Pediatric Primary Care Case Studies (122 page)

Other Treatments

Some other treatments that may be used include:

•   
Ultraviolet (UV) light therapy:
Psoralen plus ultraviolet A light (PUVA) therapy should only be used in patients with severe, widespread, recalcitrant atopic dermatitis (Leung & Bieber, 2003). Referral to a dermatologist would be indicated for such a condition.

•   
Antibiotics:
These are recommended for patients with an active infection or heavy colonization of
S. aureus
(Darsow et al., 2005). If a flare-up of atopic dermatitis occurs with evidence of skin infection, a course of oral antibiotics is recommended.

•   
Antivirals:
Acyclovir should be used in herpeticum eczema because this infection can be life threatening in patients with atopic dermatitis.

•   
Atopiclair:
This is a new steroid-sparing prescription cream whose safety and efficacy have been previously demonstrated in adults with atopic dermatitis. It is also reported to be effective and safe in children and infants. The most frequent side effects are stinging, burning, fever, urinary tract infection, and the common cold (Louden, 2007). Its main drawback is its price. Again, a dermatologist probably should prescribe this medication if more common, less expensive medications are ineffective.

•   
MimyX:
This product is indicated for relief of burning and itching associated with atopic dermatitis, allergic contact dermatitis, and radiation dermatitis. It contains olive and vegetable oils, glycerin, squalene, lecithin, and palmitoylethanolamide (PEA). PEA is thought to be missing in atopic skin. Its main action seems to be downregulating mast cell activation. When applied two times a day, studies have shown a decrease of 80% in itching, a 63% reduction in steroid use, and a 65% improvement in sleep quality in children (Smith, 2008).

How would you proceed to treat this patient with mild to moderate atopic dermatitis?

Parental education is key to the successful treatment of AD in a child. Bathing is first addressed by instructing the mother to use only tepid bath water and Dove soap. After patting her daughter dry, she is to apply Aquaphor cream two times a day. On the affected areas she is to apply triamcinolone 0.1% ointment three times a day for 4–5 days. At night the child is to be given Benadryl liquid to help her sleep until the eczema improves and the itching subsides. You ask the mother to follow this initial treatment plan for 5 days and then return for re-evaluation. You are expecting improvement in that time.

The child is rechecked in 5 days and the areas of involvement are already healing well. The mother is instructed to use a step-up/step-down approach to her daughter’s eczema, and hydrocortisone 2.5% ointment is prescribed for application to the affected areas until the inflammatory reaction has cleared. Once the inflammation has resolved, emollients alone are recommended for daily application to the skin of her body and face.

Patient Education

Patient and family education is an integral part of managing atopic dermatitis (Chisolm, Taylor, Balkrishnan, & Feldman, 2008). Education should include information on causes and triggers of atopic dermatitis, prognosis, treatment, and its prevention. Written instructions facilitate understanding and adherence (Chisolm et al., 2008). The healthcare provider must also address the patient’s quality of life.
In this particular case, you instruct the mother to avoid the triggers that contributed to her daughter’s condition, especially clothing and bathing, and tell her that the routine use of emollients on a daily basis is foremost in the care of a child with atopic dermatitis. You may address food allergens later if Anna’s condition remains problematic after treatment is started.

The use of midpotency corticosteroids with emollients during periods of flare-up and how to taper to less potent steroids over the course of the treatment needs to be understood by the family. Educate that there will be flare-ups and exacerbations, but provide reassurance that with a step-up/step-down treatment approach by the family these conditions can be brought under quick control. A significant percentage of children will outgrow atopic dermatitis in time, so constant reassurance to the family is extremely important and helps the family to adjust to the difficult times they may often have.

When do you wish to see this patient again?

Anna and her mother were to follow up in 3 weeks to reassess the treatment program and address any new questions the family may have.

When the patient and her mother return in 3 weeks, you notice a happier child with improved color and no dark lines under her eyes. The mother says her daughter is sleeping much better and her scratching has almost cleared. Reexamination of the patient’s skin shows only a faint redness in the affected areas, and the lichenified areas are almost clear now. The mother is advised to continue with the emollients daily and to return if her daughter has a new flare-up that does not respond to step care by the family.

Key Points from the Case

1. Atopic dermatitis is treated through a multimodal approach.

2. In mild to moderate disease, the use of emollients and mild potency corticosteroids should be initiated.

3. In moderate to severe cases, the primary care provider may need to use emollients, moderate potency topical steroids, and topical calcineurin inhibitors in a step-wise approach.

4. In extreme cases, one would use all of the above as well as phototherapy and even systemic therapy. Care would be transferred to a dermatologist at this level.

5. Therapy for barrier dysfunction, inflammation, infection, and pruritus as well as the identification of possible trigger factors are all necessary in the management of atopic dermatitis.

6. Sometimes bacterial superinfection also needs to be treated.

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