CLINICAL PRACTICE : Updates and refreshers

Consistent messages needed

for childhood eczema
Eczema, often described as atopic
dermatitis, commonly presents
as a chronic relapsing widespread
or patchy itchy rash. Pharmacists
are often confronted by parents
requesting advice for this problem
and should be aware of the stand
ard treatments and management.
jOHN DUNLOP

&

LINDA BRYANT

CLINICAL ADVISORY PHARMACISTS

Clinical medication
review
Case Study
Mrs J comes into the pharmacy
at 4.30 in the afternoon with her
23-month-old daughter, Mary, who
was diagnosed one year ago with
atopic dermatitis. The mother is in
a hurry to get home and presents a
prescription for Mary for emulsifying ointment and clobetasol cream.
She tells you Mary is not sleeping
well and wants to know what she
can do about this. She has had
previous prescriptions for aqueous
cream from you.

Epidemiology
Eczema is a relatively common
and poorly managed problem,
which affects up to 17% of the
population in the US, with 65%
affected by 18 months of age, and
about 80% of cases presenting
before the age of five.1
Pathophysiology
The pathophysiology of eczema
is not well defined.2 There appear
to be two theories proposed, the
first being that inflammation
results in an immune dysfunction
resulting in IgE disturbances which
compromise the epithelial layer of
the skin. The second theory sug
gests that the epithelial barrier is
disorganised in such a way that the
immune response is compromised
leading to inflammation.
In eczema there is an increased
loss of transdermal water and
increased penetration of allergens,
which is thought to be due to the
loss of function of a key epidermal
barrier protein, filaggrin.3 The
combined effect of this is to increase
sensitivity and inflammation.
Symptoms
An assessment of the skin indi
cates the individual treatment of
the child. (Table 1)
Diagnosis
The validated Hanifin and
Rajka diagnostic criteria4 requiring
the presence of itchy skin, with
three or more of the following:
history and visible signs of
eczema around skin creases
history of dry skin
onset under age 2

Eczema is relatively common in children before the age of five

history of asthma.
The presentation of symptoms
will define the diagnosis, but there
is also a need to determine what is
of concern to the family as this will
prioritise the plan of care. There
is a need to be aware of the history
in order to determine if there are
any underlying conditions. NICE
describes the severity of eczema
according to Table 2.5
Differential diagnosis
Other conditions such as
contact or allergic dermatitis,

immunodeficiency, psoriasis,
lichen simplex and scabies are rela
tively easily distinguished condi
tions that may be confused initially
with atopic dermatitis. A list of
conditions to consider is in Table 3.

Learning objectives

Treatment
Social factors that may influ
ence management of childhood
eczema should be recognised by
pharmacists working with children
with eczema. They may include:
the socioeconomic status of the
family

understand the
pharmacotherapy for
eczema.

To understand the

p revalence of atopic
dermatitis.
To recognise and

To recognise the

importance of the role of the

pharmacist in treatment.

Table 1. Assessment of the skin

Classification

Description

Treatment

Dermatitis
Pruritis
Spongiosis

Indicates a need for emollients and topical steroids. Also

indicates exposure to allergens

Excoriation
Lichenification

Inflammation of skin
Itching of the skin
Oedema in the epidermis
Redness of skin occurring in patches of
varying size
Scratched skin
Leathery hardened skin

Icthyosis

Dry skin

Erythema

Indicates the need for topical steroids to constrict vasodilation. Also indicates a need for emollients
Indicates the need for greater use of emollients
Indicates the need for emollient therapy. The more severe
the icthyosis, the greater the need for emollient

Table 2. Eczema severity

Skin/physical severity

Impact on quality of life and psychosocial wellbeing

Clear

None

No impact on quality of life

Mild

Little impact on everyday activities, sleep and

psychosocial wellbeing
Moderate impact on everyday activities and
psychosocial wellbeing, frequently disturbed
sleep
Severe limitation of everyday activities and
psychosocial functioning, nightly loss of sleep

Mild
Moderate

Severe

30 | October 2014

Normal skin, no evidence of active atopic

eczema
Areas of dry skin, infrequent itching (with or
without small areas of redness)
Areas of dry skin, frequent itching, redness
(with or without excoriation and localised
skin thickening)
Widespread areas of dry skin, incessant
itching, redness (with or without excoriation,
extensive skin thickening, bleeding, oozing,
cracking and alteration of pigmentation)

Moderate

Severe

PharmacyToday.co.nz

Updates and refreshers : Clinical Practice

the carers language

literacy and ability to under
stand
confidence in own ability
previous experience with the
condition
concern about whether the
condition is infectious
awareness of when to request
medical help
support from public health
nurse
support from their general
practitioner.
Emollients
The basis of care in childhood
eczema is the proper use of emol
lients. Correct emollient use is
associated with increased soften
ing and elasticity of the skin, due
to an increase in hydration and a
decrease in:
dryness and scaling
erythema
spongiosis
pruritis
Staphylococcus aureus (due to
decreased skin dryness)
need for high potency cortico
steroids.
Emollients should be used
in almost every case of eczema
to help restore the skin barrier.
They should be used at least twice
daily and are best applied immedi
ately following a shower or a bath.
Creams and lotions are not as effec
tive as ointments, as they often are
not oily enough, but are easier to
apply.
Often trial and error is the best
way to find the right emollient for
an individual. Most are equally
effective on a population basis, but
individuals may respond better to
one rather than another.
Simple emollients such as
cetomactogol and HealthyE Cream
are recommended, rather than
those with multiple ingredients,
perfumes, some preservatives and
others that are not generally pH
neutral.

Emulsifying ointment and

sometimes aqueous cream can be
used a soap substitute, though both
these preparations contain sodium
lauryl sulphate.
Sodium lauryl sulphate has been
shown to cause skin reactions in
some people,6 such as reduced skin
thickness, increased permeability
(water loss) and inflammation with
peeling,6 though emulsifying oint
ment has been found to be accept
able for most cases, both topically
and as a soap substitute.
Aqueous cream which may
cause stinging and discomfort in
children,7 encourages greater water
loss,8,9 and is not now considered
appropriate treatment.
Topical corticosteroids
These form an integral part of
the treatment for eczema and are
employed when there is a flare-up
to reduce the inflammation and
accompanying itch. When used
correctly, topical steroids are both
safe and effective.
Applications should involve a
covering layer of potent topical
corticosteroid applied two to three
times daily while skin is flared,
then, once the inflammation is
controlled, reduce the treatment
to twice daily over the next three
days, using a moderate strength
topical corticosteroid.10
In practice, the use of hydro
cortisone 1% is the mainstay of
topical corticosteroid use. Stronger
topical preparations include
betamethasone, mometasone and
clobetasol.
Care is required with the sug
gestion to apply sparingly. This is
no longer a suitable instruction and
can lead to patient confusion.
No matter how much cream
is actually applied, the amount of
cream adjacent to skin remains
constant. The goal is to ensure
the flare-up is covered adequately
with a potent topical steroid, and
the use of hydrocortisone cream

Table 3. Differential diagnosis

Contact dermatitis allergic

Rash on localised area exposed to substance

Contact dermatitis irritant

Rash on the area exposed to the substance.

Lack of family history for atopy

Psoriasis, plaque

Localised, well-demarcated erythema in

patches, usually on extensor surfaces, scalp

Scabies

Burrows and finger web involvement, plus

distribution, including hands, feet, waist, groin

Tinea corporus

Pink to red circular raised borders with clear

central mass

Immunodeficiency

Measles, varicella,

Lichen Simplex Chronicus

Figure 2. Diagram
illustrating the
areas of skin likely
to be involved and
the superficial
layer implicated in
eczema (copyright
Sedico.Co)

or ointment should be liberally

applied, when needed.
Topical immunomodulators
Pimecrolimus and tacrolimus
creams and ointments have been
shown to be useful in mild-tomoderate dermatitis. Both of these
calcineurin inhibitors appear to be
equally effective,11 with tacrolimus
demonstrably superior to hydrocor
tisone 1% ointment, but more likely
to demonstrate adverse events.12
Wet wraps
Wet wrapping cannot be used
when eczema is infected. The use
of wet wraps may be useful for
children whose eczema is not well
controlled by appropriate emollient
and topical steroid use.
They are also useful for the
child who doesnt sleep well and
for those who are for whatever rea
son not happy to apply the correct
amounts of emollients and steroids.
Wet wraps are applied over the
corticosteroid application to the
inflamed area. All that is required
is one layer of wetted gauze cov
ered by a dry layer of gauze.
The gauze can be covered by
a sock or other bandage to keep
it in place which is usually left on
overnight.
Wet wrapping should only be
instigated if recommended by a
dermatologist or GP or nurse with
a special interest, as greater cor
ticosteroid absorption may occur
under occlusion.
Infected eczema
Treatment of infected eczema is
somewhat controversial. The use of

short-term courses of oral antibiot

ics may be appropriate for infected
eczema.13 A Cochrane Review
concluded there was no clear evi
dence for antibacterial soaps, bath
additives or topical antibiotics or
antiseptics.14
Trigger factors
The NICE Guidelines5 listed
trigger factors that had been shown
to exacerbate childhood eczema
(Table 4). From the following list
it can be deduced that almost any
thing might trigger eczema and so
this makes the concept of keeping
a diary impractical. The problem
for those involved with the childs
care is to determine what that trig
ger might be.
What is the role of the
pharmacist?
The pharmacist is in an ideal
position to help people with this
debilitating condition. Reinforcing
the messages provided by public
health nurses and GPs to apply gen
erously an appropriate moisturiser
is the first step.
Second, it is extremely impor
tant to reassure parents and carers
that good and continuous coverage
of topical corticosteroids to mini
mise the effects of flare-ups is safe.
The pharmacist should ensure
the person can answer three ques
tions before they leave:
What are they going to do rou
tinely to keep their skin healthy?
What are they going to do
when their skin condition gets
worse?
Where are they going to go to
get more information or support

Table 4. Potential eczema trigger factors

Irritants

Wool or synthetic clothing, soaps, detergents,

disinfectants, perspiration, topical antibiotics,
chemical reagents

Contact allergens

Preservatives, perfumes, metals, latex

Foods dietary factors

Cows milk, eggs, peanuts, tree nuts, wheat, soya,

fish, shellfish; rarely, sesame, kiwi, legumes

Inhalant allergens

House dust mites, animal dander, cockroach,

moulds, tree and grass pollens

Chronic pruritic superficial dry scaling

demarcation of hyperpigmented shapes

Infections

Staph aureus, Steptococcus sp, Candida albicans,

Pityrosporum yeasts, Herpes simplex

Mycosis fungoides

Uncommon chronic lymphoma primarily

affecting the skin.

Climate

Seasonal variation, extremes of temperature and

humidity

Mollusca contagiosa with

dermatitis

Skin coloured numerous small papules

210mm in diameter

Environmental factors

Hard water, cooking with gas, proximity to road

traffic, second-hand smoke

Nummular dermatitis

Chronic pruritic inflammation of skin with

coin-shaped crusty scaling lesions

Familial factors

Genetics, family size, sibling order

Social factors

Seborrheic dermatitis

An inflammatory scaling disease of the scalp,

face and, occasionally, other areas

Higher incidence in more affluent classes in Great

Britain. In New Zealand, childhood eczema is
prevalent in low socioeconomic areas

Relative zinc deficiency

Psoriasis-like dermatitis accompanied by hair

loss, diarrhoea and growth retardation

Morbidities

Concurrent illness, teething, psychological stress,

lack of sleep

PharmacyToday.co.nz

for any questions that arise?

They should also ensure that,
if the condition is not improving in
five to seven days, the child should
be referred back to the prescriber
for review.
Prognosis
Most children outgrow this
condition, though significant
numbers go on to develop allergic
rhinitis and/or asthma. n
References
1. Spergel J. Epidemiology of atopic dermatitis and atopic march in children. Immunol
Allergy Clin North Am 2010;30(3):26980.
2. Farhi D, Taieb A, Tilles G et al. The historical basis of a misconception leading to
understanding atopic dermatitis (eczema):
facts and controversies. Clin Dermatol
2010;28(1)4551.
3. Kubo A, Nagao K, Amagai M. Epidermal
barrier dysfunction and cutaneous sensitization in atopic diseases. J Clin Invest
2012;122(2):440-47.
4. De D, Kanwar A, Handa S. Comparative
efficacy of Hanifin and Rajkas criteria and
the UK working partys diagnostic criteria in
diagnosis of atopic dermatitis in a hospital
setting in North India. J Eur Acad Dermatol
Venereol 2006;20(7):853-59.
5. Anonymous. Atopic eczema in children.
NICE clinical guideline 57. In: Excellence
NIfHaC, (ed). London: RCOG Press, 2007.
6. Neppelberg E, Costea D, Vintermyr O et al.
Dual effects of sodium lauryl sulphate on
human epithelial structure. Exper Dermatol
2007;16(7):57479.
7. Cork M et a. Using emollients for eczema.
Br J Dermatol 2003;7(2):68.
8. Tsang M, Guy R. Effect of aqueous cream
on human stratum corneum in vivo.
Br J Dermatol 2010:95458.
9. Mohammed D, Hadgraft J, Lane M. Influence of aqueous cream BP on corneocyte
size maturity, skin protease activity, protein
content and transepidermal water loss.
Br J Dermatol 2011;164:130410.
10. Hong E, Smith S, Fischer G. Evaluation
of the atrophogenic potential of topical
corticosteroids in pediatric dermatology
patients. Pediatric Dermatol 2011;28(4):
39396.
11. Kirsner R, Heffernan M, Antaya R. Safety
and efficacy of tacrolimus ointment versus
pimecrolimus cream in the treatment of
patients with atopic dermatitis previously
treated with corticosteroids. Acta Derm
Venereol 2010;90(1):5864.
12. Mandelin J, Remitz A, Virtanen H et al.
One-year treatment with 0.1% tacrolimus ointment versus a corticosteroid
regimen in adults with moderate to severe
atopic dermatitis: A randomized doubleblind,comparative trial. Acta Derm Venereol
2010;90:17074.
13. Tidman M. Improving the management of
atopic eczema in primary care. Practitioner
2012;256(1750):2123.
14. Birnie A, BathHextll F, Ravenscroft C et al.
Interventions to reduce Staphylococcus aureus in the management of atopic eczema.
Cochrane Skin Group. Cochrane Database
Syst Rev 2009(4).

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