Paediatric Eczematous Rash

ACEM Fellowship

Atopic eczema

Usually begins in infancy
Commonly on face +- trunk/limbs
In older children typically localised to flexures
Acute lesions
- Erythema, weeping, excoriation +- vesicles
Chronic lesions
- Scale and lichenification
Exacerbations often due to:
- Poor mosituriser/steroid compliance
- New irritant
- Superinfection (S. aureus or H. simplex)
85% grow out of eczema by age 5

General management

Education re: possible triggers, steroid therapy requirements
Avoid irritants
- Soaps, bubble baths, seams, car sat covers, sand, carpets, overheating, pets
- Smooth cotton clothing preferred
Avoid heat
Keen skin moist
- Paraffin ointment (50% paraffin)- Dermeze up to 4-5 times per day (RCH) [Cameron said sorbolene, RCH says may irritate)
- RCH says over steroids, eTG does not

Treat inflammation with steroid creams
- Face: 1% hydrocortisone ointment BD (or cream if not tolerated)
- Body: Betamethasone valerate 0.02% ointment BD (moderate potency)
- Body: Mometasone furoate 0.1% ointment daily (strong potency)
Control itch: Distraction, wet bandaging, trial of antihistamines (often fail)
Wet dressings
Treat infections

Risks of steroids

Long-term, widespread use of moderately potent steroids can cause skin atrophy and striae
- Especially on face, nappy area and sites of rapid growth e.g. thighs of pubertal girls
Long-term, widespread use of potent topical steroids can rarely cause adrenal suppression (need to consider this possibility at least)
Telangiectasia, purpura, cataracts, juvenile rosacea
Alternatives to steroids
- Pimecrolimus 1% (topical calcineurin inhibitor)
- Zinc and tar combinations on limbs

Wet dressings

Superinfection

Increased itch, erythema, weeping and yellow areas that fail to respond should prompt consideration of superinfection
- Take cultures and treat with simple wet dressings and oral cephalexin
- For recurrent bacterial infection
  - Bleach bath
Herpes typically presents as vesicular lesions, satellite lesions, pustules and/or erosions
Often tender and not particularly itchy
DDx
- Scabies
- Miliaria
- Psoriasis
- Zinc deficiency
- Histiocytosis
- Immunodeficiency

Recurrent superinfection

Consider elimination of carriage of S. aureus
- Nasal mupirocin
- Oilatum bath oil (benzalkonium chloride/triclosan/parrafin)
- Triclosan cream (Microshield-T)

Dietary principles

Normal diet for most
If immediate urticarial reaction to food – avoid
In difficult to control cases, consider formal allergy assessment
- Avoidance of specific irritants e.g. preservative, artificial colours, shellfish, orange, tomatoes, eggs, nuts may be okay but any more extensive elimination diet should only be performed under guidance
Babies with first degree relative with eczema
- 50% chance of developing eczema
- Exclusive breastfeeding recommended for minimum 4 months
  - If not possible, supplement with partially hydrolysed formula
- Consider soy-based formula only if dairy allergy is considered likely
- Peanuts and other nuts should be avoided until 1 year of age

Who gets admitted with eczema?

Perioral eczema vs. juvenile rosacea

Perioral eczema is common in infancy and early childhood
- Irritation from saliva is the main cause
- Thicker moisturisers can be used as a moisturiser and barrier to protect from saliva
- Moderately potent topical steroid ointment is warranted to gain quick control of the area
Juvenile rosacea
- Perioral ’dermatitis’ but is actually a subset of rosacea
- Seen after use of topical steroids in young child predisposed to rosacea
- Erythematous papules around the mouth but spare skin immediately next to the lips
- Steroids often settle things temporarily followed by flare-up
- Treatment involves cessation of steroids and introduction of erythromycin PO (takes 3-4 weeks)

Periorbital eczema

Often associated with airborne allergnes (house dust mites, cat dander and pollens)
Allergen avoidance, moisturiser and pimecrolimus 1% are warranted

Acute flare of eczema

Look for evidence of scabies, superinfection, molluscum lesions
Could be irritant or allergic contact sensitivity to constituent of topical steroid treatment
If itch is a major issues, likely virus or allergy to drugs, food or environmental agent
- Trial of antihistamine is often helpful
Rarely iron deficiency or thyroid disease may cause exacerbation

Molluscum

Can trigger marked local or generalised reaction in children
Widespread itchy and excoriated eczematous lesions in surrounding skin, usually on lateral chest and axillary region or between thighs
Molluscum lesions can be hidden amongst eczematous lesions
Careful history may reveal clear, firm papules were present at some point

Discoid

Focal circular crusted lesions seen in children with psoriatic tendency
Relatively resistant to therapy and usually have Staph superinfection
Oral cephalex, ointment moisturiser, potent topical steroid therapy and regular wet dressings for 2 weeks are usually sufficiency
Hospital admission, intralesional steroid injections, UV light therapy or oral ciclosporin may be considered

Erythema, dry, cracked anterior sole and undersurface of toes
Seen in mid-childhood in children with tendency for sweating
Usually symmetrical disease
May have painful fissures
DDx including tinea (culture), psoriasis, contact dermatitis
Cotton socks, leather shoes and regular ointment moisturiser should be used daily
Topical steroids may be necessary

Last Updated on November 22, 2021 by Andrew Crofton