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
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
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 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)
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:
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’
20
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