Transcript Management of the infant and pre-schooler

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)
Mild
Moderately Potent
Hydrocortisone 0.5-2.5% 2-25 times as potent
as 1%
hydrocortisone
DermAid
DP Lotion-HC
Skincalm 1%
Lemnis Fatty Cream HC
Pimafucort
Eumovate
Aristocort
Viaderm KC
Kenacomb
Potent
Very Potent
I00-150 times as potent
as 1% hydrocortisone
Up to 600 times as
potent as 1%
hydrocortisone
Beta, Betnovate,
Daivobet 50/500
Fucicort
Nerisone
Hydrocortisone 17butyrate
Clobetasol propionate
Dermol C/Ointment
Betamethasone
dipropionate
Locoid Cream/Crelo
Emulsion/Lipocream/Oi
ntment/Scalp Lotion
Elocon C/Lotion/Oint
Advantan Cr/Oint
Diprosone OV
Cream/Ointment
2 Case studies
Case one
Current history
Past 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
Born full term
Unremarkable pregnancy
Normal weight and length
Mother has asthma and hayfever
during breast feeding
Irritable
Disrupted sleep
Failing to thrive
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
Infant
Children(2-10 years)
Older children
Cow milk
Cow milk
Peanut
Eggs
Eggs
Tree Nuts
Wheat
Peanut
Fish
Soy
Tree Nuts
Shell fish
Fish
Sesame
Shell fish
Pollen-associated foods
Sesame
Kiwifruit
Does food allergy resolve ?…
cow’s milk
hen’s egg
peanuts, fish, seafood, …
prevalence
age
6 months
3 yrs
5 yrs
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 50th centile to 25th centile
 Developed significant behavioural issues
Case 2 continued....
Referred back to allergy clinic
 Retested and found to have outgrown both egg and
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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