Eczema: Article written to the Mississippi Osteopathic Medical Association
Pediatric atopic dermatitis (AD) is a challenging and often difficult to control condition that can be confusing and frustrating for both patients and clinicians. Herein I have attempted to simplify the process of treatment and the decision to pursue a more in depth work-up. Below is a copy of a care plan that you may give to all patients with AD. This protocol is appropriate for most children with mild to moderate disease. I typically select ointments over creams yet some patients may not comply due to the greasy feel. For simplicity, I recommend treatment with this protocol for two weeks. Re-evaluation should take place at the end of the two-week treatment period. Feel free to copy this form and use it in your practice.
Atopic Dermatitis Care Plan (Eczema)
- Bathe or Shower daily in lukewarm water, for no more than 5-10 minutes, with a mild skin cleanser such as unscented Dove, Cetaphil, CeraVe, Purpose, Eucerin Gentle Hydrating Cleanser, Aveeno non-soap cleanser, or Oil-of-Olay Complete Unscented soap-free cleanser. Immediately after getting out of water PAT, do not RUB, dry with a soft towel.
- Shampoo scalp __________ TIMES PER WEEK with a mild baby shampoo. For extreme flaking, use T-Sal or Head and Shoulders (dark blue bottle) or Selsun Blue or Nizoral shampoo. Leave on 5-10 minutes then rinse well.
- Apply a thin film of topical prescription medication TWICE A DAY to the AFFECTED AREAS: (RED, ROUGH, RAISED, DRY AREAS ONLY) for 2 weeks then stop for 2 weeks.
- Apply moisturizer to the entire body immediately after the topical Rx medications, and frequently throughout the day. For infants, applying moisturizers all over with every diaper change is appropriate. Vaseline is the best and the cheapest. Never apply moisturizers immediately before or after a medication application as this can decrease the effectiveness of the medication.
- Antihistamines are used to decrease the itching, which helps in the overall eczema process. The dose can be adjusted up or down depending on the response. Not all patients need to use antihistamines.
- Topical antibiotics may be needed if there are many cracks in the skin. This helps treat, or prevent, a secondary infection as well as help in the healing process.
Hydrocortisone 2.5% Lotion / Ointment Triamcinolone Cream / Ointment
Cutivate Lotion / Ointment Derma-Smoothe Oil
Elocon Cream / Ointment Topicort Cream / Ointment
Locoid Lipocream / Lotion Desonide Cream / Ointment
Betamethason Valerate Cream / Ointment Other Steroid: _______________
Ointments: Petroleum Jelly, Aquaphor Healing Ointment, A&D Ointment
Thick CREAMS: Cetaphil (in 1lb jar), CeraVe, Eucerin Eczema, Cetaphil Restoraderm, Aveeno Eczema Care, and Creamy Vaseline.
Recommended: NONE Other: ____________________
Recommended: NONE Other: ____________________
Always consider cutaneous pyodermas in patients who do not respond. Antibiotic therapy should only be initiated in patients with confirmed infection. Remember that treatment of Staph Aureus must include topical treatment of the nasal passages, axilla, umbilicus and gluteal crease with mupiriocin ointment or similar. Neglecting this treatment can lead to repeat infections despite systemic therapy. Fomites in the household must also be considered and other household members may need evaluation for carriage. If needed, you can add 2 oz. bleach to an entire tub of water once a week.
If a lack of significant improvement is noted over the two-week interval, and it is believed that the patient and their parents have been compliant with therapy, wet wraps must be discussed.
Wet wraps have been a mainstay of therapy for decades and are an extremely effective way to improve even severe atopic dermatitis in patients of any age. The biggest hurdle that must be overcome is the amount of work and dedication that needs to be committed to make this therapy successful.
Immediately following application of topical prescription therapy, wet dressings are applied to the skin. These can take the form of wet towels, or wet clothes. Long sleeve pajamas work fantastic. The child is allowed to play for 45-60 minutes and then the wet dressings are removed and emollients are applied. It is require that this process be repeated at least twice daily.
If performed correctly, even patients suffering from severe atopic dermatitis should demonstrate significant improvement in 3-5 days. Patients who do not show signs of improvement must be evaluated for alternate diagnoses if it is believed that they have been compliant with therapy. These include but are not limited to immune deficiency syndromes, cutaneous lymphoproliferative disorders such as mycosis fungoides, autoimmune disease, and eczema herpeticum.
With appropriate therapy and strict patient compliance, pediatric AD patients can be managed effectively with relative ease. Those patients who do not respond will need further work-up and referral to a specialist.
Dr. David Roy