Severe eczema requires dedication to deal with. Lack of sleep for the whole family is a significant problem and should not be underestimated. So what is eczema?
Dryness – needing moisturiser
Inflammation – needing steroids
You won’t get rid of eczema unless you treat both.
Frequently Asked Questions
"How long have they had it?"
"Are they ill?"
"Do they have a fever?"
"What have you tried?"
"How much? Frequency?"
"Steroid potency? Duration?" etc.
If they are ill with a fever or show signs of sepsis that is related to their eczema they may need to be admitted.
Consider the social impact
This doesn’t have to be a long-winded social history. Does the child sleep? Does anyone else get sleep? The impact on school/nursery will be enough if you have no other concerns.
Please note: if you think they cannot be bothered to treat their child’s horrendous eczema or are making no effort with it, that would be a safeguarding concern.
A Typical Examination
How widespread is the dryness?
How widespread is redness?
Are there signs of a superadded infection?
Outside of this, conduct a general paediatric examination as normal.
Stages of Treatment
A bit dry: any old moisturiser will do, literally doesn’t matter, apply as much as is required to keep skin smooth and normal looking
Bit dry with patches of redness: QDS moisturisation + BD topical hydrocortisone* until two days after the redness has gone. Longer than 7 days? GP review to check improvement followed by CONTINUED moisturisation to keep skin smooth and normal looking (*you can use this anywhere on the body safely).
- Red and inflamed all over: this is likely to be long-standing eczema and parents may have tried a variety of treatments. They will need to know:
To win, it won't be easy!
At least QDS moisturisation, plus moisturising to be used in the bath and before bed.
BD topical steroids; at least moderate steroids on the body and mild for face/genitals until two days after redness is gone. If it takes longer than 7 days; GP to review.
Topical antibiotics for at least 7 days. These type of patients may have low-grade staph infections and their eczema is unlikely to go without treating it.
Consider fungal treatments if patient appears clinically indicated.
Likely to benefit from a sedating antihistamine if not already on one.
Turn down heating in child’s room.
If crusting/yellow lesions (impetigo) also give oral antibiotics.
Once skin is no longer red, continue moisturiser as often as is required to keep skin smooth and normal looking, at least QDS, and they may never achieve this.
This is as far as I would go in ED, but don’t be afraid to refer on, or back to the GP if the family is struggling. There are more levels of treatment than this!
Use as much moisturiser as you possibly can.
Ointments provide better moisturisation but can be tricky to apply/tolerate – consider an aqueous cream in the daytime and ointment at night. Be aware that this will ruin sheets and clothes, but putting an oily baby into a tight baby grow is effectively wet-wrapping them and can be quite effective, although technically challenging.
Always wash your hands before applying moisturiser.
Use a pump device or a spatula/spoon to extract the moisturiser so that you don’t introduce bacteria into the pot – they will happily replicate there and then you'll be spreading them over damaged skin.
If the family are already at the 3rd stage and compliant with terrible skin, the patient is likely to benefit from a dermatology opinion.
Eczema flares up with coughs and colds (even spontaneously) so you may need to restart steroids if skin becomes red and inflamed. Some parents will be confident and/or sensible enough to do this themselves, however, others will need GP input.
Obviously, safety net if you have any concerns about infection.
This may sound like a lot of information, so put it in a letter and give it to them. You may not save any lives… but sleep is precious 😴