumovate Aristocort Viaderm KC Kenacomb I times as potent as 1% hydrocortisone Beta, Betnovate, Daivobet 50/500 Fucicort Nerisone Hydrocortisone 17- butyrate Locoid Cream/Crelo Emulsion/Lipocream/Oi ntment/Scalp Lotion Elocon C/Lotion/Oint Advantan Cr/Oint Up to 600 times as potent as 1% hydrocortisone Clobetasol propionate Dermol C/Ointment Betamethasone dipropionate Diprosone OV Cream/Ointment

2 Case studies

Case one Current history 6 month old boy Severe, generalized eczema Weeping, crusted lesions No fever Still exclusively breast fed No solids introduced No improvement Daily applications of steroid creams Several exacerbations of eczema during breast feeding Irritable Disrupted sleep Failing to thrive Past history Born full term Unremarkable pregnancy Normal weight and length Mother has asthma and hayfever

Diagnosis and treatments Severe infected atopic eczema Allergy tests were performed RAST, specific immunoglobulin E (IgE) and Skin Prick Test, SPT Positive to milk, wheat, egg, kiwifruit and peanut Exclusion diet by the mother for 4 weeks, supervised by a paediatric dietitian. Exclusion diet led to clear improvement in the child’s eczema

Foods that account for more than 90% of food allergies - by age InfantChildren(2-10 years)Older children Cow milk Peanut Eggs Tree Nuts WheatPeanutFish SoyTree NutsShell fish FishSesame Shell fishPollen-associated foods Sesame Kiwifruit

Does food allergy resolve ?… cow’s milk hen’s egg peanuts, fish, seafood, … prevalence age 3 yrs 5 yrs6 months

Case two 3 year old boy Mild eczema On a highly restricted diet Developed severe eczema at 2 months of age when breastfeeding was stopped Eczema had been diffuse and resistant to topical treatments He had an assessment by an allergist SPT showed strong positive results to milk and egg His diet excluded egg and milk and he had an amino acid formula (Neocate) By age 2 years his eczema was mild and he tolerated egg in baking. At that point he was seen by a general practitioner who suggested RAST testing

Case 2 continued.... The results showed Decrease in egg Sensitisation to other food allergens; soy, wheat, fish and beef Advised that exclusions of these other foods would lead to further reduction in his already ‘mild’ eczema However There was no reduction in the eczema Weight dropped from 50 th centile to 25 th centile Developed significant behavioural issues

Case 2 continued.... Referred back to allergy clinic Retested and found to have outgrown both egg and milk allergies Diet was completely liberalised Residual eczema managed with topical steroids Achieved appropriate weight gain Behavioural problems improved

Discussion Diet manipulation more pronounced under the age of 2 years with severe, early onset of eczema Caution with allergy tests interpretation without clinical history Over interpretation of the results Irrelevant sensitisation to foods rather than true allergy Stress of adhering to unnecessary food exclusions Nutritional compromise Careful history, 4-6 week exclusion trial, then reintroduction Supervised by a dietitian

Take home messages Basic management principles apply across the ages especially when severe, exacerbated or poorly controlled eczema In the younger child help and support is required to maintain self care Allergies may play a role but skin management is always the most important intervention