Transcript Slide 1
The basics!!
Assessment
Age of child –
developmental &
emotional
Caregivers & environment
Daily routine
Skin condition of whole
body
Acute, chronic, atopic,
contact dermatitis and /or
seborrhoeic
What could be irritants in
regards to age & activities
Is to repair and maintain skin integrity and barrier function
Moist Wound Healing
Provide moist environment
Keep temperature close to body temperature
Infrequent dressing changes
Prevent or reduce scab formation
Practical Skin Care
Emollients
Topical Steroids
Bacterial Management
Wet Wraps / Dry wraps
Identify irritants
Behaviour modification
Management
Practical tips on how to apply steroid and
emollients – amount, how often, when, why
Prophylactic as well symptomatic
Bathing – with emollient and volume
Emollients
Should be applied in a variety of ways
including prophylactically
Trouble shooting eg bacterial
contamination
Behaviour management
Demonstrated multiple effects of
emollient on skin
Decrease desquamation of the epidermis
Improve skin barrier repair
Decrease erythema and TEWL
Increase SC hydration –
Hydration persists with repeated application of emollient
but effect is shorter in atopic skin compared to normal skin
Decrease potency of topical corticosteroid required (steroid
sparing)
Cork, M.J et al. (2003) Comparison of parent knowledge, therapy utilization and severity of atopic
eczema before and after explanation and demonstration of topical therapies by a specialist
dermatology nurse. British Journal of Dermatology, 149, 582-589
The clinical response observed in skin
with effective emollient use
Decrease in dryness and scaling
Softening and increased elasticity
Decrease in erythema
Decrease in spongiosis
Decrease in itch
Decrease in Staph. Aureus
(due to decrease in skin dryness)
Decrease in pigmentation changes
(over a period of weeks)
Topical Steroids
When / how much to use
The ‘step approach’
What about infection?
Classes of topical steroids
1: Very Potent ; up to 600 x
hydrocortisone
Dermal, Diprosone
2: Potent ; 150-100 x
Beta, Betnovate, Locoid,
Elocon, Advantan
3: Moderate ; 2-25 x
Aristocort, Eumovate
4: Mild
hydrocortisone
0.5 - 2.5%
( DermNet NZ )
Precautions with:
Risk depends on:
Children: higher
Steroid strength
absorption due to thin skin
and larger surface area
Occlusive dressings:
nappies, wet wraps
infection, weeping areas,
pruritis etc
Presence of excipients such
as coal tar, urea
Length of application
Site and type of skin
problem
For example, if using
hydrocortisone(mild)
would need to use 500g per
week for adverse effect
Aim is use the least potent topical steroid that is effective
Choice will be dependent on age of the child, severity & site
For the older child/ young adult a moderately potent
steroid may be used 1-2 x week for maintenance
A step approach may be needed to effectively manage skin
inflammation
Topical steroid must be used in conjunction with
emollients
Antihistamines
Classified on their ability to
block actions of histamine
receptors in responsive
tissue
1st generation may help due
to sedating effect
Eczematous disease is T- cell
mediated
Histamine plays no significant
role
No evidence to show oral
antihistamines decrease itch in
eczema
Oilatum Plus/ QV Flare Up
Bath additive : benzalkonium chloride 6%,
triclosan 2%, light liquid paraffin
For topical tx of eczema including eczema at risk from infection
1 - 2 mls in infant bath, 4 - 8 capfuls in bath
Can be used on infants under 6 months
If used daily for more than 5-7 days then step approach needs to
be used when decreasing
‘Since focusing on her baths the change in her skin has
been dramatic’
‘I think if more parents with eczema kids knew about
the importance of baths, we’d spare more kids (and
their parents) a lot of misery’
Bleach in the Bath!
Evidence based
Drying of skin & difficult to use on daily basis
Gentler antimicrobials can be used daily
Cost factor
Half a cup of bleach in full bath
Dry Wraps
Use once appropriate use of emollients and topical steroids are
in place (there are always exceptions)
if overall eczema well managed but areas remain dry and /or
excoriated
Can introduce a family/individual to wrapping
Provides protection of skin & hydration
Tool in the ‘Tool Box’
Dry Wraps
Advantages:
Disadvantages
Increased maintenance
Drys out
of skin hydration
Decreases emollient
application
Protects skin
Decreases itching
Easy to use
Requires regular
emollient application
initially
Becomes itchy once
emollient absorbed
Not as effective as
wetwraps
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Wet Wraps
Should be considered for the severely affected child that is not well controlled despite adequate
emollients and topical steroids being applied appropriately.
the child who does not sleep well at night despite good skin
management
the child and /or family who have a good understanding of emollient
therapy but cannot or are unwilling to apply the amounts required.
Surprisingly, this is a good option for adolescents.
Wet wrapping cannot be used when eczema is infected. The moisture
will encourage bacteria growth
Wet Wraps
Need to be taught, managed and supported by
health professional who knows what they are
doing
Otherwise can be ineffective and a valuable
management tool is lost
If so can disappoint family and increase
disillusionment
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