Guidance in Primary Care
Often described as “the itch that rashes,” eczema is best controlled with managing the itch (avoiding triggers and providing antihistamines) and moisturizing the skin (humidifying and protecting skin). Further complications include severe rash that may become infected or require topical steroids for long periods of time. Itch can also commonly affect sleep, which can then disturb the sleep of caregivers of our pediatric patients.
Although not life threatening, the severe itch and rash that can accompany eczema in young children under the age of two can be a miserable experience. According to a 2008-2009 survey, eczema affects nearly 10 million children under the age of 18.1 Eczema in the young child can be a persistent and troubling condition to manage for both parent and provider. Choosing between multiple over-the-counter treatments can be confusing and dermatology referrals can be delayed. How can the provider empower the parent with the best information to address the needs of the eczematous child?
The erythematous rash can sometimes contain vesicles and, if not infected, should not have discharge. In children under two it usually affects the face, whereas older children and adults have rashes in the flexor surfaces. Providers should ask about severity of symptoms including metrics such as bleeding, interference of sleep and co-infection.
Several metrics exist for establishing severity of eczema: severity of atopic dermatitis (SCORAD), eczema area and severity index (EASI) and patient-oriented eczema measure (POEM). Although newer treatments are available, co-management with a dermatologist may be most appropriate in severe or recalcitrant cases.
Pediatric eczema or atopic dermatitis can be related to a food allergy, thus if a parent notices a possible relationship between food and rash, parents should avoid the offending food item and receive a referral to an allergist. Typical offending foods can include (but are not limited to) eggs, peanuts, milk, seafood, soy and wheat. The APRN can educate parents about reading labels on food, elimination diet and avoiding cross contaminants at home.
Online resources can be a helpful resource for parents that extends patient care education beyond the walls of the clinical office visit and help empower the parent to learn about their child’s condition and affect positive change. Nationaleczema.org is a comprehensive resource with reviews on over-the-counter products and educational videos from experts in the field.
All treatment should begin with education, scoring the severity, and encouraging quality skin care. Discussing potential complications of the illness (interruption of sleep and staphylococcal aureus infections including methicillin-resistant staphylococcal aureus or MRSA) and discussing expectations (when to return for follow up and when to include dermatology referral) can enhance the parent-provider relationship. This author suggests a stepwise approach to include the following recommendations for managing eczema in the outpatient primary care setting in Figure 1 (see below).
Bathing remains a controversial aspect of home care for children with eczema. Surveys yield PCPs recommending baths less frequently than specialists.2 Truly, evidence is conflicting and bathing may have individualized responses, as a 2015 meta-analysis of patients with atopic dermatitis who bathed daily yielded 29% favorable responses among eczematous children who bathed daily.3 Bleach baths are a mainstay of preventative treatment in pediatric patients; giving a dilute solution can reduce colonization of MRSA and reduce infectious outbreaks in eczematous children.4 Dilution instructions are to use 1/2 cup of 6% bleach in a full (40 gallon) bathtub or one-half of a teaspoon in one gallon of water.
If topical steroids remain ineffective, it is time to refer to dermatology. When used in combination with wet wraps, one can use intermittent or lower dose corticosteroids, as the medication is absorbed at a higher rate.5 Topical corticosteroids at low doses are most appropriate for children under the age of 2; while topical calcineurin inhibitors remain an option, they have similar efficacy, but have neither been studied extensively nor are available as “on label” use for children less than two years of age.6 Phototherapy and oral cyclosporine are also options for severe or recalcitrant atopic dermatitis, however are not evidenced as safe for very young children and would be considered step up therapy in the specialty dermatological setting.
Indeed moisturizers used in combination with steroid creams have provided the best results with controlling symptoms and improving outcomes than either topical prescriptions or moisturizing alone as noted in a 2017 Cochrane review of literature.5 This Cochrane review confirmed the importance of regular use of creams with glycyrrhetinic acid-, urea- and glycerol ; no brand was superior to others for control of flares.5 Of note, oat-containing moisturizers were associated with more adverse events in one particular study.5 Careful instruction to use moisturizing cream with ceramides and urea within minutes after a bath can improve dryness and help moisturize skin as parents “soak and seal” the skin.7 Parents should be instructed to hydrate the skin shortly after a bath (within 3 minutes), using steroid or other cream at that time then cover with petroleum as an pseudo-occlusive dressing.
Antihistamines such as cetirizine and diphenhydramine have been well studied as beneficial for controlling itching and improving outcomes in eczema; although they do not directly affect improvement in eczema, they can control the pruritis and sedation can be a positive side effect.8 Cetirizine is safe for use in children over the age of 6 months while diphenhydramine is usually started after 24 months of age. Wet wraps (covering the skin with a wet cloth for 1-2 hours, or overnight if tolerated) have been a mainstay recommendation and would be an appropriate “third step” for providers to instruct parents before referring to dermatology.9 If tolerated these can be left on overnight. Consideration should be made about using lower dose topical steroids due to increased absorption, chills and possible folliculitis.
Eczema can present throughout the lifespan and be successfully managed in the primary and specialty care settings. Establishing effective outpatient teaching and nonpharmacological standards of care can help bridge the gap for parents to help ease exacerbations.
- Discuss the condition in depth with parents/patient and empower them to make observations about exacerbating and improving factors such as bath frequency and type of moisturizer.
- Bathing either daily or every other day with hypoallergenic, unscented cleanser OR in plain tap water.
- Soak and seal! Hydrate skin within 3 minutes of exiting bath with cream containing ceramides. Second layer with petroleum jelly.
Control the itch
- Add daily or intermittent (as needed) antihistamine (cetirizine for children < 2 years of age, diphenhydramine if > 2 years) for severe itching symptoms, especially night-time pruritis
- Low-medium dose steroids to reduce inflammation
- Wet wraps for 1 hour (up to overnight) with decreased topical steroid use
- Dilute bleach baths to prevent staph/MRSA infections
- Silverberg J, Simpson E. (2014) Associations of Childhood Eczema Severity. Dermatitis. 25(3):107-114. doi:10.1097/der.0000000000000034
- Cardona ID, Kempe E, Hatzenbeuhler JR, Antaya RJ, Cohen BA, Jain N. (2015). Bathing Frequency Recommendations for Children with Atopic Dermatitis: Results of Three Observational Pilot Surveys. Pediatric Dermatology 32(4) e194-e196
- Sarre ME, Martin L, Moote W, Mazza JA, and Annweiler C. (2015) Are baths desirable in atopic dermatitis? Journal European Academic Dermatology Venereology. Jul;29(7):1265-74. doi: 10.1111/jdv.12946 n . Epub 2015 Jan 27.
- Wong SM, Ng TG, Baba R (2013) Efficacy and safety of sodium hypochlorite (bleach) baths in patients with moderate to severe atopic dermatitis in Malaysia. Journal of Dermatology. 2013;40(11):874. Epub 2013 Sep 20.
- van Zuuren EJ, Fedorowicz Z, Christensen R, Lavrijsen A, Arents BWM (2017) Emollients and moisturisers for eczema. Cochrane Database Systematic Review. 2017;2:CD012119. Epub 2017 Feb 6.
- Sigurgeirsson B, Boznanski A, Todd G, Vertruyen A, Schuttelaar ML, Zhu X, Schauer U, Qaqundah P, Poulin Y, Kristjansson S, von Berg A, Nieto A, Boguniewicz M, Paller AS, Dakovic R, Ring J, Luger T (2015) Safety and efficacy of pimecrolimus in atopic dermatitis: a 5-year randomized trial. Pediatrics. 2015 Apr;135(4):597-606. Epub 2015 Mar 23.
- Stein Gold LF, Eichenfield LF (2017) Nonpharmacologic strategies and topical agents for treating atopic dermatitis: an update. Seminars in Cutaneous Medicine and Surgery. 36(2 Suppl 2):S42.
- He A, Feldman SR, Fleischer AB Jr (2018)Journal American Academic Dermatology. An assessment of the use of antihistamines in the management of atopic dermatitis 79(1):92. Epub 2018 Jan 6.
- Sala-Cunil A, Lazaro M, Herraez L, Qunones MD, Moro-Moro M and Sanchez I. (2018) Basic Skin Care and Topical Therapies for Atopic Dermatitis: Beyond Essential Approaches. Journal of Investigative Allergol Clinical Immunology. Jul 13:0. doi: 10.18176/jiaci.0293.