Eczema in Pediatric Patients (under 12)
Cristy Garza-Mayers, MD, PhD, a pediatric dermatologist at Massachusetts General Hospital, reviewed eczema in patients under 12 at SDPA’s Summer Conference in Boston. Dr. Garza-Mayers initiated her talk with an overview of the pathophysiology of atopic dermatitis (AD). The presentation of eczema tends to vary in distribution with the age of the patient. Morphologies associated with AD include ichthyosis vulgaris, pityriasis alba, Dennie-Morgan sign, follicular prominence and hyperlinear palms. The “atopic march” is the tendency for patients to present with AD first, with development of asthma and allergic rhinitis later in childhood. Patients with more severe dermatitis have a higher likelihood to develop asthma and allergies to food and environmental allergens over time. Dr. Garza-Mayers notes IgE-mediated food allergy can trigger an AD flare with common triggers being milk, soy, egg, wheat and peanut. Newest data reveal early introduction of foods is thought to reduce the risk of peanut, egg, and cow’s milk protein allergies.
Coverage: SDPA Annual Summer Dermatology Conference, June 22-25, 2023 – BOSTON
Contact dermatitis was next highlighted by Dr. Garza-Mayers. Allergic contact dermatitis is a delayed hypersensitivity reaction that can occur as soon as 12 hours with re-exposure to the allergen. The history is key in evaluating these patients with distribution a clue to the cause. Patch testing can help identify specific allergens, though positive results do not always equate to clinical relevance.
A mainstay of management of patients with AD begins with barrier repair through use of emollients. Ointments, such as petrolatum, are the preferred vehicle of emollients. Successful treatment of AD includes avoidance of triggers, intermittent, short-term use of topical medications including steroids and treatment of superinfection. Bathing recommendations include dilute bleach bathes with a ¼ cup regular bleach in half a tub. Recent data show that in addition to the antibacterial effect, there is an anti-inflammatory effect which may be a result of cytokine regulation. Dr. Garza-Mayers reviewed the different classes of topical steroids and their side effects. A meta-analysis which evaluated hypothalamic-pituitary-adrenal (HPA) axis suppression with topical steroid use for up to four weeks revealed patients with suppression had no clinical symptoms and this suppression resolved after therapy was discontinued. Therefore, in the absence of signs and symptoms of adrenal insufficiency, there is no need to test HPA axis.
Additional topical agents including calcineurin agents, crisaborole and ruxolitinib were discussed by Dr. Garza Mayers. She mentions antihistamines tend to be overused though the sedating effects can help with sleep in these patients. Of note, leukotriene antagonist is ineffective for treating the itch in AD. Lastly, Dr. Garza-Mayers reviewed systemic treatments for AD.
Byline: Sarah B.W. Patton