Live Blog: Atopic Dermatitis in Children – Anita Haggstrom, MD
In this live blog from the 12th Annual SDPA conference in Indianapolis, Dr. Anita Haggstrom spoke on the topic of Atopic Dermatitis in Children. Here are some of the highlights.
Unfortunately there is no cure to atopic dermatitis (AD) in children; we can only offer management skills. Management includes education, bathing, emollients and barrier repair, topical steroids or topical calcineurin inhibitors for inflammation and sedating antihistamines to help with pruritus and sleeping issues.
Dr. Haggstrom presented two true and opposing facts when it comes to bathing: 1) Bathing dries the skin, especially long baths with hot water, 2) Bathing hydrates the skin (if the “5-10 minute rule” or “pruned fingers rule” followed). Therefore, she recommends daily bathing and twice daily bathing with a bland, fragrance free, neutral or acidic PH bar or liquid cleanser when there is skin flaring. Some cleanser recommendations are: for CeraVe, Cetaphil, and Dove. Most cleansers are too acidic (pH) for childhood AD.
Dr. Haggstrom mentioned that many parents will ask, “Can my child with AD swim?” The answer is yes, if dermatitis not worsened. Caution parents to limit the child’s time in water, and rinse and apply emollient following swim time. In some cases the chlorine and brominein in pools may actually help symptoms. Sun protection should also still be used. Patients should use sunblocks over sunscreens, particularly those made with zinc oxide or titanium dioxide.
Dr. Haggstrom recommended the following sunblocks:
– Aveeno Active Natural Protection Mineral Block lotion SPF 30
– Banana Boat Natural reflect (Baby or Kids) SPF 50+
– Burt’s Bees Chemical-Free Sunscreen SPF 30
– Blue Lizard Baby SPF 30+
– Blue Lizard for Sensitive Skin SPF 30+
– Côtz Pure SPF 30
– Côtz Face SPF 40
– Côtz 20% Zinc SPF 35
– CVS Sensitive Skin SPF 30
– CVS Baby Lotion Sunscreen SPF 60+
– Neutrogena Sensitive Skin SPF 30
– Neutrogena Sensitive Skin SPF 60+
– PreSun Sensitive Sunblock SPF 28
– Vanicream Sunscreen for Sensitive Skin SPF 60
– Walgreen’s Sensitive Skin SPF 70
You will probably encounter some parents who may have picked up various misunderstandings about corticosteroids. Topical steroid myths contribute to parent phobia and noncompliance. Explain to parents that the following are myths: Topical steroids are unsafe and will stunt my child’s growth, topical steroids cause hypopigmentation (“Steroid use will cause white spots on my child’s skin”), topical steroids can only be used for 5-7 days then discontinued. Make sure to education your patients and their parents that hypopigmentation is due to skin inflammation and low to mid potency steroids will not cause clinically significant adrenal suppression.
Steroid side are actually rare. Reversible effects include telangiectasia/prominent blood vessels, atrophy/thin skin, acne/rosacea, and increased hair growth. One non-reversible steroid side effect is stretch marks. Dr. Haggstrom cautioned to avoid side effects by employing the “The Touch Rule”: Use steroids on rough red skin until smooth, and then stop. The eczema might be gone from that spot for one day, one week, one month, and as soon as it reappears you can restart treatment.
Pearls for use of topical steroids: Low strength steroids are not useful for moderate-severe disease as they often lead to prolonged use and ineffectiveness. Physician confidence and subsequent parent comfort with steroid use are important for effective treatment.
Dr. Haggstrom also addressed the sleep disorders that are common to AD. Sleep problems occur in up to 80% incidence in children with AD. Common complaints are that the child will have trouble falling or staying asleep due to itch. Poor sleep habits often become a learned behavior that persist during remission. And parents are also affected by sleep loss and exhaustion. When the child doesn’t sleep neither do parents! When children are sleep deprived they often display discipline problems, have trouble staying awake in afternoon, and experience impaired daytime alertness. Sleep loss may also be linked to increased prevalence of ADHD.
Antihistamines may be used for pruritus that is causing sleep disruption. The goal is to stop the itch-scratch cycle and improve sleep to at least 5-6 hours of “good” sleep.
In general, when dealing with parents you should use education with written instructions or handouts, as treatments can be confusing. Don’t forget: Parents remember about half of what they are told in your office. Also remember: the Internet can be an enemy of AD treatment. Encourage the parent to visit the websites of the National Eczema Association (NEA) at www.nationaleczema.org and Under My Skin: A Kid’s Guide to Atopic Dermatitis www.undermyskin.com. You may see increased compliance with education, written instructions, quality websites, and handouts.