Eczema

Eczema
(infantile and childhood eczema)
by; Sandi Effendi
urology staff nurse in mubarak al kabeer hospital kuwait

Atopic dermatitis the most common cause of eczema in childhood, is a characteristic inflammatory response of the skin. The major problem features include pruritus, a typical
Morphology and distribution, a chronic or chronically relapsing nature, and personal or family history of atopy (asthma, hay fever, and atopic dermatitis). There is tendency toward dry skin and lower threshold of itching.
Atopic dermatitis affects 10 % to 15% of the childhood population. It usually starts after 2 months of age. By age 5, 90% of the patients who will develop atopic dermatitis have already manifested the disease. It may stop after an indefinite period of time, or it may progress from infancy to adulthood with little or no relief. It is rare of adults to develop atopic dermatitis without a history of eczema in childhood.

Pathophysiology and Etiology
1. Atopic dermatitis involves immunologic abnormalities, such as elevated immunoglobulin E levels and increased rates of sensitization to common contact allergens and to intradermal skin tests. Although the exact cause is unknown, there is a constitutional predispotition to develop pruritus. In general, the skin of patients with atopic dermatitis is different from that of healthy patients in the following respects:
a. Increased tendency toward dryness
b. Lowered threshold for pruritis from minor irritants, such as soap, perspiration, cold weather, and heat
c. Tendency toward lichenification (leathery thickening of skin ) and production of a rash when the skin is rubbed or scratched
2. The etiology is unknown but has familial tendencies. Almost 75 % of patients with this form of eczema will develop hay fever or asthma themselves.

Clinical manifestations
Age and Distribution of the lesions
Atopic dermatitis is divided into three phases based on the age of the patient and the distribution of the lesions. There are referred to as the infant, childhood, and adult phases.
1. Infant (2 months to 2 years):
a. The onset is between 2 and 6 months of age. Half of affected infants have spontaneous resolution by age 2 or 3
b. Characterized by intense itching, erythema, papules, vesicles, oozing, and crusting
c. The rash usually begins on the cheeks, forehead, or scalp and then extends to the trunk or extremities in scattered, often symmetric patches. The perioral, perinasal, and diaper areas are usually spared
2. Childhood (4 to 10 years):
a. Affected persons in this age group are less likely to have exudates and crusted lesions. Eruption are characteristically more dry and popular and often occur as circumscribed scaly patches. There is a greater tendency toward chronicity and lichenification
b. The typical areas of involvement are the face, including the perioral and perinasal areas, neck, antecubital and popliteal fossae, wrists, and ankles.
3. Adult (puberty to old age):
a. Predominant areas of involvement include the flexor folds, face, neck, upper arms, back, dorsa of the hands and feet, fingers, and toes.
b. The eruption appears as thick, dry lesions, confluent papules, and large lichenified plaques. Weeping, crusting, and exudation can occur, but they are usually the result of superimposed external irritation or infection.

Clinical Appearance
Atopic dermatitis is also divided into three stages based on the clinical appearance of the lesions. The acute, subacute, and chronic stages can occur in infants, children, and adults,
1. Acute moderate to intense eryhema, vesicles, a wet surface, and severe itching.
2. Subacute:
a. Erythema and scaling are present in various patterns with indistinct borders. The redness may be faint or intense. The surface is dry. There are varying degrees of pruritus.
b. The subacute stage may be an initial stage or may follow an acute inflammation or exacerbation of a chronic stage. Irritation, allergy, or infection can convert a subacute process into an acute one.
3. Chronic the inflamed area thickens and the surface skin markings become more prominent. Thick plaques with deep parallel skin markings are called lichenified. Lichenification is the hallmark of chronic eczema. The surface of the skin is dry and the border of the lesion well defined. There is moderate to intense itching.

Diagnostic Evaluation
Atopic dermatitis is usually a clinical diagnosis based on the evaluation of the aggregate of signs, symptoms, stigmata, course, and associated familial findings. The major features include pruritus, a characteristic morphology and typical distribution for the age of the patient, a chronic or chronically relapsing nature, and a personal or family history of atopical disease. When the diagnosis is in doubt, a skin biopsy may be performed.

Treatment
Acute
1. Open wet dressing for 1 to 3 days
2. Avoidance of any known allergen
3. Topical corticosteroids
a. Topical corticosteroids are ranked into seven groups according to potency. Group 1 contains the most potent topical steroids and group 7 the least potent ones. The concentration listed on the medication does not correlate with its potency or safety, but is merely a statement of its specific chemical formulation.
b. Very potent (Group 1) topical corticosteroids are avoided in children younger than 12 years of age because of greater skin absorption.
4. Oral medication to relieve itching- hydroxyzine hydrochloride (ataraz), diphenhydramine hydrochloride (Benadryl), or protmethazine hydrochloride (Phenergan). Diphenhydramine and promethazine cause more sedation than hydroxyzine hydrochloride. Mild sedation may be desirable.
5. Management of secondary infection, if present, with oral antibiotics
6. Initiation of a hypoallergenic diet to eliminate any responsible food for infants and young children with severe, recalcitrant atopic dermatitis
Subacute and Chronic
1. Prevention of dry skin:
a. Diminish the frequency and duration of bathing
b. Use mild soap and hydrophilic lotion
c. Lubricate the skin with emollients
d. Add tar preparations to the bath water
e. Maintain environmental humidity above 40% in winter months
2. Same measures as acute stage with exception of wet dressings

Nursing Assessment
1. Take a nursing history focusing on clinical manifestations:
a. Onset and duration of rash
b. Location, course, and distribution of lesions
c. Change in morphology of lesions
d. Local and systemic symptoms
e. Exposure to possible allergens
f. Previous episodes of rashes
g. Personal history of allergies, asthma, or hay fever
h. Family history of eczema, allergies, or hay fever
i. Medications, treatments tried, and their effect
2. Perform a physical assessment.
a. Examine the entire skin in an orderly fashion with specific attention to the type of lesion (ie, macule, papule, vesicle, etc), its appearance (shape, border, color, texture, and surface), and its distribution (areas of the body involved)
b. Note any associated symptoms, such as scratching, fever, or drainage.
3. Document findings:
a. Describe skin finding using dermatologic terminology
b. Draw pictures to facilitate communication.

Nursing Diagnoses
 Impaired skin Integrity or high risk for impairment, related to skin pathology and scratching
 Sensory/ Perceptual Alterations (Tactile), related to skin pathology
 Risk for infection related to increased bacterial colonization of skin and possible break in defensive barrier

Nursing Interventions
The nurse may perform the following interventions or teach the patient or family to do the following:
Improving skin integrity
1. Reduce inflammation during the acute stage with the topical application of open wet dressings.
a. Use a soft, lightweight cloth, such as a handkerchief, a thin diaper, or strips of bed sheeting. Do not use gauze (adheres to skin), washcloths, or towels (too heavy)
b. Open wet dressings should be clean. In certain situations, they should be sterile to prevent contamination.
c. Solutions should be lukewarm or at body temperature to soothe the skin and prevent chilling.
d. Compresses should be moderately wet, not dripping, and removed after 20 minutes, unless otherwise directed. They should be reapplied three to four times a day.
e. After the compress, a topical corticosteroid may be applied to further reduce itching and inflammation.
f. Observe the skin for changes in response to therapy
2. Prevent dry skin during the subacute and chronic stages.
a. Decrease the frequency and duration of bathing, long, hot tub are not be avoided.
b. Avoid hot water and harsh soaps. Patients should bathe in lukewarm water using mild soap (dove, Neutrogena); avoid bubble baths ;rinse well and pat skin dry with towel.
c. If bath water stings, add 1 cup of table salt.
d. Apply unscented emollients (eg, Eucerin, Keri, Lubriderm) within 3 minutes of bathing, when the skin is slightly moist. Creams and ointment are more effective than lotions because they are better at preventing evaporation of water from the skin. Bathing will dry and damage skin unless an emollient is applied immediately after existing bath.
e. Some patients may benefit from soaking in a tar bath for 15 to 20 minutes daily, preferably in the evening. Add to bath skin and clothing and may cause sunlight sensitivity.
f. For patient with extremely dry skin, cleanse with a hydrophilic lotion (eg. Cetaphil). Apply without water until light foam occurs. Remove by wiping with soft cotton cloth or cleansing tissue.
g. Keep environmental humidity above 40 % in winter months. Use a humidifier.
h. Observe the skin for changes in response to therapy.

Controlling Pruritus
1. Apply topical corticosteroids.
a. Apply a thin layer of topical corticosteroids to the affected skin two to four times a day as directed. Use only for the duration prescribed.
b. Observe for possible side effects from long-term use of topical corticosteroids (ie, striae, cutaneous atrophy, telangiectasia, acne, and growth retardation).
c. Note any scratching and intervene as necessary
2. Administer oral antipruritic medications
a. Give medications exactly as prescribed
b. Note the degree of sedation and presence of scratching.
3. Teach the care taker or family of infants and small children a hypoallergenic diet when indicated.
a. Write any known allergens on care plan and chart. Inform the dietitian of the child’s food allergies
b. Avoid substances that have a high potential for sensitization, such as cow’s milk, eggs, tomatoes, citrus fruits, chocolate, wheat products, spiced food, fish, nuts, and peanut butter.
c. A minimal diet is prescribed. The trial diet may be composed of milk substitute, rice cereal, two fruits, two vegetables, beef, a multivitamin, and no eggs.
d. A new food is added to the diet every 3 to 5 days, during which time the response to the food is observed.
e. An allergic response occurring during this 3 to 5 day period indicates sensitivity to that food. The food is then eliminated from the diet. If no response is apparent, the food is added to the child’s diet.
f. Another food substance is then added, and child is observed for the following 3 to 5 days period. This method is followed until the food allergen is determined.

Preventing infection
1. Assess and/or treat secondary infection:
a. Observe the skin for sign of bacterial infection (discharge, oozing, crusts). Report positive findings
b. Administer antibiotic as prescribed.
c. Loosen exudates and crusts with water or wet dressings, unless otherwise specified.
d. Note changes in the skin in response to therapy

Selected references
Boiko,S (200), Making rash decisions in the diaper area. Pediatric annals
Habif, T.P. (1996), Clinical dermatology: A color guide to diagnosis and therapy
Hall, J.C. (2000) Sauer’s manual of skin diseases. Philadelphia: Lippincott Williams and Wilkins.