In what way might age, diet, disease, ethnicity, the environment, internal and external stresses, and soaps and cleansers affect the function of the skin in a child with eczema?

Answer: Infants are not able to communicate their needs such as being too hot, which can aggravate eczema. In some cases, diet can cause allergic reactions which aggravates the eczema. Environment, including changes of temperature and central heating, can cause a dry ambient environment which can affect the skin. Soaps and cleansers containing perfumes cause skin irritation and increase the dryness of the skin.

Saleh was diagnosed with eczema when he was 2 months old. At the age of four his eczema was poorly controlled and he found it very itchy and annoying, particularly at night when he would scratch until his skin bled. At the age of five Saleh started seeing a dermatology nurse, who provided creams and educated the family in the application. The nurse reviewed Saleh’s skin regularly. After some time his skin began to improve, and now, at the age of six, his body is clear and most of the eczema is gone.

Figure 26.2: Saleh’s skin before regular emollients and steroids

Figure 26.3: Saleh’s skin after regular emollients and steroids

• Why was Saleh’s skin so itchy?
• What can be done to ease the itch?
• What is the itchscratch cycle?

Answer:

Saleh’s skin was itchy as his skin was very dry which is a feature of eczema.

Salah needs to have his skin moisturised regularly throughout the day to reduce the dryness and resulting itch. If Saleh has inflamed areas on his skin, then those need to be treated with steroids.

The itch–scratch cycle is when scratching relieves the itch but this action releases a chemical called histamine which causes more itching and scratching.

Five-year-old Ben was referred to the primary care nursing clinic by his GP to have his eczema reviewed. Ben has had eczema since he was 2 months old. His GP has been managing his eczema by prescribing various creams. He has also been referred to the dermatology clinic twice, but the appointments were not attended. In children’s nursing there is a recent drive to say the child ‘was not brought’ to the appointment rather than say the child ‘did not attend’. This recognises the fact that attending clinics is beyond the ability of the individual child and the responsibility for this lies with the parent or family members. It is another example of respecting the rights of the child.

Ben’s arms, legs, hands and feet were covered in severe active eczema with areas of thickened skin. He also had small scabs on his wrists and hands from previous scratching that caused bleeding. After assessing Ben’s skin, taking a full history and making a new eczema care plan, it was decided it would be more appropriate to visit Ben and his mother at home, where adequate time could be spent educating and supporting.

There was no initial improvement in Ben’s skin. However after demonstrating how to use the cream, Ben’s skin quickly showed signs of improvement.

The assessment and treatment of eczema often requires more than a 10-minute consultation. Many families are unable to comply with the specialist’s instructions as they do not know how to apply creams. Spending time with Ben and his mother in their home was an essential aspect of care and education, and highlighted their needs. With support and encouragement, they were empowered in their understanding and treatment of Ben’s eczema. As a result, Ben’s skin improved and he now lives a much happier life.

• Name five skin symptoms of atopic eczema.
• What is an emollient?
• How often is emollient used?
• How do topical corticosteroids work?

Answers: Dry skin, itchy skin, red and inflamed, thickened and discoloured.

An emollient is another word for a moisturiser that helps to rehydrate the skin, helping the skin to stay soft and supple.

Emollient should be used regularly throughout the day to prevent the skin becoming dry and itchy. This should be part of the daily routine even when the skin is clear of eczema.

Topical corticosteroids work by reducing the inflammation in eczematous skin.

Using the current British National Formulary (BNF) publication for children, give an example of a topical steroid for each potency level.

Answer: See www.bnf.org/

Topical corticosteroids preparation potencies

There are four strengths of corticosteroids – mild, moderate, potent and very potent. The stronger the potency of corticosteroid the greater the risk of side effects, especially if used for prolonger than prescribed. Here are examples of the different potency of corticosteroids:

Mild – Hydrocortisone 1%

Mild with antimicrobials – Fucidin H

Moderate – Eumovate

Moderate with antimicrobials – Trimovate

Potent – Elocon

Potent with antimicrobials – Fucibet

Very potent – Dermovate (only to be prescribed by Dermatologist or specialist)

1. When undertaking a history and skin assessment, what findings would cause you concern and how would you address this? Reflect on your safeguarding training and how the nurse can protect children.
2. Explain what steps you could take to safeguard a child in this situation?

Answer: From the skin assessment the areas that would cause concern are:

• An unkempt child
• Behaving inappropriate for age
• Quiet
• Bruising
• Poor family dynamics
• Severe uncontrolled eczema

Steps to take to safeguard a child in this situation:

• Take a full history
• Document rashes and bruises on a body map
• Look at weight and growth to assess if the child is thriving
• Liaise with the health visitor if under 5 or school nurse if over 5 to establish if any concerns
• Timely and legible documentation of your findings and any concerns
• Discuss with the safeguarding lead
• Follow your local safeguarding policy
• Check if family known to social services
• Read available electronic notes and check for any alerts