Childhood Eczema

Eczema (atopic dermatitis) is a chronic condition caused by inflammation of the skin. It's a component of the "atopic march" which includes asthma, hay fever, and food allergy. Though the exact cause is unknown, the risk of developing eczema is higher in children with dry skin (xerosis) and those with immune dysfunction. 

Additionally, possible triggers reported include:

• irritants (wool, soaps and chemicals)
• contact allergens (latex, metals, perfumes)
• food allergens (cow's milk, eggs nuts, soy, wheat and shellfish)
• house allergens (tobacco smoke, hard water, dust mites, animal dander)
• other irritants (extreme changes in humidity, pollens, molds)

Eczema is most common in children younger than 5 years old. Studies show that 66% of patients first experienced eczema before 7 years of age. The amount of children affected by eczema varies by country and, in the United States, from state to state. Numbers reported are from 1 to as high as 22% of children younger than 18. Studies also show that preterm infants (<37 weeks gestation at birth) have a higher risk of developing the condition. 

Possible risk factors include atopy (positive reaction to at least one skin prick allergen), not breast feeding, immunosuppressants and stress.

Children with eczema are at an increased risk of skin infections caused by staph, strep, herpes simplex 1 and various fungi. Chronic itching may lead to scarring and sleep disturbances. 

The pediatrician will make the diagnosis based on physical examination. It's important to rule out conditions such as parasitic infections (scabies), fungal infections (tinea), metabolic conditions (zinc deficiency), immunological deficiencies (Wiskott-Aldrich Syndrome, dermatitis herpetiformis, lupus, HIV dermatitis), systemic disease (primary biliary cirrhosis, polycythemia vera and renal failure) and other skin conditions (contact dermatitis, ichthyosis, psoriasis and seborrheic dermatitis).

Most cases of childhood eczema improve with age, and up to 70% of cases clear by teenage years. 

The secret to managing eczema lies in both controlling the dryness of the skin and minimizing any inflammation. This includes:

• Use moisturizing soap (Dove brand preferable) at very END of bath to avoid irritation
• Moisturizing cream (such as Vaseline or Eucerin) applied immediately after bath (while still damp) to affected areas 
• An anti-inflammatory (steroid cream such as triamcinolone) may be prescribed. Use twice a day.
• Avoiding irritants or triggers

Reference

Atopic dermatitis. Dynamed database. Updated January 21 2014. Accessed July 2, 2014.

Asthma in children

Asthma is a condition of the small airways of our lungs in which hypersensitive cells are aggravated by environmental substances, leading to inflammation, swelling and poor air flow. It is estimated that 70% of cases are caused by allergic substances such as dust, pollen and pet dander. Other causes include viral illnesses, exercise and cough.

It’s estimated that in the United States, 1 in 10 children younger than 18 years suffer from asthma. Many children with asthma have experienced what is known in dermatology as the “atopic march”, which is essentially a trifecta of asthma, atopic dermatitis (eczema), food allergy and allergic rhinitis (hay fever). Additionally, having asthma makes airways of children vulnerable, putting them at increased risk for diseases like pneumonia, influenza and obstructive sleep apnea.

Signs of asthma in children younger than 2 years old include noisy breathing, grunting and cough while the classic signs in children with are wheezing, chest tightness, cough and difficulty breathing.

Pediatricians will attempt to get specific information regarding the asthma in order to both determine the level of severity and prescribe the most appropriate course of treatment. Questions asked include daytime or nighttime cough, possible triggers (such as viral illness, changing seasons, exercise, etc) and previous episodes. This can reveal special cases such as cough-variant asthma and exercise-induced asthma. Additionally, the pediatrician will want to rule out other conditions such as viral bronchiolitis, cystic fibrosis (CF), bronchopulmonary dysplasia (scarring of the lungs in premature babies) and aspiration of a foreign body. Tests ordered may include spirometry in children >5 years old (blowing into a tube to test lung strength/capacity) and/or a sweat chloride test in children younger than 3 (to rule out CF).

The treatment for asthma depends on the severity. All asthma patients, regardless of severity, are placed on a short-acting beta agonist (SABA, an inhaler) on an as needed (prn) basis. The child’s response to the treatment will be reassessed at follow up in 2-6 weeks.

There are 4 levels of asthma, organized by their level of severity:

Intermittent (episodes < 3 d/week, no nighttime awakenings)

Mild persistent (episodes 3+ d/week)

Moderate Persistent (daily episodes)

Severe Persistent (episodes throughout the day with weekly nighttime awakenings)

The treatments for each are as follows:

Intermittent: SABA prn

Mild persistent: SABA + low-dose Inhaled corticosteroids (ICS)

Moderate Persistent: SABA + medium-dose ICS

Severe Persistent: SABA + high-dose ICS + long acting beta agonist (LABA)

An oral corticosteroid, such as prednisone, may be added in very severe cases where the inhaled medication isn’t working well. The reason for this is that if the airways are severely blocked, the inhaled medication will not be able to reach the tissues to be absorbed.

If a child experiencing an asthma exacerbation is not responding to his or her treatment, experiences a late night attack or has had a severe episode in the past, it’s important to bring them to the emergency room for monitoring. They may require endotracheal intubation, IV antibiotics and/or an IV theophylline drip.

The goals of the parent should include both prevention and preparedness:

• Be sure to limit your child’s exposure to cigarette smoke, pollution, aerosol chemicals and any known triggers

• Some studies have shown that breastfeeding reduces the risk of developing asthma, and others suggest that swimming helps improve lung function and reduce the severity of exacerbations

Reference

Asthma in Children. Dynamed Database. Updated May 7, 2014. Accessed July 1, 2014.