Skin-Directed Management of Childhood Atopic Dermatitis

December 16, 2014

Skin-Directed Management of Childhood Atopic Dermatitis

  1. Mary Wu Chang, MD

A monograph on the treatment of childhood AD for the pediatric primary care provider

  1. Mary Wu Chang, MD

Atopic dermatitis (AD), also known as eczema, occurs in 10% of children in the U.S. It is a chronic, relapsing, pruritic inflammatory skin disorder that greatly impacts quality of life of both child and family. Given the prevalence of AD and the insufficient numbers of pediatric dermatologists and pediatric allergists, particularly in rural areas, primary care providers will provide most of the care to these children.

In this comprehensive monograph on the treatment of AD for the pediatric primary care provider, main summary points include:

  • AD origin is multifactorial, stemming from genetic predisposition, skin barrier dysfunction, environmental triggers, and immune dysregulation.

  • Food allergies are overemphasized. Although food allergy is associated with AD and worsens prognosis, it is usually not causative.

  • Treatment of AD should be skin-directed. Bathing and moisturization are the cornerstones of skin maintenance. Flares are treated with judicious use of topical steroids (first-line treatment) and topical immunomodulators (second-line). Wet wrap therapy is appropriate for severe flares.

  • Some patients require continued intermittent use of steroids and immunomodulators for control. Intermittent topical anti-inflammatories can be an effective proactive strategy.

  • Infections are appropriately treated with topical or oral antibiotics. Bleach baths can be useful in certain individuals prone to repeated infections.

  • Oral antihistamines are useful for pruritus.

Comment

This is an excellent summary of atopic dermatitis for the primary care provider. Skin-directed management, a concept that is often difficult for parents to understand, is key. Parents often seek blood tests, allergy tests, and skin biopsy when the child fails to be “cured.” Realistically, AD is chronic and requires ongoing management — clinical examination of the skin dictates what the management should be. Patient and caregiver education is important to ensure proper adherence.

Editor Disclosures at Time of Publication

  • Disclosures for Mary Wu Chang, MD at time of publication Consultant / Advisory board Pierre Fabre; Valeant Speaker’s bureau Galderma

Citation(s):

Reader Comments (3)

Danielle Turner Physician, Pediatrics/Adolescent Medicine

I was just wondering about unique cases of when oral steroids can be helpful. I recently saw an adolescent girl with severe eczema to her body and the worst I've ever seen to her face. She already had significant scars to her face and areas of hypo-pigmentation. She was unable to apply mild steroids since they burned her skin. I opted to use 5 days of oral steroids in addition to medication for itching and topical steroids. I've seen this done before & the patient and family were aware of possible post-use flare. Thoughts?

James Ransom, MD Physician, Allergy/Immunology

Difficult to know where to start, so I'll start by saying that it is less confusing if one thinks of "allergy" as being solely an IgE-mediated disorder, and avoids Dr.Mervyn's conflation of "allergy" with "intolerance." Some triggers for allergy-related disorders, then, are not "allergens" but are substances acting through other mechanisms, sometimes unknown.
In the summary of the article it states, "Food allergies are overemphasized." Exactly by whom this is being done is unclear, but the burden of the statements following suggest that the primary care provider needn't concern herself (himself) about it.
Nothing could be further from the truth! All children with persistent atopic dermatitis can benefit from an allergy evaluation. Since the skin barrier is dysfunctional, testing is best accomplished by using an antigen-specific serum survey (ELISA technology is current standard) for foods as WELL AS a small group of environmental exposures commonly encountered, always to include dust mites, cats, dogs and cockroaches, but may include other substances depending on history.
There may be a shortage of allergists in some areas, but the blood tests for common foods and inhalants is readily available from laboratories. If any antigen is significantly elevated, an allergist can be consulted by phone for management suggestions, or the test results can be used as a filter to decide who might benefit from referral for more detailed management suggestions.
Simply treating such patients with skin therapies and drugs doesn't cut it, except when no allergies are present. In those cases where allergies may be significant triggers, it is good to remember that small children with eczema/allergy are in the first stages of what has been called "the allergic march" and many are headed for future problems with asthma and rhinitis. Treating their allergic state will definitely improve eczema, and may prevent or ameliorate future complications.

Garrett Mervyn Physician, Gold Coast

I disagree strongly with the statement that food allergy is not important. Certainly IgE food allergy isn't but non-IgE food allergy or intolerance certainly is and is the most underrated management option in this problem. I have lectured to GPs for 25 years and have said if you can't fix eczema in a child contact me and will both fix it. It is a multifactorial disease with varying importance of each factor yet we still have clinical trials excluding one particular trigger which is simply wrong. In some patients skin barrier is the most important but in others it is just another factor. The most common non-IgE food reactions that cause it are milk chocolate egg citrus tomato soy and later on the cereals as well and in some cases food additives as well. There are some rare patients that I haven't done that much for and I jolly well remember them . In one case the teenager had a pyrrole disorder which I didn't realise but correction with treatment he did well eventually. In my opinion to neglect non-IgE food allergy is negligent. If you ever see the loss of pigment in an eczema that is a marker for chocolate intolerance which of course cross-react with colour and it usually goes with chronic eczema and a milk problem. Chronic snuffly nose and some Ptyriasis alba due to chocolate is diagnosed before they even sit down and on a milk chocolate free diet they do well and these patients are resistant to steroid sprays. We tell our patients that they will grow out of their food problems that is silly because the genetic ability to react to foods persists for life and it will come back and bite you in another way sometime later in life and a history of eczema 40 years ago is important .I have just retired after graduation in 1957.

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