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Overview of childhood eczema Allergy NZ Conference 2010

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Pauline Brown Clinical Nurse Specialist Eczema/Allergies Northland DHB Child Health Centre Debbie Rickard Child Health Nurse Practitioner Candidate – PowerPoint PPT presentation

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Title: Overview of childhood eczema Allergy NZ Conference 2010


1
Overview of childhood eczemaAllergy NZ
Conference 2010
  • Pauline Brown
  • Clinical Nurse Specialist Eczema/Allergies
  • Northland DHB
  • Child Health Centre
  • Debbie Rickard
  • Child Health Nurse Practitioner Candidate
  • Capital coast DHB

2
This session
  • What is eczema?
  • Who it affects and prevalence
  • Non-allergic triggers
  • Eczema and Atopy (allergy)
  • The skin barrier
  • Gene-environment interactions
  • Reasons for treatments
  • Costs and stresses on families
  • Pathophysiology of skin and eczema
  • Complications of eczema bacteria, fungus, virus
  • Nurse led clinics Debbie
  • Basic Skin treatments/management concepts Debbie
  • Management infant/pre-school Pauline
  • Management in the school age/adolescent/adult
    Debbie

3
What is eczema
  • Eczema is a chronic, inflammatory skin condition
    that is characterised by
  • Dryness
  • Deep-seated itch
  • Redness and inflammation
  • Sometimes areas can be weepy or oozing

4
Incidence
  • The incidence of eczema has increased steadily in
    westernised countries, over the past 40 years
    (Cork et al 2006, p3 ISAAC study, lancet, 2006)
  • It is believed that up to 1 in 4 children may be
    affected and there is no cure. (Gold Kemp,
    2005)
  • It affects around 30 of preschool-age children,
    15 of school-age children and 9 of adolescents
  • 60 of the children will have onset before the
    age of 1 year (Krakowski, Pediatrics, 2008)
  • Historically it is poorly understood and
    frequently under treated.

5
Name Confusion?
  • Eczema has been historically thought of as an
    allergic disease hence the name Atopic Dermatitis
    (inflammation of the skin due to allergies) (Cork
    et al, Exchange, NES 2006)
  • However, more recently it has been suggested that
    we should be dividing the condition of eczema
    into 2 terms
  • (Darsow etal European Task Force on Atopic
    Dermatitis, JEADV, 2010, Ricci etal, Am J Clin
    Derm, 2009, Cork et al, Exchange, NES 2006)

6
  • Atopic - having allergic tendencies (extrinsic)
  • Non atopic not having allergic tendencies
    (intrinsic)

7
Eczema - Atopic
  • Atopy, or the tendency to be sensitised or
    allergic
  • approximately 1/3rd of all individuals with
    eczema has either
  • IgE (immediate hypersensitivity) (example
    hayfever, asthma, food allergies)
  • or
  • Cell-mediated (delayed type hypersensitivity).
    (example contact dermatitis to nickel, dyes etc.)
  • Cell mediated allergy does not show on skin prick
    testing or RAST
  • (Cork et al 2006)

8
Eczema Non Atopic
  • 2/3rds have non allergic eczema
  • Trigger (things that irritate) factors include
  • Soap based products, body wash chemicals
  • Heat, dry air or heating
  • Stress and anxiety
  • Woolly/rough clothes/fabrics
  • Certain food chemicals or colourings/preservatives
    (intolerances and not allergy)
  • Some infections/bacterial, viral, fungal
  • teething

9
  • However................
  • Regardless of the classification, it is thought
    that the primary problem is the skin barrier

10
Functions of the skin
  • Skin cells (keratinocytes) divide at the bottom
    of the epidermis to make a new supply of skin
    cells
  • The new cells mature as they move up through the
    skin
  • At the top of the skin, the skin barrier (stratum
    corneum) is formed
  • The barrier protects the body from the
    environment and prevents the penetration of
    irritants and allergens
  • The skin cells in the stratum corneum are locked
    together by structures call corneodesmosomes and
    the skin cells are surrounded by lipid bi-layers.
  • (Cork et al, Exchange, NES 2006)

11
The skin barrier
  • The stratum corneum can be viewed as a brick wall
  • Comparing skin cells to the bricks and lipid
    lamellae to the cement
  • The wall is stabilised by passing iron rods
    though the bricks which are compared to the
    corneodesmosomes
  • The iron rods keeps the skin together
  • In order to maintain a constant thick barrier
    skin cells shed from the surface of the skin

12
Malfunctioning skin barrier
  • The skin cells in the stratum corneum are locked
    together by structures call corneodesmosomes and
    the skin cells are surrounded by lipid bi-layers.
  • ?Faulty genes break down the skin barrier's
    binders or iron rods much faster than
    normal.People with eczema have gaps in their
    lipids or mortar.This results in cracks all the
    way through the skin barrier.
  • Irritants such as soap cause more break down and
    the "brick wall" starts to fall apart.
  • A broken barrier lets allergens enter the skin
    easily.Germs and more irritants then lead to an
    eczema flare

13
(No Transcript)
14
Management includes repairing the skin barrier
with moisturisers (more discussion later)
15
Why has the prevalence increased?
  • The genes that predispose us to eczema has not
    changed, but our environment has
  • One theory - we are exposing our skin to more
    soaps and surfactants such as bubble baths to
    wash babies
  • Soap and surfactants shown to decrease the
    stratum corneum by 40 (Cork et al Dermatol in
    Practice, 2002)

16
The rising prevalence of atopic eczema and
environmental trauma to the skin. Cork et al.
Dermat Pract 2002, 10, 22.
UK data 1960 - 1981 1995 - 2001
Personal use of soap -detergent 76 million 453 million
Water for personal washing 11 L /day 51 L/day
Increased skin barrier dysfunctions
17
Genes associated with strength of skin barrier
  • Chemicals called proteases break down the
    corneodesmosomes (iron rods)
  • Normal skin has low levels of proteases so skin
    barrier is thick
  • Non-allergic eczema has a change in the gene
    which produces higher levels of protease
  • Leads to premature break down of the iron rods.
  • The lipid lamellae (cement) is also incomplete

18
  • Normal pH of the skin is 5.5
  • Exposure to soap and surfactants ? 7.5 or higher
  • The protease SCCE is pH sensitive
  • 50 increase in protease activity
  • Equals greater breakdown of the skin barrier
  • Increase penetration of irritants and allergens.

19
Aqueous Cream
  • Contains surfactants
  • Surfactants break down the skin barrier
  • Aqueous cream was designed as a soap substitute
    for eczema
  • Widely used as a leave on moisturiser
  • Audit of children attending dermatology clinic
    showed aqueous cream caused irritant reactions in
    gt 50
  • (Cork et al, Pharmaceutical J, 2003)

20
Genetic link
  • If a child has one parent with atopic eczema
    20
  • If both parents have (or had) atopic eczema 50

21
Which leads us to the treatments
  • Our increasing knowledge and understanding of how
    the skin barrier breaks down, reinforces the
    importance of skin-barrier maintenance and repair
  • This is the first-line treatment ?
  • Complete emollient (moisturiser) regimes

22
2nd line of treatment
  • ?
  • Identification and avoidance of irritants and
    allergens

23
3rd line of treatment
  • ?
  • Treatment of flares
  • The more attention paid to the first two steps,
    the less often flares will occur

24
Loss of skin barrier
Produces more Itch and inflammation
Desire to scratch
Moisturise Bathe Cleanse
Excoriation occurs
Steroids Antibiotics
Creates allergic response
Immune system responds to Bacterial invasion
Primary/secondary infection occurs
25
Triggers micro-organisms (staph. Aureus)
26
Eczema is no small itch
27
It is far more yet it is a disease that is
often minimized by health professionals
28
Consider The Impact Of Eczema
  • Overall it is the commonest specific skin
    disorder encountered yet very poorly managed
  • Second commonest skin disorder seen in
    dermatologist office yet very poorly managed

29
Major issues
  • Physical symptoms
  • Pruritus, skin discomfort, sleep disruption
  • Emotional problems
  • Stigma associated with the visibility of the
    disease
  • Social dysfunction
  • Loss of work, school, social activities

30
Financial Burden in Australia
  • Approx. A1142/year/per person for mild eczema
  • Approx. A6099/yr/person for severe eczema
  • A157Million/year per mild eczema population
  • A316.7 Million/year per severe eczema population
  • These figures do not include national expenditure
    on subsidised medications
  • Annotation/Atopic eczema Its social and
    financial costs AS Kemp, Department of
    Immunology, Royal Childrens Hospital, Parkville,
    Victoria, Australia - 1998

31
Major negative impact on the quality of life (QoL)
  • Since 1987 impact measured in a repeatable
    standardised way
  • Dermatology Life Quality Index
  • Childrens Dermatology Life Quality Index
  • Skinex
  • the impairment of the QoL and the psychological
    wellbeing has been well documented
  • Br J Dermatol 2006 155 145-151

32
Recent study on monitoring course of life (CoL)
impact on children with AD
  • CoL refers to fulfilling age specific
    developmental tasks and milestones
  • Hampered CoL has been found in adults who have
    had
  • Childhood cancer
  • End-stage renal failure
  • Anorectal malformations
  • Hirschsprung disease
  • Esophageal atresia
  • ...but this is 1st study on eczema
  • Paediatric Dermatology, Vol. 26 No. 1, 114-22,
    2009

33
Study results
  • 117 patients, median age of 23.4 years
  • 508 control patients, median age 24.2 years
  • Need for support was identified
  • 87 needed more information about treatment
    regimes
  • 85 wanted improvement of personal guidance and
    advice of the physician during their treatments
  • 52 desired contact with fellow-sufferers
  • 68 felt they needed psychological support

34
CoL Results
  • Compared mod eczema to severe eczema
  • Less friends in primary and secondary school
  • Spent less leisure time with friends
  • Fewer belonged to a group of friends
  • Less went to school dances
  • Comparing severe eczema with healthy peers
  • Less were members of sports clubs during primary
    and secondary years
  • 70 felt shame around their peers
  • 49 avoided intimacy
  • 25 reason for missing school
  • 24 did things on their own

35
Physical aspects
  • 90.7 experienced pain and itch
  • 69 sleeplessness
  • 60 fatique
  • 74 had increase in eczema when stressed

36
International Study Of Life with ATopic Eczema
(ISOLATE)
  • Largest and most comprehensive study conducted
    into the impact of eczema on patients' lives and
    relationships
  • Revealed the extent of the emotional suffering
    caused by eczema. (2004)
  •  

37
Results
  • 55 either always or sometimes worried about the
    next eczema flare
  • 51 always or sometimes unhappy/depressed
  • 86 avoid at least one type of everyday activity
    during a flare-up
  • 43 fairly or very concerned about being seen in
    public during a flare
  • 74 of patients and caregivers state that their
    physicians have never discussed the emotional
    impact that eczema has had on their lives

38
..yet very poorly managed
39
Australian Study
  • Indicated that the family stress related to the
    care of a child with moderate or severe atopic
    dermatitis is significantly greater than that of
    care of children with insulin-dependent diabetes
    mellitus. (Kemp, 1999)
  •  

40
..yet very poorly managed
41
Patients and their families experience
considerable emotional distress, anxiety, and
embarrassment because of peoples response to
this illness.  In fact, the emotional scarring on
both patient and family members may outlast
eczema's physical effects.
42
Never underestimate the emotional cost of eczema
  • Single young mother
  • 1 year old
  • Moderate severe eczema and receiving multiple
    and conflicting advice
  • Multiple food allergies conflicting advice
  • Multiple environmental allergies
  • No family living in same town
  • Mother studying
  • Minimal income
  • Sleepless nights
  • Irritable child during day
  • Difficult finding childcare due to eczema
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