The Successful Treatment of Children With Atopic Dermatitis


February 26, 2018 by: Richard J. Antaya, MD
Alvin W. Li, BS
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Atopic dermatitis (commonly referred to as “eczema”) is a common skin condition that affects approximately 15% of the population. Eczema tends to appear in children in the first year of life as areas of itchy, pink to red skin. When eczema is severe, the involved skin can look like it is wet or “weeping.” The word eczema is derived from the Greek word meaning to “boil over,” which describes the characteristic oozing in severe cases. In babies, eczema tends to affect the cheeks, scalp, arms, and legs. In older children, eczema typically affects the inside of the elbows, back of the knees, and neck area.

The treatment of eczema generally consists of two phases: the initial “clearance phase” and the subsequent “maintenance phase.” These two phases are distinctly different, but require equal attention, so it is best to discuss them separately.

Clearance Phase
The clearance phase is intensive therapy for eczema flares, when the affected skin is very itchy, red, swollen, oozing and/or crusted, and interfering with daily activities (school, sleep, play). The goal here is to clear the skin and restore its normal appearance by aggressively and completely treating the flare. In this process, itch and discomfort will also decrease. Depending on the severity of your child’s eczema, the clearance phase can last anywhere from several days to several weeks.

If we imagine an eczema flare as a raging fire, the clearance phase will be the large bucket of water we are throwing on the fire to put the flames out. Again, the goal of this phase is to completely extinguish the flames, as residual embers can cause the flame to reignite. When the flames are extinguished more completely, the benefit is twofold: decreased flames (better symptom control) and decreased embers (longer period until a subsequent flare).

This phase will typically involve a topical (applied to the skin) anti-inflammatory medication such as topical steroids or topical calcineurin inhibitors, in addition to strict avoidance of irritants and allergens that come into contact with the skin. Additional treatments, such as oral antihistamines, tar products, or topical antibiotics, may be needed to either make your child more comfortable or to treat infected skin areas.

Maintenance Phase
The maintenance phase is started after successful clearance of affected skin. The skin now looks closer to its normal appearance (though thickened skin lines and darker/lighter skin color in previously affected skin sites may persist) and itch and discomfort are decreased. At this point the eczema should no longer be significantly affecting the child’s daily activities.

Returning back to our fire analogy, now that the fire is out, all that remains are the smoldering embers. The maintenance phase is similar to periodically sprinkling some water onto the embers to keep them at bay. Although the embers will inevitably reignite the flame, the maintenance phase treatments and practices can dramatically prolong the time before another flare occurs.

The topical steroids or topical calcineurin inhibitors used in the clearance phase are stopped in the vast majority of cases. Infrequently, for the most severe cases they are continued, but on an intermittent schedule to avoid any of the problems that can occur with continuous use. Avoidance of possible irritants or allergens to the skin, however, should be continued. The maintenance phase will continue until the next flare, when the clearance phase will begin once again.

Parental Concerns About Eczema Treatment
Many parents of children with eczema are often unsure or fearful of applying topical steroids to their children’s skin, a phenomenon researchers have termed “topical corticosteroid phobia.” These feelings are often related to instructions by some healthcare providers to “apply medication sparingly” and fear of causing irreversible skin thinning. Some studies have identified healthcare professionals, friends and family, the Internet, and broadcast media as potential sources of misinformation regarding topical steroids.

The concerns associated with topical corticosteroid phobia, however, are largely unfounded and stem from outdated information. Although skin thinning is certainly a known side effect of high-potency topical corticosteroids, with the low- to moderate-potency steroids typically prescribed to treat pediatric eczema, it has only been shown to be a problem with continuous prolonged use (months to years), in areas of the skin that are easily occluded (skin folds), and under artificial occlusion (plastic wrapping). When these medications are used correctly under the supervision of a trained healthcare provider, they are effective and very rarely cause irreversible side effects. Having said that, all children respond differently to medications, so if you suspect signs of skin thinning (increased transparency and shininess) or stretch marks on your child’s skin, bring this to the attention of your child’s primary healthcare provider.

Although topical steroid phobia is still very much prevalent and very likely causing underutilization of topical steroids, physicians are beginning to take notice and act. For example, a consensus statement published in 2015 by a group of dermatologists in Australia has recommended topical steroids to be “applied liberally” in the treatment of pediatric eczema (Mooney, 2015). In another consensus statement authored by Dr. Bewley on behalf of the Dermatology Working Group, the group proposes a change in pharmacy labelling of topical steroids, which generally advises parents to apply “sparingly” or “thinly”.

So How Much Medication Should be Applied?
The fingertip unit, or FTU, is the amount of ointment squeezed out of a standard tube of medication starting from the furthest skin crease of your index finger to the fingertip. The FTU approximates 0.5 g of medication, which should be enough medication to cover a skin area equivalent to two adult hands.

The FTU, however, becomes impractical to use when the prescribed medication does not come in a tube. Fortunately, 0.5 g of medication is also roughly equivalent to the amount measured in 1/8 of a teaspoon. A useful tool to estimate the amount of medication required to cover the entire body based on age is the “rule of 5s”, which recommends 5 grams of ointment for children 5 months old, 10 grams for children 10 years old, and 20 grams for a 20-year-old adult. This roughly translates to 1 teaspoon for children 5 months old, 2 teaspoons for children 10 years old, and 4 teaspoons for a 20-year-old adult for full-body coverage. We advise our patients to “apply liberally” to the affected area, spreading until evenly coated while being careful not to apply a layer too thick that is wasteful.

Conclusion
Atopic dermatitis, or eczema, is a common but treatable skin disorder. Treatment should involve an aggressive treatment phase (clearance phase) during flares to significantly decrease inflammation and a preventative phase (maintenance phase) in between flares to keep the skin under control. The better the skin is maintained during the maintenance phase, the more likely the length between flares will be longer. Under the supervision of a trained medical professional, parents should not be afraid to liberally apply low- to moderate-potency topical steroids to treat areas of active eczema.

Richard J. Antaya

Richard J. Antaya, MD

Dr. Antaya Professor of Dermatology, Pediatrics, and Nursing and Director of Pediatric Dermatology at Yale University School of Medicine. He has longstanding research and clinical interests in the treatment of children with atopic dermatitis.

Alvin W. Li

Alvin W. Li, BS

Mr. Li is a fourth-year medical student at the Yale School of Medicine. He has an interest in pediatric dermatology and is currently conducting a research project investigating the relationship among topical corticosteroid phobia in parent-caregivers, the clinical outcome of atopic dermatitis, and medication adherence.