IntroductionAtopic eczema (atopic dermatitis) is a chronic inflammatory itchy skin condition thatusually develops in early childhood and follows a remitting and relapsing course. It oftenhas a genetic component that leads to the breakdown of the skin barrier. This makes theskin susceptible to trigger factors, including irritants and allergens, which can make theeczema worse. Although atopic eczema is not often thought of as a serious medicalcondition, it can have a significant impact on quality of life.DiagnosisX Diagnose atopic eczema when a child has an itchy skin condition plus three or more ofthe following:– visible flexural dermatitis involving the skin creases (or visible dermatitis on the cheeksand/or extensor areas in children aged 18 months or under)– personal history of flexural dermatitis (or dermatitis on the cheeks and/or extensorareas in children aged 18 months or under)– personal history of dry skin in the last 12 months– personal history of asthma or allergic rhinitis (or history of atopic disease in a first-degree relative of children aged under 4 years)– onset of signs and symptoms under the age of 2 years (do not use this criterion inchildren under 4 years).In children of Asian, black Caribbean and black African ethnic groups, atopic eczemacan affect the extensor surfaces rather than the flexures, and discoid or follicularpatterns may be more common.GÌhffdÌ 3`bwtÌvX When assessing a child, identify potential trigger factors, including:– irritants (such as soap and detergents)– skin infections– contact allergens– food allergens– inhaled allergens.AllergyX Consider food allergy in:– children who have reacted immediately to a food– infants and young children with moderate or severe uncontrolled atopic eczema,particularly with gut dysmotility or failure to thrive.X Consider inhalant allergy in:– children with seasonal flares of atopic eczema– children with associated asthma and rhinitis– children over 3 years with atopic eczema on the face.X Consider allergic contact dermatitis in:– children with an exacerbation of previously controlled atopic eczema– children who react to topical treatments.X Reassure children with mild atopic eczema and their parents or carers that mostchildren with mild atopic eczema do not need clinical testing for allergies.X Advise children and their parents or carers not to have high street or internet allergytests because there is no evidence of their value in the management of atopic eczema.
Bacterial infectionX recognise the symptoms and signs of bacterial infection with staphylococcus and/orstreptococcus– access appropriate treatment when a child’s atopic eczema becomes infected.X Take swabs from infected lesions of atopic eczema only if you suspect microorganismsother thanStaphylococcus aureus or if you think antibiotic resistance is relevant.Herpes infectionX Consider infection with herpes simplex virus if a child’s infected atopic eczema fails torespond to antibiotic treatment and an appropriate topical corticosteroid.X how to recognise eczema herpeticum:– areas of rapidly worsening, painful eczema– possible fever, lethargy or distress– clustered blisters consistent with early-stage cold sores– punched-out erosions (usually 1–3 mm) uniform in appearance which may coalesce.Atopic eczema in childrenguidance.nice.org.uk › Guidance by type › Clinical guidelinesEczema in children
Whether you’re a parent, caregiver, or teacher, caring for a child with eczema requires an understanding of the physical and emotional impact of this frustrating disease. One in 10 children have eczema, with most cases being diagnosed before the age of 5. Although eczema may clear up by the teenage years, many people continue to suffer from it throughout their lives. Even though eczema runs in families, its unclear exactly how it passes from parent to child. If other family members have eczema, asthma, or allergies like hay fever, the chances are about 50% that a child will also have one or more of these diseases. However, there is not always a family connection. Approximately 30% of those with eczema have no family members with eczema, asthma, or allergies. How to Recognize Eczema in Children Eczema, which is sometimes called atopic dermatitis, is an itchy skin disease with red patches that come and go. The itch may lead to rubbing and scratching, which can begin a vicious itch-scratch cycle. Scratching can lead to open sores on the skin, which may become infected. The skin in children with eczema becomes dry, scaly, and thick, and may be darker than the surrounding normal-looking skin. In very young children, eczema is usually seen on the face, scalp, arms, and legs. As children get older, eczema appears in the skin-fold areas—the front of the elbow, back of the knee, inside the wrist, near the ankles, and around the neck. In teenagers, eczema may appear around the eyelids, neck, hands, wrists, and behind the elbows and knees, or it may completely clear up.Trigger factorsFor many children, flare-ups can be caused by skin irritants such as soaps, chlorinated water,wool clothing, or sudden changes in temperature or humidity. For some eczema sufferers, pet fur,pollen, and certain foods can also trigger a flare-up. A common problem for young children witheczema is that their own saliva is often an irritant, which is why their cheeks and skin around theirmouths are often affected.One of the most difficult trigger factors to predict in children is emotional stress. Children witheczema often react to stress by experiencing red itching and flushing. For the child with eczema,normal childhood feelings like anger, frustration, and fear can lead to an eczema flare-up.Infant Seborrhoeic DermatitisSynonyms: cradle capSeborrhoeic dermatitis is a condition that can affect infants and cause hard scales on thescalp - often referred to as cradle cap.It also affects adults, starting around puberty and peaking at around 40 years.PathogenesisSeborrhoeic dermatitis is a papulosquamous disorder affecting the areas with mostsebum, such as the scalp, face, and trunk. An association with a yeast infection hasbeen known for over 30 years:
• Immunological abnormalities and activation of complement are involved. • There is also an ability to activate the alternative complement pathway. • Malassezia furfur appears to be the species associated with infantile seborrhoeic dermatitis.EpidemiologySeborrhoeic dermatitis is extremely common in infants. Many children with the conditionare not brought to the attention of the medical services and so the precise incidence isunknown.PresentationSeborrhoeic dermatitis presenting in infancy is a very common condition which may bebrought to the attention of the health visitor or GP.In the majority of cases it is a benign self-limiting condition which usually clearsspontaneously during the first 12-24 months of life but, in a small number, it can beparticularly troublesome and require treatment.Seborrhoeic dermatitis occurs most commonly in the lipid-rich areas of skin and, ininfants, occurs predominantly on the scalp and upper face, producing an appearancewhich may give rise to some concern from parents.Cradle cap is very common and usually appears in the first few weeks of life. There aregreasy, yellow scaling patches that may eventually coalesce to a thick, scaly layer. Thecondition is not itchy and the child is not distressed by it.Other findings may include: • Plaques around the ears, nose and eyebrows. • Sharply demarcated brightly erythematous rash in the groin and perianal area (may be confused with ammoniacal dermatitis or candidiasis). • Itching. • Excoriation of the skin (where the child has scratched). • Dandruff. • Loss of small amounts of hair in the area of the plaques. • Patches of redness surrounding the plaques. • Areas of secondary bacterial infection (where scratching has occurred).Differential diagnosis • Areas of reddened skin with scales may be mistaken for eczema. • If the plaques become infected, they may resemble impetigo. • Psoriasis may cause confusion and can look similar in babies. • Fungal infections, eg tinea.
InvestigationsUsually no investigation is required and the diagnosis is made on clinical appearancealone.Seborrhoeic dermatitis is uncommon in preadolescent children, and tinea capitis isuncommon after adolescence. Dandruff in a child is more likely to represent a fungalinfection. A fungal culture may aid the diagnosis but the disease may occur with anegative culture and a positive culture is not diagnostic.