Cost can also become a factor, as many of the required treatments, particularly emollients and bath oils, are not listed on the PBS. In addition, many parents are confused by conflicting information on the safety of treatments, particularly corticosteroids, and almost paralysed by the fear of long-term effects of treating their children.
The management of children with AD is not simple, particularly in severe cases. The following factors need to be considered:
- compliance and counselling
- environmental modification
- control of skin dryness
- medical management of the dermatitis
- control of infection
- management of the dermatitis plus psoriasis combination
- in some cases, investigation and management of allergy.
Compliance and counselling
It cannot be stressed too strongly that AD is a chronic genetic condition. The patient’s parents or carers must understand the need for both continuous suppressive therapy at times of activity and ongoing preventive environmental modification in times of remission (see Practice Points and the Parent and Carer Handout). Further, they must understand that AD is rarely entirely caused by allergy and that management of allergy alone rarely delivers good outcomes. Treatment often fails because therapy is ceased as soon as the dermatitis clears, in the belief that a ‘cure’ has been achieved. When the inevitable relapse occurs, parents may then believe that treatment has been a failure and subsequently abandon further therapy.
Treatment also often fails because parents are apprehensive about using topical corticosteroids. Parents need to be reassured that, when used correctly, topical corticosteroids have an excellent safety record. An Australian study has demonstrated that appropriate use of topical corticosteroids in mild to moderate eczema can maintain an EASI score of 0, without side effects.4 To encourage compliance, parents need education about the nature of AD, that it tends to become less severe with each passing year, the safety of the medication and the relative unimportance of allergy in aetiology and management.
It is often little things that make a big difference, such as:
- devising a simple regimen that fits in with the family lifestyle
- minimising cost with the use of authority prescriptions
- providing clear written instructions
- recommending that the parents talk to the child’s teachers about dust, sand and grass exposure at school. Small children are often expected to sit on the bare floor during school hours and are exposed to grass during sport and recess.