Ask the expert: managing and treating childhood eczema

The strength of the TCSs and length of use depends on the disease severity and body area (face vs the rest of the body). NICE guidelines for the treatment of childhood eczema use a stepwise approach, with mild potency TCSs used in mild disease, moderate strength preparations in moderate disease and potent or even ultrapotent preparations for the severe end of the disease spectrum often (under the guidance from a dermatologist). ¹

In general, potent and ultrapotent TCSs should not be used on the face due to the risk of skin atrophy. There are a few exceptions, but such cases should be referred to specialist care. Furthermore, discoid eczema (more often seen in black and Asian children) is distinctly different from the more common flexural variant and often only responds to potent or even ultrapotent TCSs. Finally, there is no evidence that twice a day TCSs are more effective than prescribing them once daily. It is important to review the treatment response, after a step up in TCSs strength.

Following an initial, more prolonged burst on a TCS (for example for around two weeks), intermittent and shorter five-seven day courses early on into disease flares are often sufficient. Proactive twice weekly topical treatment even without eczema being present has been shown to be safe and reduce the number of flares and amount of TCSs. However, this approach only makes sense where adequate disease control has been achieved, in particular in children with well-defined flare areas, such as the flexures of the arms and legs. The patient’s age also comes into the equation, with mild-to-moderate strength TCSs generally being used during the first year of life and moderate-to-potent TCSs reserved for older age groups. There are no officially accepted age cut offs though, and specialists sometimes use potent TCSs in very young children, albeit for short bursts only.

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What topical steroids are safe to use on the face? And are there any areas which require stronger steroids?

In infants, mild TCSs are safe to use on the face, where the skin is thinner. In older children this can be increased to moderate strength TCSs without concern. An exception are the eyelids, where only mild TCS should be used. The arms, the trunk and the legs should, in my view, only be treated with moderate-to-potent steroids, as under-treatment of the skin inflammation is more likely to lead to more frequent flares and disease chronicity. However, it is not only the strength of the steroid that matters but also the length of treatment. Generally speaking, applying topical steroids for only one or two days does not settle the skin inflammation sufficiently, meaning the eczema often rebounds quickly upon stopping treatment.

I recommend using topical steroids on the face for at least five days and for seven days on the body. A more prolonged burst of reducing frequency is often needed initially though, eg, for two weeks once a day and then alternating days for a week before stopping, even if clearance is achieved earlier. Such an approach is also more likely to switch off the itch-scratch cycle that most patients are in, which drives the cutaneous inflammation further and is a major factor that leads to eczema chronicity as well as recurrent skin infections.

Can we ever instigate topical pimecrolimus or tacrolimus in primary care if steroids are not tolerated?

Topical calcineurin inhibitors (TCIs) were introduced to the UK market more than 10 years ago and are approved for use in moderate to severe eczema in immunocompetent patients over the age of 2 years; tacrolimus 0.1% only from 16 years of age. There was concern about their use based on animal studies in association with oral ingestion, suggesting a higher risk of malignancy. However, this has not been confirmed with topical use in humans, and there is nothing to stop a GP from prescribing pimecrolimus or tacrolimus, provided they have experience in their use, as many GPs with a special interest in dermatology have.

According to the NICE guidelines, ¹ TCIs should only be prescribed when TCSs are contraindicated or have failed to work. In my view, the main place for TCI is in body areas where the skin is particularly delicate, such as around the eyes or on the neck, especially where an inadequate response to TCSs has been observed or when patients are contact allergic to TCSs (although this is rare). It is important to warn patients that TCIs sometimes sting or even burn, especially during the first few applications and when applied to inflamed skin. TCIs are also much more costly than TCSs. Additionally, the manufacturers  recommend rigorous sun protection during usage because of a theoretical long-term risk of skin cancer, although there is no clinical data to support this.

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Any good tips which can be shared with parents?

A Parental eczema education, especially with regard to the use of topical treatments, is an important part of disease management. This includes reassuring parents that adequate use of TCSs will not thin their child’s skin (see above for guidance on steroid strength in the face and on the body at different ages). Unfortunately, GPs working under tight time constraints in their clinics may find it difficult to spend too long on eczema education. However, experienced practice or community nurses are often an excellent additional source of information for parents and patients.

Where such advice is not available, the National Eczema Society provide a lot of helpful resources on their website and run local events for parents.

• The application of moisturiser and TCSs should be separated by 20-30 minutes to avoid diluting the steroid. The moisturiser should be applied first
• The greasier the moisturiser the better the emollient effect
• Soaps should be avoided, as they dry out the skin and are a potential skin irritant.Most moisturisers can be used instead
• There is little evidence that bath emollients provide additional help in controlling eczema
• It is important that an emollient is used directly after a bath or shower. If applied several times daily to the whole body, children will require at least 250g per week and adults 500g per week
• Sports are not contraindicated and improve quality of life  
• With regard to swimming, showering directly after coming out of the water followed by ample application of a greasy moisturiser helps to prevent chloride-induced skin irritation
• There is no good evidence that exclusive breastfeeding beyond three months of age protects against the development of eczema
• Non-biological washing powder is not better than biological ones.

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Are there any complementary therapies available, and is there any evidence to support their use?

A A long list of complementary therapies and dietary supplements are being used in the treatment of eczema. There is limited evidence from a small number of randomised control trials that systemic traditional Chinese medicine compared with placebo might improve eczema both in children and in adults. Evening primrose oil taken orally might also have an effect in some cases of moderate to severe eczema, but again the evidence for this is weak. It should be given in doses of 160-320mg daily in children age 1-12 years and 320-480mg in older children and adults for three months. If no improvement is noted after that period, it is unlikely to be helpful. Clinical trials on other complementary therapies, such as homeopathic remedies, multivitamin supplements, acupuncture, hypnotherapy, massage, or aromatherapy have not shown any clear benefit.

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Is there any difference between the efficacy of the different moisturisers available?

The choice of moisturisers is staggering. Unfortunately, there is little research evidence available to help us choose between different preparations. Even in a specialist setting, we encourage patients to try different emollients to see what suits their skin type and dryness best. As a rough guide, creams are used for mild-to-moderate skin dryness, with greasier preparations being used for more stubborn skin dryness. Lighter creams are more suitable for frequent daytime application, as they sink in quicker, while a once daily ointment used at night time might be enough for some. There are now also emollient sprays on the market, which many teenagers prefer, as they can be applied quickly. Again, it is best to give the patient a choice, as this is likely to enhance adherence to treatment.

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What is the role of antihistamines?

A Histamine is not a main mediator involved in the itch pathway in eczema. This is probably why non-sedating antihistamines rarely make a difference. We occasionally use sedating antihistamines, such as chlorpheniramine, to help a child fall asleep. I only use non-sedating antihistamines during the day in children who have immediate-type allergies (eg, hay fever), in particular with known sensitisation to grass and tree pollen. In such cases, eczema is often strikingly focused on the face, neck and arms.

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When should eczema be referred?

A NICE guidelines for childhood eczema are quite clear and suggest referral to secondary care where:

• The diagnosis is uncertain
• There is inadequate disease control based on subjective assessment by the child or parent/carer (eg, one-two weeks of flares/month or reacting adversely to topical Rx)  There is need for advice on specialist treatments (eg, wet wraps)
• Contact allergy is suspected
• There is significant quality of life impairment
• A child experiences recurrent skin infections, and
• Where food allergy is suspected as a main trigger factor.

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When should we consider an underlying food allergy if a child presents with eczema and what are the next steps of management?

A Food allergy should be suspected in all children with moderate-to-severe eczema, and which does not respond to adequate strength topical treatments, especially if the child is under six months old and skin infection has been ruled out as a trigger factor.

It is important to consider that not all children with food allergies develop immediate-type symptoms, such as urticaria, angioedema or respiratory distress. Reflux and delayed eczema flares up to 48 hours after food exposure can be responsible for difficult to control disease (delayed type hypersensitivity). In such cases, skin prick and specific Immunoglobulin E (IgE) testing will be negative and the suspected culprit food needs to be removed from the child’s diet for four-six weeks, followed by reintroduction to see whether this will lead to a re-flare.

Suspected food allergy is a reason to refer to secondary care for further assessment. This will often include input from a paediatric dietitian.

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