Karina Jackson, BA [Hons], RN.
Dermatology Sister, St John’s Institute of Dermatology, St Thomas’ Hospital, London
Atopic eczema, or atopic dermatitis, is becoming more prevalent in the UK. Up to 20% of children are affected [Hughes, 1998] although 60-70% grow out of it by their mid-teens. Hospital dermatology and paediatric units see most of the more severe cases, but the majority of patients are cared for by primary-sector health-care professionals. Guidelines for referral to a specialist service are currently being piloted by the National Institute for Clinical Excellence [NICE, 2001]. This paper focuses on the nursing assessment and care of children with atopic eczema.
What is atopic eczema?
Atopic eczema is a noncontagious, chronic inflammatory skin disease. It has a number of possible clinical features, including an erythematous rash with ill-defined borders, papules, vesicles, exudation and crusting, scaling and lichenification [Peters, 2000]. The classic distribution of atopic eczema in children involves the flexures, ankles, hands and neck, with mostly facial, trunk and extensor involvement in babies [Gordon, 1999].
Clinical signs and distribution differ between black and white skin and these differences are important to note. Erythema can be more difficult to observe against dark skin. The predominant colour changes are often those of post-inflammatory hyper- or hypo-pigmentation [Pityriasis alba].
The elbows, knees and extensor aspects of the limbs can be involved in the ‘reverse pattern’ of atopic dermatitis and the lesions can also be accentuated around hair follicles [follicular eczema] [Archer and Robertson, 1995].
In all cases, eczema activity tends to fluctuate, and acute flares that require immediate and more aggressive treatment may arise at any time.
What causes eczema?
The aetiology of atopic eczema is unknown, although there is a strong hereditary link to the development of the disease [Gordon, 1999]. The pathophysiology of the disease is now better understood and it is clear that the atopic patient has an abnormal immune response to certain allergens. Commonly cited allergens include house dust mites, animal dander, Staphylococcus aureus and certain foods including nuts, eggs, dairy products and seafood [Wollenberg et al, 2000].
Definitions
There have been many attempts to pinpoint exactly what signs, symptoms and relevant medical histories lead to the diagnosis of atopic eczema [Thestrup-Pedersen, 2000]. The UK Atopic Dermatitis Diagnostic Criteria Working Party has identified six reliable features of the condition, regardless of race [Williams et al, 1994]. These are listed in Box 1.
These criteria include only one clinical sign, which demonstrates the variability of clinical signs that can be seen between cases. They also emphasise the importance of a patient’s past medical history. [For other differential diagnoses, see Box 2.]
Nursing assessment
No standardised nursing assessment tools are used in paediatric atopic eczema, although some tools have been developed and evaluated by Lawton [1999], Hughes [1998] and Gordon [1999]. There is, however, a Children’s Dermatology Life Quality Index [CDLQI], which is specifically designed to indicate the extent to which the disease affects the child’s life [Lewis-Jones and Finlay, 1995]. Visual analogue scales can be used for subjective measurement of itching or sleep loss. The categories below cover the main areas of concern in a nursing assessment and provide examples of the kind of questions it may be useful to ask.
Skin assessment - When assessing eczema, it is important to ascertain which areas of the body, limbs and head are affected. This can be documented using a body chart. It is then useful to describe what you see using the correct terminology [Box 3]. How active is the eczema? Is there any sign of infection? When assessing the skin it is important to look and touch. It is preferable not to wear gloves for the skin examination, unless you suspect the patient has an infection. Wearing gloves can make the patient feel stigmatised and unapproachable; it may also frighten young children. Good handwashing hygiene is essential before and after examining the patient.
Symptom assessment - Itching is the most common and frustrating symptom patients experience with atopic eczema. Itching can be particularly troublesome at night and may cause sleep deprivation. In a National Eczema Society [NES] survey, 60% of children with atopic eczema cited sleep disturbance as a problem [Savin, 1997]. The resultant scratching may damage the skin. This can cause bleeding and soreness and allows the easy entry of pathogens into the epidermis, possibly resulting in clinical infection and certainly exacerbating the existing inflammation.
Other symptoms of the condition include pain, stinging and soreness. These can be made worse during the application of treatments.
Assessment of diet and allergies - Does the child have known food allergies? Is the child receiving adequate nutrition? Are there other known allergies that exacerbate the eczema? How is allergy avoidance achieved? Does the child need a referral to a dietitian? Does the child have other allergies, such as hay fever, asthma or urticaria and, if so, how are these managed?
Social assessment - Who does the child live with and in what kind of housing? Does the family have adequate facilities to manage a treatment regimen? What support is available to the child and carer? Is the school/nursery understanding and helpful? How does the disease interfere with normal daily activities/sports and hobbies? Are there ethnic or cultural issues to take into account? Some families may be eligible for disability living allowance if the child’s condition has a significant impact on the carer. Is there a need for further referral to other health- or social-care professionals?
Psychological assessment - How does living with eczema affect the child, siblings and carers? How does the child relate to other children and family members? Is the child subjected to teasing or bullying? Do the carers have concerns about the child’s mood or behaviour? Children may be psychologically affected by their eczema. This can manifest itself in any number of ways, for example by withdrawal, self-consciousness, depression, anxiety, dependence or disobedience.
Parent/carer assessment
It is important to know who cares for the child and how the treatment regimen is managed. What are the carer’s strategies for coping? What are the carer’s feelings about the role of carer and the relationship with the child? In a report by Lawson et al [1998], 71% of parents experienced feelings such as guilt, exhaustion, frustration, resentment and helplessness as a result of caring for children with eczema. How much do the carers know about the disease, its management and the practical aspects of treatment application? What are their educational needs? What are their expectations? What kind of support do they need? It is important to listen to carers and establish what problems they have as a result of the child’s eczema, as these may need to be addressed to achieve a successful outcome. Carers may also have received conflicting advice from a multitude of sources: GPs, dermatologists, allergists, alternative therapists, dietitians, pharmacists and lay individuals.
Medical treatment of atopic eczema
The main treatments for eczema are emollients, bath oils and corticosteroid ointments. Night sedation and antibiotics are sometimes used. There is risk involved in using potent topical steroids over a protracted period of time. They are known to cause skin atrophy [thinning] and striae. If the steroid is absorbed through the skin, other risks may be created, such as growth retardation, osteoporosis and Cushing syndrome. Children should therefore be prescribed only mild topical steroids, such as hydrocortisone 0.5%-2.5%, unless they are under the supervision of a dermatologist. Many parents try homeopathic or other alternative treatments in an attempt to manage the condition. Parents should be advised to obtain a list of registered practitioners from the relevant professional body.
Nursing management in atopic eczema
Dermatology nurse specialists, hospital and community nurses, health visitors, practice nurses and school nurses may play a role in paediatric eczema management. Much nursing time in the management of atopic eczema is spent providing health education and practical advice. A case study in Box 4 demonstrates how nurses can improve the quality of life for patients and carers with atopic eczema.
Conclusion
Nurses can play an extremely important role in the management of atopic eczema. Many of the needs of both patients and carers relate to education, advice and support. Most eczema management is conducted in the community, therefore it is important that expert nursing knowledge is fostered in this area. The development of skin disease management clinics by primary care nurses and health visitors is happening, but strong links with specialist dermatology services are required to enable access to expert advice. These services can also provide support for nurses in their continued professional development.
Useful resources
- The National Eczema Society: Tel: 020-7281 3553; www.eczema.org
- The British Dermatological Nursing Group: Tel: 020-7383 0266; www.bdis.org.uk/BDIS/intro_pages/BDNGhome.html
- The Primary Care Dermatology Society: Tel: 01844-276271.
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