Initial Therapy.

The aim of treatment should be to clear the eczema over a period of 1–2 weeks, earlier if possible, and then to adopt an effective maintenance regimen to treat areas of eczema as and when they appear. The treatment prescribed needs to be tailored to the response and several remedies may be required before the best combination is found.

Bathing and Moisturizing Agents

Over the years there has been conflicting advice regarding the benefit of bathing. This is because ordinary soaps and detergents can irritate and aggravate eczema [19]. Acceptable practice now is to encourage carers to bathe children with eczema daily with the proviso that an oil emollient is added to the bath water and the use of a soap substitute, such as aqueous cream, is prescribed [20,21]. For children with severe eczema, twice-daily bathing is recommended. This regime allows debris to be removed from the skin, including exfoliated skin scales, which are an excellent medium for bacterial colonization. The addition of an oil to the bath allows a thin lipid film to be applied to the skin.

Other useful tips in bathing are to ensure that the water is not too hot, as heat will intensify itching, and to make the session fun so that children look forward to bath time. Time spent soaking in an oily bath is an important part of therapy. A point of caution is to remember that oil added to the bath water does make the bath slippery and babies must therefore be held firmly and children warned not to stand up and jump around in the bath. Bath time should be 10–15 minutes and on coming out of the bath, the child should be patted dry carefully. Rubbing is to be avoided, as this will precipitate the sensation of itch. Immediately following a bath is the best time to treat the eczema, either with an appropriate topical steroid or with one of the calcineurin inhibitors, applied specifically to the areas of inflammation. It is important not to apply an emollient at the same time to the same site because it will wipe off and dilute the effectiveness of the treatment application.

Most children with atopic dermatitis have a generally dry skin, sometimes with fine scale and cracking. The application of emollients (moisturizing agents) improves the integrity of the skin barrier. It is often useful to supply a selection of emollients when first treating a child so that he or she can try various preparations to find the most suitable. Some emollients sting some children, some are too messy and some are not oily enough, and parents have to manage the use of emollients to suit various occasions. If the emollient is too greasy then it can cause overheating of the skin and folliculitis. Emollient oily creams are often more acceptable.

It is important that the application of emollients is an enjoyable time for children. Ideally, in infants, it should be applied as a gentle massage at the time of changing the nappy. In older children, dotting on the cream or making pictures is fun, and as they grow up it is important to involve children in their own treatment and encourage them to at least apply the emollients themselves. Care has to be taken, particularly in adolescence, to ensure that the product is cosmetically acceptable and compliance is often better with a less greasy preparation.

The application of a moisturizer should be encouraged twice per day. It is important that sufficient quantities are prescribed. It is often necessary to reapply a moisturizer more frequently throughout the day to exposed areas on the hands and face, which are more susceptible to environmental factors, such as washing the hands and, for the face, extremes of temperature.

Anti-Itch Strategies

The most intense and distressing symptom in atopic dermatitis is itch. It results in lack of sleep for the child and parents and disturbs the entire family, who become irritable and distraught watching the child’s interminable scratching. The sensation of itch is responded to by scratching, and this in turn causes breaking of the skin and, often, secondary infection. The first scratch initiates the second and the whole scratching process becomes a vicious circle. It is important to minimize scratching. There is no point in saying ‘no’. Children must be distracted from the process of scratching by involving their hands in another process such as playing with games or distracting the mind with stories, music or any other suitable games. Sometimes scratching becomes a habit or a form of attention seeking.

There are many tips for minimizing the sensation of itch. It is important to make sure that children do not overheat as this intensifies the symptom. The temperature in the bedroom should not be too high. Nightclothes should be light and bed covers should not be too heavy. Bathing should be in cool rather than warm water. Cotton clothing is more comfortable next to the skin. Wool tends to aggravate itching, not because of any allergy but because of the nature of the fabric, which irritates the skin.

Evidence of severe itching is seen with excoriations and lichenification. Examination of the nails will often reveal a polished appearance when they have been rubbing the skin excessively. It is also advisable to keep the nails well cut and buffed, as long sharp nails will cause more damage when scratching and are more likely to result in secondary infection.

Itch can be reduced by the application of topical emollients, paste bandages (such as ichthymol), wet dressings, topical corticosteroids, topical calcineurin inhibitors and antihistamines. The latter should not be applied topically as they can induce a contact allergy reaction. However, they are well tolerated orally and are useful for children who have difficulty sleeping or who scratch while asleep. Sedative antihistamines should be prescribed for night-time use and non-sedative antihistamines can be added in the day time, especially for children with allergies such as grass pollen [22]. There may be tachyphylaxis with oral antihistamines and it is often worth rotating the various drugs in order to avoid this problem [23]. Antihistamines may cause some children to become hyperactive at bedtime.

Infection

Children with eczema usually have colonization of the skin with Staphylococcus aureus, with some phage types producing exotoxins that act as super-antigens, giving rise to widespread activation of eczema [24]. Weeping and crusting of the eczema are often indicative of secondary bacterial infection. Treatment is with flucloxacillin for staphylococcal infection and penicillin V or erythromycin for streptococcal infection. Localized infected areas can be treated with a topical antibiotic preparation but often this proves to be inadequate and repeated use can lead to bacterial resistance. If a short pulse of a topical antibiotic is required, it is best to use an antibiotic that is not available systemically, such as mupirocin. If the infection is limited and the eczema active, there are some who advocate the use of antibiotics combined with topical steroids [25,26]. Another approach to reduce the bacterial colonization of the skin is to use antiseptics added to the bath water either alone (e.g. potassium permanganate) or combined with bath emollient. More recently, the use of dilute bleach baths has been shown to reduce the severity of eczema when colonized by Staphylococcus [27,28].

Atopic dermatitis sufferers also have a problem in dealing with viral infections of the skin. The human papillomavirus (HPV) (wart virus) and pox virus of molluscum contagiosum are frequent complications of atopic dermatitis. Likewise, herpes simplex infection, instead of being localized to a single area, may become generalized, resulting in eczema herpeticum, and there are also patients who develop recurrent HSV at multiple sites as an ongoing problem. The treatment of eczema herpeticum is with intravenous aciclovir. For children with recurrent HSV infections, prophylactic vitamin C has been shown empirically to be beneficial.

Topical Corticosteroids

The use and abuse of topical corticosteroids have caused considerable confusion and controversy since their introduction in the 1960s and have resulted in the undertreatment of many children with eczema. They can, however, be used safely. Many sufferers from mild eczema respond adequately to the weaker preparations, such as 1% hydrocortisone ointment, but others will require more potent steroids to clear the eczema over a short period of time and then use them intermittently to treat any new areas of eczema. When prescribing topical corticosteroids for atopic dermatitis, there are many factors that need to be taken into consideration (Box 30.3).

Base.

Box 30.4 lists the bases in which the steroid may be available. An ointment is often the most effective preparation as it is likely to provide better penetration of the contained corticosteroid as a result of its occlusive effect and, in addition, offers greater emollient benefit. This greasy effect, however, may be cosmetically unacceptable and must be borne in mind when trying to achieve good compliance. The more cosmetic creams may be quite drying and the preservatives that they contain can cause stinging or even induce a contact allergy. They are more comfortable than ointments and recommended for use in acute severe eczema when there is weeping and oozing.

Emulsions of oils in creams can be a compromise so that the greasy effect is achieved with good cosmetic acceptance. An emulsion is also more acceptable when extensive areas of the trunk have to be covered as the preparation is easily applied in a thin film with good effect. Hairy areas tend to become matted with ointments and creams and in these locations, gels and lotions are more appropriate. Great care must be taken in choosing the best base to achieve compliance with treatment.

Potency.

Topical corticosteroids are available not only in different bases but also with variation in potency. Box 30.5 explains the potency grouping of steroid preparations, according to the European classification. In the USA topical steroids are classified in groups I–VII and, confusingly, in contrast to the European classification, I is the most potent and VII the weakest grouping. A further classification is used in Japan with classes ranges from 1 to 5, with 1 the strongest. European groups 1 and 2 can be used with relative safety, but groups 3 and 4 must be used with caution and be closely supervised.

Doctors around the world use varying regimens. Some practitioners use topical steroids in short bursts followed by ‘holiday’ periods of emollients only. Others may start with a potent preparation and then decrease to a lower potency preparation as the condition improves (the step-down approach). Treatment depends on the location and severity of the eczema. There is a dearth of randomized controlled trials to determine the best regime. Thomas et al. [29] demonstrated that a short burst of a potent topical corticosteroid is just as effective as the prolonged use of a milder preparation for controlling mild to moderate atopic dermatitis in children. The majority of children will respond to treatment with topical steroids and, if they fail to do so, causes of failure should be sought.

The use of 1% hydrocortisone ointment (group 1) is relatively safe even in infants, but persistent use of potent steroids (groups 3 and 4) will cause side-effects locally in the skin, such as skin thinning, striae, visible veins and bruising and, if applied over large areas of inflamed skin, systemic absorption can result in pituitary–adrenal axis suppression with stunted growth and Cushing syndrome. It is this sort of outcome that has frightened many carers into avoiding the use of all topical steroids. However, if topical steroids are used appropriately under supervision, ill effects are rare, and they are an effective treatment for eczema [30,31]. The UK NICE guidelines recommend that topical steroids are the first-line anti-inflammatory treatment for eczema. This needs to be carefully explained to the parents and they need to be reassured that the appropriate use of topical steroids is effective and safe. Detailing how and when to use the topical steroid is an essential aspect of the steroid prescription. Both carers and older children should become familiar with the names and potency of each topical steroid they use.

Age and Location.

For young children the preference is for 1% hydrocortisone, but for those with severe eczema a more potent steroid may be necessary for a limited period to bring the eczema under control. For older children, medium-potency steroids are usually necessary, but again some children may require the use of a more potent steroid. The location of the eczema is important to note and this may dictate not only the potency of the steroid but the base of the preparation. Box 30.6 indicates the areas for special attention when choosing the potency of a topical steroid; 1% hydrocortisone is usually appropriate for lesions on the face and eyelids. Caution must be exercised in the use of potent topical corticosteroids around the eyes because of the risk of inducing glaucoma [32–34]. In adolescence, breasts and thighs are rapidly developing areas and potent steroids at these locations can result in striae much more easily than would normally be anticipated. The hands and feet have thickened areas of skin and there can be more liberal use of the more potent steroids at these sites.

Surface Area and Activity.

The more active and inflamed the skin becomes, the greater is the potential for absorption of the medicament applied. Also, the more widespread the eczema, the greater the quantity of corticosteroid necessary to cover the affected skin. Both these factors have to be programmed into the choice of potency and period of use of each strength of corticosteroid. When the eczema is acute, a short sharp burst of a potent steroid to precipitate a remission and achieve comfort is of great benefit. In the long term, the intermittent use of topical steroids is favoured.

Treatment Regimen.

Most topical steroids are recommended by the manufacturers to be applied twice daily. Some of the newer topical corticosteroid preparations (e.g. fluticasone propionate and mometasone furoate) should be used once per day [35]. This is probably best at night and is likely to result in improved compliance. These once-a-day applications are in the more potent range, but the quantity used is less in total than similar products requiring twice-a-day applications, thereby reducing the risk of potential side-effects. Berth-Jones [36] demonstrated that after eczema had been controlled with the daily application of fluticasone propionate, the ongoing application of this preparation twice weekly to the same sites for a maintenance period of 4 months, together with regular daily emollients, significantly reduced the risk of relapse.

The word ‘sparingly’ is often on prescriptions of topical steroids but this can be misinterpreted and lead to underusage. The best option is to demonstrate exactly how to apply the preparation, what areas should be covered and how thick the layer of cream or ointment should be. Ideally this could be done by a nurse after the consultation with the doctor. The quantity of steroid medicament prescribed is important as too often, not enough medicament is given and parents/patients stretch the use of a tube for long periods rather than ask for more. There is a large variation in the amount of topical steroids applied by different patients and, in an effort to standardize treatment, Long and Finlay [37] developed the finger-tip unit technique. Although this approach is to be commended in that it was the first published attempt to quantitate the amount of topical steroid needed, in routine clinical practice the term ‘finger-tip’ too often leads to dabbing the topical steroid on the skin with one finger-tip, rather than applying an adequate thin film to cover all the affected areas, which too often results in undertreatment.

In the past, the widespread use of polythene occlusion of topical steroids to treat eczema was prevalent, but this is not now generally recommended. However, it does remain useful for thickened areas of skin such as the palms, soles or discrete lichenified patches of eczema. The effectiveness of topical steroids in these areas can be enhanced by the use of impermeable or semi-permeable films.

It is the doctor’s duty to ensure that the patient and family have been correctly instructed, educated and supplied with an appropriate quantity of preparations, together with advice regarding the safe and sensible use of them. Inappropriate fears about the use of steroids in eczema must be allayed and dispelled. To withhold mild or moderately potent steroids for fear of adverse effects is unreasonable.

Topical Calcineurin Inhibitors

The macrolactam derivatives tacrolimus and pimecrolimus act by inhibiting inflammatory cytokine transcription in activated T-cells and other inflammatory cells through inhibition of calcineurin [38,39]. They are more specific than corticosteroids in modulating and targeting the inflammatory process in atopic dermatitis and their side-effect profile to date is less concerning than that of corticosteroids in that they do not cause skin thinning, telangiectasia, striae, glaucoma and suppression of the hypothalamic–pituitary adrenal axis [40–43]. Their most common adverse effect is local application site discomfort [44–47]. It is, however, of short duration and transient. Percutaneous absorption of both tacrolimus and pimecrolimus has been shown to be low with no long-term accumulation of either [48–51], and clinical trials have shown no evidence of systemic toxicity. The possibility of local immunosuppression with topical application is a potential for concern. However, clinical trials have shown no significant increase in systemic or local skin infections and with both compounds, there is a decreased rate of skin infection over increasing length of use [47,52].

There have been a series of long-term, multicentre, randomized, double-blind, controlled, parallel group studies to demonstrate the efficacy and safety of both tacrolimus and pimecrolimus in a paediatric population [44,47,53], and these topical calcineurin inhibitors are licensed for use in children aged 2 years and over; neither is yet licensed for use in children under 2 years, a group in whom one would wish to use these products, as eczema is often at its most severe and predominant on the face.

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