Approaches to Disease Management: Dermatologic Disorder

The clinical presentation of eczema varies with age. In infants, it commonly affects the face, scalp, outer surfaces of arms and legs, and the trunk. The rash often appears as red, weepy, and crusty patches. In toddlers and older children, the distribution shifts to the flexural areas, such as the creases of the elbows, wrists, knees, and ankles. The skin in these areas tends to be dry, thickened (lichenified) due to chronic scratching, and may have scaling and papules. Intense itching is a hallmark symptom at all ages, often leading to a vicious itch-scratch cycle that worsens the inflammation and can result in secondary bacterial infections characterized by crusting and oozing.  

Managing eczema in children requires a comprehensive and often long-term approach involving various treatment modalities tailored to the severity of the condition and the individual child's needs. The primary goals of treatment are to relieve itching, reduce inflammation, hydrate the skin, and prevent infections.  

Emollients (Moisturizers): Emollients are the cornerstone of eczema management. Frequent and liberal application of bland, fragrance-free moisturizers helps to hydrate the skin, restore the skin barrier function, and reduce dryness and itching. Ointments and creams are generally more effective than lotions due to their higher oil content. Application is crucial immediately after bathing, while the skin is still damp, to lock in moisture, and should be repeated several times a day.  

Topical Corticosteroids (TCS): TCS are prescription medications that reduce inflammation and itching during eczema flares. They come in various potencies, and the choice depends on the severity and location of the rash. Mild corticosteroids are often used for the face and milder flares, while stronger ones are reserved for thicker, more inflamed areas. It's essential to use TCS as directed by a healthcare professional to avoid potential side effects like skin thinning with prolonged or inappropriate use.  

Topical Calcineurin Inhibitors (TCI): TCIs, such as tacrolimus and pimecrolimus, are non-steroidal anti-inflammatory medications that can be used as an alternative to TCS, particularly on sensitive areas like the face and neck, or for long-term maintenance therapy. They work by suppressing the immune response that contributes to inflammation.  

Antihistamines: Oral antihistamines can help alleviate itching, especially nocturnal itching, which can significantly impact sleep quality. Sedating antihistamines (first-generation) are often more effective for itch relief, while non-sedating options can be used during the day to avoid drowsiness.  

Wet Wrap Therapy: For severe eczema flares, wet wrap therapy can provide significant relief. This involves applying a topical medication (TCS or TCI) and a thick layer of moisturizer to the affected areas, followed by wrapping with damp bandages and then a layer of dry bandages. This helps to hydrate the skin, enhance medication absorption, and reduce itching and inflammation.  

Bleach Baths: Diluted bleach baths can be recommended for children with recurrent skin infections associated with eczema. The low concentration of bleach helps to reduce bacteria on the skin. It's crucial to follow the healthcare provider's instructions carefully regarding the dilution and frequency of bleach baths.  

Phototherapy (Light Therapy): In cases of moderate to severe eczema that do not respond well to topical treatments, phototherapy using controlled amounts of ultraviolet (UV) light may be considered.  

Systemic Medications: For severe, refractory eczema, systemic corticosteroids or immunosuppressants may be prescribed for short periods to control inflammation. Newer biologic medications, like dupilumab, which target specific inflammatory pathways, are also available for severe atopic dermatitis in older children and adolescents.  

Management of Triggers: Identifying and avoiding known triggers is crucial in preventing eczema flares. This may involve using gentle, fragrance-free skin care products, avoiding harsh fabrics, managing environmental allergens, and addressing potential food sensitivities under the guidance of a healthcare professional.  

Educating parents and children about eczema management is paramount. This includes proper skin care techniques, recognizing early signs of flares and infections, and understanding the appropriate use of medications. Providing emotional support and strategies to cope with the chronic nature of the condition and the impact of itching on daily life is also essential. With a consistent and tailored treatment plan, most children with eczema can achieve significant symptom control and enjoy a good quality of life. Regular follow-up with a dermatologist or pediatrician is important to monitor the condition and adjust the treatment as needed as the child grows.