Coping with recalcitrant pediatric eczema

An intensely pruritic disorder, severe atopic dermatitis (AD) can impact quality of life not only for children who have it, but also for their families, says Amy S. Paller, M.D., professor and chair of dermatology and professor of pediatrics at Northwestern University. Strategies include education, trigger avoidance, moisturizers, topical anti-inflammatory agents and, for children with difficulty sleeping, sedating antihistamines, she adds.

Confounding factors for children

"They may be poorly compliant, or there might be other issues like psychological issues or secondary infection," she tells Dermatology Times.

Additionally, adverse reactions to treatments sometimes limit physicians' options, and sometimes eczema is misdiagnosed, she adds.

Management options

"I always remind people to start with the basics," Dr. Paller says. "That means bathing daily to every-other-day, followed by moisturizer."

Patients should avoid bubble baths and harsh soaps, while there's some question about the benefits of soft water, she adds.

"People have suggested that hard water can worsen eczema," Dr. Paller explains. "But we don't have good evidence" to support this contention.

Conversely, she says wet wraps have proven very helpful for her patients.

"I've been doing wet wraps for years without topical steroids. One should apply them in the evening after moisturization and just before bed. It's been extremely helpful for increasing the comfort of babies in particular, who can generally tolerate going to bed wet without making much fuss," she says.

When manipulating patients' diets, she recommends always working with a nutritionist and an allergist.

"Allergy testing can only provide a guideline. Dietary avoidance, then gradually adding foods back, is the way to go."

Regarding probiotics, Dr. Paller says studies have suggested once- to twice-daily dosing in infants for four to eight weeks may be efficacious, especially in infants allergic to cow's milk (Weston S et al. Arch Dis Child. 2005 Sep; 90(9):892-897).

However, Dr. Paller says, "The verdict is still out on that. Nobody in the United States has access to the lactobacillus used in the encouraging studies performed in Finland."

Conversely, she says it's always important to consider the possibility of infection when treating difficult AD. For example, she says Staphylococcus aureus is known to exacerbate eczema.

To combat such infections, she says, "One of the tricks we've been using in pediatric dermatology is bleach baths (one quarter cup per bathtub of water), which I have found extremely helpful in decreasing infections, presumably through decreasing the colonization. With respect to bleach baths keeping the eczema under control, there have not been good studies to show how valuable this is. But there's anecdotal evidence of significant benefit. Bleach baths don't discriminate between methicillin-resistant Staph aureus (MRSA) and other staph infections."

By the same token, Dr. Paller says one of the best tools against severe eczema is an old tool - compounded therapy.

She says, "This is very helpful for children with lichenified AD, particularly when they become unresponsive to commercially available topical agents. They almost always respond to compounded triamcinolone (starting at 0.1 percent) with salicylic acid (3 percent) in either petrolatum or Aquaphor (Beiersdorf)."