Sponsored by SanofiSanofi

Atopic dermatitis in children aged 6-11 years: What can GPs do to deliver optimal care?

All atopic dermatitis in children, however severe, can be effectively managed. This article provides guidance on diagnosis, management and when patients should be referred, including advice from consultant dermatologist Professor Mike Cork.

Rashes often begin in the folds of the elbows or knees (Photo: Olga Kurdyukova/Getty Images)

This article was funded and developed by Sanofi for GP Connect for UK healthcare professionals only.

Atopic dermatitis (AD), or atopic eczema, is a common skin condition that has both physical and psychological consequences.1,2,3,4 However, GPs can effectively limit its impact through treatment, education, speedy diagnosis and referral when it is not controlled. All atopic dermatitis, however severe, can be effectively managed; any child with uncontrolled AD should be referred.

The burden of atopic dermatitis in children

AD, is a chronic, itchy, inflammatory, and incurable skin condition which is more common in children, with around 85% of cases occurring in those younger than five years of age.1,5,6 In the UK, it affects up to 20% of children, with around 2% of those suffering a severe form.7

Atopic dermatitis has a very wide spectrum of severity. Mild cases can be easily controlled and resolved early in life. Severe AD is a devastating disease which can have a significant impact on a child’s life.8

AD can impose a substantial burden on children and their carers, but the physical and psychological effects are often underestimated. Children who experience more severe forms of the skin condition can be affected by sleep disturbances, itch and pain, psychological disorders and bullying. The condition has also been shown to hinder their ability to forge friendships, engage in education, and experience a positive family life.2,3,4

'Moderate/severe atopic dermatitis has a profound psychological effect on the child, siblings and parents,' says Professor Mike Cork, consultant dermatologist at Sheffield Teaching Hospitals and Sheffield Children's NHS Foundation Trusts.

'It can cause depression, anxiety, poor school performance, aggression, and suicide. It is therefore essential to obtain rapid control of atopic dermatitis. This can be achieved by referring the child to a centre with a special interest in the management of AD in children.'

A quick and accurate diagnosis, referral and treatment pathway is of vital importance in making a positive difference to the life of a child, in addition to the lives of their loved ones.

Spotting the signs9,10

In children, AD typically presents as some, or all, of the following:

  • Severe pruritus (itchiness) causing sleep disturbance
  • Dry skin
  • Erythema (a skin rash as a result of inflamed blood capillaries)
  • Oedema (a build-up of fluid which causes swelling)
  • Erosions/excoriations (a raw irritated skin lesion caused by scratching or picking)
  • Oozing and crusting
  • Lichenification (thickened skin that appears leathery as a result of repeated scratching).

Polymorphous manifestations can arise, with different types of skin lesions. Some children will also start to show periods of flare and remission. Typical symptoms include:11

  • Rash that often begins in the folds of the elbows or knees, through the neck, wrists, ankles and/or crease between the buttocks and legs.
  • Itchy, scaly patches where the rash appeared.
  • Progressive appearance of bumps on the skin with colour changes and skin thickening, which can itch even when the AD is not flaring.
  • In severe AD the majority of the skin is affected.
  • The magnitude of erythema is difficult to judge in non-Caucasian skin.

Differential diagnoses12

AD must not be confused with the following:

  • Psoriasis (less itchy, well-circumscribed, reddish-coloured, flat-topped plaques with silvery scales; typically symmetrical).
  • Allergic contact dermatitis (eczematous rash, at any site related to a topical allergen – allergic contact dermatitis can be both an alternative diagnosis, and can be superimposed on to atopic dermatitis).
  • Seborrhoeic dermatitis (red, sharply marginated lesions with greasy scales; usually confined to areas with sebaceous gland activity). It is very difficult to differentiate between seborrheic dermatitis and atopic dermatitis under the age of one year.
  • Fungal infection (annular patch or plaque with slightly raised, sometimes scaly, border, and central clearing).
  • Scabies or other infestations (should be suspected when there is recent onset of an itchy rash in a family and lesions in finger webs and soles of feet).

'Diagnosis of AD can be complicated as it can be present with varying morphology and/or normal IgE levels. It is important to remember that the defining characteristic of AD is the lesions on the skin that are highly pruritic and inflamed in the acute phase, but become lichenified and plaque-like in later stages,'11 says Professor Cork.

Disease course of AD in children

The progression of AD is unpredictable, with most children experiencing alternating periods of flares (relapse) and remission, characterised by underlying chronic inflammation.13

Professor Cork explains: 'If a child presents in your practice, you should inform parents, carers and the child that though the condition often improves with time, it may persist and be accompanied by the development of other atopic conditions later in life.'8

Although no definitive predictors for persistent AD have been identified, data suggests associations between the following, for predicting disease progression and the development of atopic comorbidities:14

  • Increased AD severity
  • Early age of onset
  • Parental atopic history
  • Polysensitisation
  • Non-rural environment
  • Filaggrin gene mutation.

The figure below provides a guide as to how these factors relate to disease severity:15

Image adapted from Kim et al, 201615

Current treatment approach

'If you are concerned about your patient’s AD you should be proactive in referring for specialist dermatological advice. Skin conditions can take an enormous toll on children and their carers both physical and mentally, so it’s important that a holistic approach is taken to managing the condition,'8 comments Professor Cork

Management approach

The current management approach for children with AD is based on a stepwise approach. It is split into stages, with the level of treatment ascending through the stages, in line with disease severity:16

Mild AD

  • Emollients
  • Mild potency topical corticosteroids

With education on how to use therapies

Moderate AD

  • Emollients
  • Moderate potency topical corticosteroids
  • Topical calcineurin inhibitors
  • Bandages

With education on how to use therapies

Severe AD

  • Emollients
  • Potent topical corticosteroids
  • Topical calcineurin inhibitors
  • Bandages
  • Phototherapy
  • Systemic immunosuppression therapy

This stepwise approach is widely accepted; though it should be noted that lower-stage treatments such as topical therapy often bring challenges such as low-adherence and discomfort.17,18

For patients experiencing the moderate/severe form of the condition, recent advances in treatments have been found to address the underlying type 2 inflammation. 

Type 2 inflammation is a pathologic process common to several inflammatory conditions including AD, asthma, chronic spontaneous urticarial (CSU), prurigo nodularis (PN) and chronic rhinosinusitis with nasal polyposis.19,20,21

When to refer?

'It’s important that AD is seen as more than just a skin condition; its impact can be felt in every corner of the child’s life which is why the current NICE guidelines provide a detailed approach as to when to refer patients.' says Professor Cork.

'Specialist dermatology services can support with everything from guidance and advice on effective topical treatment application, through to effectively assessing a child’s eligibility for systemic treatments such as biologics.15 There is no child whose AD cannot be controlled – in severe and moderate AD, effective therapies can be life transforming and life-saving.'

In accordance with NICE guidelines, referral for specialist dermatological advice is recommended for children with AD if:12

  • The diagnosis is, or has become, uncertain
  • Management has not controlled the AD satisfactorily, based on a subjective assessment by the child, parent or carer (for example, the child is having one to two weeks of flares per month or is reacting adversely to many emollients)
  • AD on the face has not responded to appropriate treatment
  • The child or parent/carer may benefit from specialist advice on treatment application (for example, bandaging techniques)
  • Contact allergic dermatitis is suspected (for example, persistent AD or facial, eyelid or hand AD)
  • The AD is giving rise to significant social or psychological problems for the child or parent or carer (for example, sleep disturbance, poor school attendance)
  • The AD is associated with severe and recurrent infections, especially deep abscesses or pneumonia
  • Same-day referral for specialist dermatological advice is recommended if eczema herpeticum is suspected
  • Urgent (within two weeks) referral for specialist dermatological advice is recommended for children with AD if the AD is severe and has not responded to optimum topical therapy after 1 week; or if the treatment of bacterially infected AD has failed.

The majority of children with AD are diagnosed and managed exclusively in general practice but as the child grows older, the psychosocial impact on the family can seem at odds with the apparent physical severity of the condition.22,23

It is important that there should be a holistic approach to the assessment of AD; that is, clinicians should take into account both the physical severity of the AD and the impact on the child and their family.8

Sanofi

Sanofi is a global biopharmaceutical company focused on human health. We prevent illness with vaccines, provide innovative treatments to fight pain and ease suffering. We stand by the few who suffer from rare diseases and the millions with long-term chronic conditions. With more than 100,000 employees in 100 countries, Sanofi is transforming scientific innovation into healthcare solutions around the globe.

References

  1. Nutten S. Atopic dermatitis: Global epidemiology and risk factors. Ann Nutr Metab 2015; 66: 8-16.
  2. Na CH, Chung J & Simpson E. Quality of life and disease impact of atopic dermatitis and psoriasis on children and their families. Children. 2019; 6: 133-44.
  3. Beattie PE & Lewis-Jones MS. A comparative study of impairment of quality of life in children with skin disease and children with other chronic childhood diseases. Br J Dermatol 2006; 155: 145-151.
  4. Bridgman AC, Eshtiaghi P, Cresswell-Melville A, et al. The burden of moderate to severe atopic dermatitis in Canadian dhildren: a cross-sectional survey. J Cutan Med and Surg 2018; 22: 443-444.
  5. Lyons JJ, Milner JD & Stone KD. Atopic dermatitis in children: clinical features, pathophysiology and treatment. Immunol Allergy Clin North Am 2015; 35: 161-183.
  6. Silverberg N & Duran-McKinster C. Special considerations for therapy of pediatric atopic dermatitis. Dermatol Clini 2017; 35: 351-63.
  7. Cork M, Danby S & G Ogg. Atopic dermatitis epidemiology and unmet need in the United Kingdom. J Dermatolog Treat 2020; 31: 801-9
  8. NICE. Atopic eczema in under 12s: diagnosis and management. CG57. December 2007; 1-33.
  9. Yang EJ, Sekhon S, Sanchez IM, et al. Recent developments in atopic dermatitis. Pediatrics 2018; 142: e20181102. doi: 10.1542/peds.2018-1102.
  10. Eichenfield LF. Tom WL, Chamlin SL, et al. Guidelines of care for the management of atopic dermatitis: Part 1: Diagnosis and assessment of atopic dermatitis. J Am Acad  Dermatol 2014; 70: 338-51.
  11. American Academy of Dermatology Association. Atopic Dermatitis: Symptoms. Available at: https://www.aad.org/public/diseases/eczema/types/atopic-dermatitis/symptoms. Accessed November 2021.
  12. NICE. Eczema – atopic: What else might it be. Available at: https://cks.nice.org.uk/topics/eczema-atopic/diagnosis/differential-diagnosis/. Accessed November 2021.
  13. Abuabara K, et al. The long-term course of atopic dermatitis. Dermatol Clin 2017; 35(3): 91-297.
  14. Irvine AD & Mina-Osario P. Disease trajectories in childhood atopic dermatitis: an update and practitioner’s guide. Br J Dermatol 2019; 181: 895-806.
  15. Kim JP, Chao LX, Simpson E, et al. Persistence of atopic dermatitis (AD): A systematic review and meta-analysis. J Am Acad Dermatol 2016; 75: 681-7.e11.
  16. Wollenberg A, Barbarot S, Bieber T, et al. Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part II. J Eur Acad Dermatol Venereol 2018; 32: 850-78.
  17. Simpson EL, Bruin-Weller M, Flohr C. When does atopic dermatitis warrant systemic therapy? Recommendations from an expert panel of the International Eczema Council. J Am Acad Dermatol 2017; 77: 623-33.
  18. Krejci-Manwaring J, Tusa MG, Carroll C, et al. Stealth monitoring of adherence to topical medication: Adherence is poor in children with atopic dermatitis. J  Am Acad Dermatol 2007; 56: 211-16
  19. Sanofi Genzyme. Dupixent Summary of Product Characteristics.
  20. Pawankar R. Allergic diseases and asthma: a global public health concern and a call to action. World Allergy Organ J. 2014; 7(1): 12. doi: 10.1186/1939-4551-7-12
  21. Fahy JV. Type 2 inflammation in asthma — present in most, absent in many. Nat Rev Immunol. 2015;15(1):57-65. doi: 10.1038/nri3786.
  22. Schofield J, Grindlay D, Williams H. Skin conditions in the UK: a health care needs assessment. Nottingham: Centre of Evidence Based Dermatology, University of Nottingham, 2009.
  23. Lewis-Jones S. Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema. Int J Clin Pract 2006; 60(8): 984-92.

Date of preparation: November 2021
Document number: MAT-GB-2101080 (v1.0)

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register

Already registered?

Sign in

Follow Us:


Just published

NHS prescription and packet of pills

GPs can now prescribe flu antivirals on the NHS

GPs and other prescribers are now able to issue NHS prescriptions for antivirals...

GP sign

Prevention set to be key battleground for 2024 GP contract

Negotiations on a new GP contract from 2024/25 will need to 'align closely' with...

Talking General Practice logo

Podcast: What makes a strong PCN and how will integrated care systems affect networks?

Talking General Practice speaks to GP and PCN clinical director Professor Aruna Garcea,...

Money

GP core funding rise outstripped by staff pay awards under five-year contract

Staff pay awards have outstripped increases in core GP practice funding between 2019/20...

BMA sign

Fifth of GP time spent on non-medical work as NHS absorbs cost of 'government failure'

Doctors are 'picking up the pieces of government failures' as the cost-of-living...

COPD

How the five fundamentals of COPD care can help GPs support patients

GP Dr Andrew Whittamore, clinical lead at Asthma + Lung UK, explains NICE’s five...