Managing Childhood Diseases

Evaluating inflammation to aid disease management
Whatever the underlying etiology, eczema symptoms are inflammatory in nature. The first question to answer is, What's causing the inflammation? In children, low-level allergic sensitivities to various foods are often the culprit, triggering an IgE-mediated inflammatory response and subsequent symptoms.^1,2 Anti-inflammatory treatments will ease symptoms, but won't necessarily target the underlying cause. You can tailor effective management of eczema by determining which inflammatory process is at work—allergic or non-allergic. The results of specific IgE testing, when positive, will help to identify the specific allergic triggers involved.

When a diagnosis of AE has been confirmed, a number of topical and oral medications are available to treat both the symptoms and the underlying allergic cause. In addition, experts recommend the control of allergens and other symptom flare factors. Quite often, a combination of avoidance or environmental control and medication may be necessary to relieve symptoms as part of a multipronged management approach.¹

Trigger control
Each patient’s management plan should be individualized to address his or her specific allergies and other trigger factors. In young children, specific IgE blood testing offers a convenient means of identifying the low-level sensitization to specific food allergens (which, in these patients, occurs in about 40% of AE cases).¹ In vitro testing will also help to identify inhalant allergens (such as house dust mite and animal dander), which have also been shown to trigger symptoms in some patients.² Once offending allergens and/or other non-allergic trigger factors (eg, soaps, detergents, and irritating clothing) have been identified, parents can be counseled to help the child avoid or control exposure to those things.²

Targeted rotational food elimination diets
In the case of food-borne allergy, removal of the offending allergens from the diet can go a long way toward reducing inflammation and relieving symptoms. According to the Joint Task Force on Practice Parameters of the American College of Allergy, Asthma & Immunology, the American Academy of Allergy, Asthma and Immunology, and the Joint Council of Allergy, Asthma & Immunology, “elimination of suspected causal foods may be undertaken to determine whether symptoms are diet responsive.”³ Care should be exercised to maintain adequate nutritional levels, and referral to or consultation with an allergist is generally recommended for a food challenge or elimination diet.²

If the patient’s test report shows multiple food sensitivities and the clinician feels comfortable following through on managing them, it is reasonable to assume that he or she could formulate a rotational food elimination diet based on the patient’s in vitro allergy test results. Such a diet would follow this approach:

• Focus first on the food with the highest reported specific IgE level and counsel the patient’s parents to eliminate that one food from the child’s diet
• Follow up in 2 to 3 weeks to see if symptoms have resolved or improved
• If symptoms have not improved, rotate the diet by counseling elimination of the food that registers the next highest level of specific IgE and adding the previous food back to the patient’s diet
• Patients showing even low-level reactivity to anaphylaxis-prone allergens (eg, peanut, tree nuts, and shellfish) should be referred directly to an allergy specialist for further evaluation
• Elimination may involve avoidance of foods in which an allergen is an ingredient. Thorough counseling and patient/parent education is therefore required.⁴ To avoid malnourishment, dietary supplementation may be required²
• If the clinician has any doubts or concerns regarding a patient’s diet or the management of food allergy sensitivities, specialist referral is strongly recommended²

Formula switching
In young infants who drink formula, the offending allergen may be one or more ingredients in the formula. Avoidance may be achieved by switching the infant to a different formula, so it is important to know formula ingredients, not only to aid avoidance therapy, but also to ensure proper nutrition. The main source of potential allergy is derived from a formula’s key protein. As a result, formula products are generally categorized as cow’s milk-based, soy-based, or hypoallergenic. In the last category, formulas are either hydrolyzed (in which the cow’s milk protein [casein] is broken down either partially or extensively into amino acids) or amino acid-based (considered the most hypoallergenic).⁵ In order to be labeled hypoallergenic, formulas are required to undergo extensive preclinical studies to ensure that at least 90% of infants with documented cow’s milk allergy will not react with defined symptoms under double-blind, placebo-controlled conditions.⁶ The following chart lists top infant formula brands according to their protein source.

*The formulas listed above are the products or registered trademarks
  of their respective manufacturers.

Medications for Allergic Eczema (AE)^1,2,8

Topical corticosteroids—Due to their strong anti-inflammatory effects, these agents are considered essential treatment for AE. In general, the least potent agent able to provide symptom control should be used. In addition, the patient should be switched to a less potent agent when control is achieved. Topical corticosteroids come with a range of potential side effects (including thinning of the skin, infections, and growth suppression), and should be used with caution in children. Seven classes of topical corticosteroids are ranked for potency. These comprise a number of agents (creams, lotions, and ointments), including various formulations and strengths of hydrocortisone, betamethasone, and fluocinolone.

Immunomodulator creams—These medications work by targeting the autoimmune reaction in order to control inflammation. Agents in this category include tacrolimus ointment and pimecrolimus cream. Both have been shown to offer significant reduction in AE symptom flares and to reduce the need for topical corticosteroids.

Oral corticosteroids—Systemic steroid treatment is reserved for extremely severe exacerbations. Because patients often experience a rebound of symptoms after discontinuing oral steroids, a short course of treatment is recommended. Side effects of oral corticosteroids should also be considered.

Coal tar preparations—Due to their potential antipruritic and anti-inflammatory properties, coal tar preparations may be used as an alternative or adjunct to topical corticosteroids.

Antihistamines—Non-sedating antihistamines (eg, Zyrtec^®, Claritin^®) may be used, and because pruritus often occurs at night, sedating antihistamines (hydroxyzine, diphenhydramine) are suggested for use at bedtime.

Immunotherapy—Currently no data support the use of allergen immunotherapy for the treatment of atopic dermatitis.

Special considerations

Antibiotics—AE patients are prone to secondary skin infections. These are treated with macrolide antibiotics (eg, erythromycin, azithromycin, and clarithromycin). Patients with macrolide-resistant Staphylococcus aureus may use penicillinase-resistant penicillin (dicloxacillin, oxacillin, or cloxacillin).

Antifungal agents—AE patients may be vulnerable to dermatophyte infections.² These patients can benefit from topical antifungal treatments^1,2 (eg, clotrimazole, miconazole, oxiconazole).⁹

Hydration—Patients with AE often experience dry skin, which can crack or develop fissures (and therefore become infected or otherwise irritated). Wet dressings help to maintain moisture and aid penetration of topical corticosteroids. In addition, patients can use emollients or moisturizers to help reduce skin dryness and aid tissue integrity.

Stress reduction—AE carries the potential for embarrassment, frustration, and depression for patients and families.¹⁰ In children with AE, emotional stressors can exacerbate pruritus, and, therefore, scratching. Psychological counseling and support, relaxation exercises, or other behavioral modification may be required.

Next: Gastrointestinal Distress