It’s estimated that atopic eczema affects 20 per cent of children in the UK, so it’s important for early years practitioners to be prepared to manage the condition, says the National Eczema Society…
Atopic eczema is a common childhood skin condition. It often starts early in life, generally in babies aged 3–6 months, with the incidence steadily rising in children under five years then tailing off. It is very likely that early years settings will have one or more children with eczema in their care, so practitioners are key to helping the parents care for their child’s skin and reducing the discomfort of eczema for the child.
Atopic eczema is a genetic condition linked to asthma and hayfever. It is an immune condition that manifests in the skin and is triggered by a multitude of individual environmental factors. It has many clinical features and symptoms, depending on whether the eczema is flaring (acute) or longstanding (chronic). When atopic eczema is flaring, the skin is dry and inflamed, often with tiny watery blisters present (called vesicles) and can be weepy, due to infection. In chronic eczema, the inflammation may be less apparent, but the skin remains very dry and itchy. In 3–5-year-olds, thickened areas of skin (called lichenification) are common, where the skin is constantly rubbed and scratched.
Itching is an unbearable symptom of eczema, causing the baby or child to scratch constantly. This becomes a vicious itch-scratch cycle and is often the most difficult and distressing symptom for parents to deal with. Babies often present with a widely distributed pattern of eczema on their faces; the pattern on the body is more diffuse with the napkin area frequently the only area spared. In toddlers and young children atopic eczema usually exhibits the classical flexural pattern affecting the elbow, knee, ankle and wrist skin folds.
Every child’s eczema is different, and parents will tell you what they feel are the triggers for their child. There are, however, a number of common triggers, and these include:
● skin infection (bacterial and viral)
● house-dust mites and their droppings
● animal dander (fur, hair, saliva)
In settings, soap and overheating are triggers that practitioners should be able to help the child avoid. Other triggers may be seasonal and environmental, and are harder to control. Most parents worry that diet is a trigger, but this is only the case for a minority. When diet is considered to be a major trigger, this should have been diagnosed by a consultant allergist/dermatologist or paediatrician, and the child’s diet will be supervised by a dietician. So it will be very important to follow dietary guidance precisely to avoid severe allergic reactions.
Eczema treatment consists of emollients and topical steroids for the majority of children. The latter, in cream or ointment form, are the mainstay of treatment for eczema flares; they are used for short periods of treatment, once or twice a day, so should be applied by the parents at home. If the eczema becomes difficult to manage and is red and weepy, there may be an infection. If child has infected bacterial eczema, they may be prescribed a course of oral antibiotics, usually three times a day; so oral antibiotics may need to be administered at a setting.
Emollients (medical moisturisers) are an eczema treatment that keeps the skin moist and supple, prevents dry and itchy skin and constantly repairs the skin barrier. Children with eczema have an abnormal skin barrier, due to additional genetic factors, so their skin needs to be constantly repaired to stop water being lost and irritants getting in. Keeping skin well moisturised is the most important thing staff can do to make the child’s skin more comfortable.
Emollients should replace all ordinary moisturisers, soaps and bath products, all of which can irritate and dry out the skin. Practitioners should use emollients for washing babies when changing nappies and children’s hands after messy play and painting, and prior to eating. Babies should have their skin re-moisturised at every nappy change and children should be moisturised in the middle of the day or if their skin is uncomfortable, dry and itchy. It is the frequency of reapplication that is essential to prevent skin drying, so emollients need to be used liberally several times a day.
Parents need to provide the medical moisturisers and should be advised to ask their GP for extra prescriptions so a 500g pump dispenser (this is best, as cross infection is less likely) or tub (decant out the amount you need rather than put fingers into the tub, to prevent cross-infection) of the child’s regular moisturiser can be left at the setting. Never use a universal emollient or share emollients between children. Apply moisturiser in gentle, downward sweeps following the direction of the hairs on the skin. Never rub in the emollient, as this is likely to set up ‘the itch’.
When a child enters a setting, have a chat with their parents/carers about their child’s eczema. This is helpful as the parents can run through their moisturising routine, giving staff any specific advice or instructions on managing their child’s eczema during the day and what their individual eczema triggers are.
● Changes in temperature can exacerbate eczema – make sure the child is not getting too hot (sitting by a radiator or sunny window) or too cold (when outside).
● Use emollients on a child’s hands prior to messy play and painting to act as a barrier to irritants. Wash the child’s hands well afterwards and moisturise.
● Make sure staff are aware that a child with eczema should avoid all skin-to-skin contact with anyone else who has the following conditions:
Cold sores – this virus can lead to the serious illness eczema herpeticum.
Impetigo – this can cause infected eczema, which usually requires oral a antibiotics to clear it.
● Ask parents to dress their child in 100 per cent cotton clothing; remove layers if a child gets too hot.
● Hand eczema can cause pain or cracks in fingers, which may prevent the child holding a pencil or paint brush – cotton gloves may be required.
● Sleep problems can commonly lead to a child being grumpy at nursery and unable to concentrate; older children may still require an afternoon nap.
● If other children ask about eczema, be honest, explain in simple terms what eczema is and emphasise that it is not catching.
The National Eczema Society provides independent and practical advice about treating and managing eczema. An helpline operates 8am–8pm on 0800 089 1122 and is the first point of contact for anyone affected by the condition. You can also call for a copy of the National Eczema Society’s Childhood Atopic Eczema booklet, which will give practitioners and their parents more information on managing atopic eczema in babies and children.