The basics!!

AssessmentAge 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 HealingProvide moist environmentKeep temperature close to body temperatureInfrequent dressing changesPrevent or reduce scab formation

Practical Skin CareEmollientsTopical SteroidsBacterial ManagementWet Wraps / Dry wrapsIdentify irritantsBehaviour modification

ManagementPractical 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 epidermisImprove skin barrier repairDecrease 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 elasticityDecrease in erythemaDecrease in spongiosisDecrease 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 useThe ‘step approach’

What about infection?

Classes of topical steroids1: 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:

Children: higher 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

Risk depends on:

Steroid strengthLength of applicationSite and type of skin

problemFor 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

AntihistaminesClassified 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 paraffinFor topical tx of eczema including eczema at risk

from infection1 - 2 mls in infant bath, 4 - 8 capfuls in bathCan be used on infants under 6 monthsIf 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 basedDrying of skin & difficult to use on daily basisGentler antimicrobials can be used dailyCost 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 wrappingProvides protection of skin & hydration Tool in the ‘Tool Box’

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Dry WrapsAdvantages:Increased

maintenance of skin hydration

Decreases emollient application

Protects skinDecreases itchingEasy to use

DisadvantagesDrys outRequires regular

emollient application initially

Becomes itchy once emollient absorbed

Not as effective as wetwraps

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 WrapsNeed 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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