INFANT ECZEMA
IN ORDER TO DIAGNOSE ECZEMA, HEALTHCARE PROFESSIONALS SHOULD TAKE A DETAILED CLINICAL HISTORY TO INCLUDE THE TIME OF ONSET, SEVERITY OF THE CONDITION, RESPONSE TO TREATMENTS, POTENTIAL TRIGGERS, THE IMPACT ON THE INFANT AND THE PARENTS/CARERS, THE INFANT’S GROWTH AND DEVELOPMENT, DIETARY FACTORS AS WELL AS FAMILY HISTORY OF ATOPIC DISEASE.
parents are affected, and 60% of children where only one parent is affected4. Environmental factors such as exposure to pets, house dust mites and pollen have a role in the development of eczema. Food allergens, including cow’s milk and eggs, are associated with eczema and can be directly related to disease severity4
.
In order to diagnose eczema, healthcare professionals should take a detailed clinical history to include the time of onset, severity of the condition, response to treatments, potential triggers, the impact on the infant and the parents/carers, the infant’s growth and development, dietary factors as well as family history of atopic disease.
NICE guidance states that a diagnosis of atopic eczema should be considered when a child has an
itchy skin condition alongside three or more of:
• visible flexural dermatitis involving the skin creases, such as the bends of the elbows or behind the knees (or visible dermatitis on the cheeks and/or extensor areas in children aged 18 months or under)
• personal history of flexural dermatitis (or dermatitis on the cheeks and/or extensor areas in children aged 18 months or under)
• personal history of dry skin in the last 12 months
• personal history of asthma or allergic rhinitis (or history of atopic disease in a first-degree relative of children aged under 4 years)3
.
Table 1 lists other conditions and associated symptoms to allow a
differential diagnosis to be made.
TRIGGER FACTORS FOR ECZEMA In infants, diet can play a big role in triggering eczema. Milk, egg, wheat, soy and peanut account for 75% of the cases of food-induced atopic eczema8. Skin that becomes itchy or red either immediately after certain foods or even a few hours afterwards may indicate allergy. Diarrhoea, vomiting and poor weight gain may also be signs of food allergy. NICE 2011 states:
”food allergy should be considered.... in infants and young children with moderate or severe atopic eczema that has not been controlled by optimum management, especially if associated with gut dysmotility (colic, vomiting, altered bowel habit) or failure to thrive…”
A food history, including breastfeeding or bottle-feeding history, can be of importance in establishing allergy.
Table 1: Determining the diagnosis of various skin conditions Condition
Information Psoriasis Seborrhoeic dermatitis
Uncommon in infants but can occur at any age. The rash tends to be less itchy, typically symmetrical and flat-topped with a silvery scale
Skin has red, sharply margined regions with greasy scales. It usually appears between the second week of life and the sixth month, but most frequently between the third and eighth weeks. It often occurs initially as cradle cap on the scalp, but can affect the face, ears, neck and also skin folds.
Allergic contact dermatitis Can occur at any age. All forms of allergic contact dermatitis present similarly. During an acute phase, the skin is red and vesicles may be present. Chronic phases are characterised by dryness, fissuring and lichenification of the skin6
Fungal infection Scabies
Skin tends to have an annular patch or plaque with a red, raised border and central clearing
Itching of the skin tends to be more intense at night, usually coinciding with a widespread eruption of papules7
.
Changes in soaps and detergents may also trigger eczema. Soaps, detergents and other chemicals can damage the lipid bilayer of the skin further, and may also act directly as allergens. Synthetic fibres in fabrics and wool can irritate the skin whilst silk is tightly woven, impeding the flow of air. Fabrics like these are not recommended for those with eczema and can trigger a flare up. Some infants may be allergic to the protein sericin found in silk. Cotton is usually recommended however it is worth noting that dyes in fabrics can cause skin sensitivity in susceptible individuals. Inhaled allergens include house dust mite, animal dander, moulds and pollen.
ADVICE FOR BREASTFED AND BOTTLE FED INFANTS Mothers of breastfed infants who are suspected of having allergy related moderate or severe atopic eczema should be referred for specialist dietary advice. An allergen-specific exclusion diet is often considered, whereby the mother avoids eating specific foods that are suspected to be causing eczema in the infant. Hypoallergenic hydrolysed or amino-acid based formula milks are an alternative option if it is impossible for mothers to undergo an exclusion diet. In bottle fed infants under 6 months of age, a 6-8 week trial of hydrolysed protein formula milk or amino-acid based formula milk can be encouraged with eczema that is not controlled by emollients and mild corticosteroids9
. .
After this time, infants who have responded well should be referred to a dietician for specialist advice. Infants who do not respond well are unlikely to have a cow’s milk allergy and should be switched back to cow’s milk and parents or carers should be
SCOTTISH PHARMACIST - 47
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