Eczema (atopic dermatitis) is a chronic inflammatory skin disease characterised by dry, itchy, and inflamed skin (Chu et al, 2023a). Approximately 70–90% of cases occur before 5 years of age, although most children present with symptoms in the first year of life (National Institute for Health and Care Excellence [NICE], 2023).
In 25% of cases, the disease will persist into adulthood (De Lusignan et al, 2021). De Lusignan et al (2020) show that although the prevalence of active eczema is greatest in children aged 1–4, there is a significant increase in the fourth and fifth decades of life.
Symptoms
Atopic eczema is characterised by pruritus (itchy), inflamed skin and resultant changes, and a personal or family history of other atopic conditions, commonly asthma and allergic rhinitis (NICE, 2024). Under-2-year-olds usually present with acute itchy papules, serous exudate and crusting, and sometimes poorly defined erythema usually affecting the face, but sometimes extensor surfaces, trunk or nappy area. Children aged 2–12 years old may present with dry skin, erythema and lichenified papules and plaques that can affect the flexor surfaces, hands, feet, and face, particularly around the eyes and lips (Begum et al, 2024).
Eczematous lesions can be:
Acute flare-ups
During acute flare-ups there is a worsening of the eczematous patches. Acute eczema flare-ups vary in appearance, from redness to vesicles, scaling, or crusting of the skin. Chronic eczema skin can also become lichenified or thickened due to constant scratching with prurigo (numerous itch papules) and xerosis (severely dried skin) (Mortz et al, 2019; Napolitano et al, 2022; NICE, 2024).
Aetiology
The pathophysiology of atopic eczema is both complex and multifactorial (Chu et al, 2024). There is certainly an interplay between genetic factors, epidermal barrier properties, immune responses and microbiome changes in the skin (NICE, 2024). This results in an altered skin barrier function, with increased water loss, dehydration and altered skin pH (Mortz et al, 2019; Napolitano et al, 2022). Certainly, there are genetic mutations that have been identified, which lead to the skin producing less fat and oil and reducing the moisturising factors such as one of the structural proteins in the skin called filaggrin (Begum et al, 2024). This deficiency makes the skin more susceptible to triggers that can increase water loss and cause skin inflammation and irritation (NICE, 2024). The triggers can vary from irritants such as soaps, shampoos, detergents, as well as skin infections, inhaled allergens, food allergens, pets, heat and sunlight. It is important to note that milk protein allergy may also lead to symptoms with or without gastrointestinal dysmotility or failure to thrive in infants (NICE, 2024).
Another theory is that atopic eczema is characterised by increased Th2 responses and an overexpression of type 2 inflammatory cytokines suggesting it is an immune dysregulation disorder possibly caused by exposure microbes at an early age (Strachan, 1989; Kim et al, 2019; Chu et al, 2024). The inflammatory response is associated with the activation of T cells (Th2 cells predominate), dendritic cells, macrophages, keratinocytes, mast cells, and eosinophils (Chue et al, 2023; Lugović-Mihić et al, 2023).
Diagnosis
The diagnosis of eczema is considered when a patient presents with an itchy skin condition and three or more of the following criteria:
NICE (2024) also recommends that when a child presents with a possible diagnosis of eczema, the clinician will need to take a comprehensive history that includes:
The skin then needs to be examined for the distribution and appearance of the rash. Infants with eczema will present with a rash on the face, the scalp, and the extensor surfaces of the limbs (National Eczema Society, 2023). Children and adults will present with eczema, which is localised to the flexure of the limbs (NICE, 2024). Often in adults, eczema on the hands may be the primary manifestation (National Eczema Society, 2023; NICE, 2024).
The commonest complication of atopic eczema is a secondary infection such as Staphylococcus aureus, presenting as impetigo (Wang et al, 2019; Alexaner et al, 2020). Herpes simplex can also occur leading to disseminated herpes simplex virus infection or eczema herpeticum that can present with widespread lesions. These can also become infected with S. aureus and there is an acute risk of sepsis (NICE, 2023).
Management and treatment
Eczema is chronic and changing, and children and their carers are often the experts in their condition. Shared decision-making with self-management strategies such as an action plan is the best way to support children in managing their care (Williams and Lakkis, 2024).
The management of atopic eczema also involves a stepwise approach, where treatment is specific to the severity of individual areas of eczema (NICE, 2024). Treatment can be titrated up and down as needed during flare-ups or periods of stability of the condition. It can be incorporated in a written action plan, which could include their triggers, how to identify and manage flares and/or infection and the benefits and implications of treatment (Van Onselen, 2021; Royal College of Paediatrics and Child Health, 2023; Willams and Lakkis, 2024).
The mainstay of treatment involves emollients, topical corticosteroids and topical calcineurin inhibitors (NICE, 2024). Pimecrolimus, tacrolimus, and moderate-potency topical steroids are among the most effective in improving eczema.
Topical antibiotics may be among the least effective treatment options (Chu et al, 2023; NICE, 2023). Certainly, oral corticosteroids can be prescribed short term in primary care for severe flares. There are also systemic treatments suitable for maintenance of severe eczema, such as ciclosporin or azathioprine, but these require a referral to secondary care.
The stepped-care plan for children and adolescents now also recommends systemic specific drugs such as interleukin inhibitors (dupilumab and tralokinumab) and the Janus kinase (JAK) inhibitors (baricitinib, abrocitinib and upadacitinib (Chue et al, 2023; Lugović-Mihić et al, 2023).
In children and adolescents, ciclosporin, dupilumab, tralokinumab and upadacitinib are strongly recommended for severe atopic eczema (NICE, 2024). Abrocitinib is also recommended, but this drug has only been approved in the United Kingdom for those aged 12 and over (Wollenberg et al, 2023).
“Shared decision-making and self-management strategies, such as action plans, are key for children and families coping with ezcema”
Skin conditions like atopic eczema can also lead to significant psychological distress and depression in children and young adults (Na et al, 2019). Children and young adults with atopic eczema can experience higher rates of behavioural problems, fearfulness and bullying and have a greater risk of depression and suicide than unaffected children (Na et al, 2019; Kelly et al, 2021). Atopic eczema is also associated with poor self-image and reduced self-confidence in children (Na et al, 2019). Other issues are sleep disturbances, coping with numerous comorbidities and cardiovascular disease (NICE, 2024).
Chue et al (2024), therefore, recommend preventive measures for this complex condition. They suggest that probiotics and vitamin D supplementation in pregnant mothers and/or infants, and avoiding antibiotic exposure, may reduce the risk of childhood disease. However, the benefits are small, and more research is needed in the field of disease prevention.
Conclusions
Although the mainstay of treatment for atopic eczema involves emollients, topical corticosteroids and topical calcineurin inhibitors, there is hope that future research will help identify the cause of this complicated multifactorial disease, providing us with a range of treatment options (NICE, 2024). Shared decision-making and self-management strategies, such as action plans, are key for children and families coping with ezcema. This also has to include supportive education to help and equip children, young adults or their carers with the knowledge, skills and confidence to take an active role in their own self-management (Greenwell et al, 2021). As nurses involved in their care, we also need to keep up to date with knowledge about the condition, and how we support diagnosis and management of atopic eczema.