In an ideal world, a child should be considered for allergy assessment if:
- the dermatitis is severe or difficult to control
- parents report exacerbations in relation to particular foods or infant formula
- there is an urticarial component
- the distribution is on exposed areas, particularly the periocular area or other parts of the face, indicating the role of an aeroallergen such as house dust mite.
In practice, however, many unnecessary allergy tests are conducted because of parental pressure, and children are sometimes put on very restrictive diets on thin evidence. Parents may also embark on expensive measures such as pulling up carpets and removing all the curtains, only to find that these make little difference. Allergy testing may be carried out by either skin prick testing (SPT) atopic patch testing (APT) or radioallergosorbent testing (RAST). The latter is a blood test and is readily available for a wide range of allergens. Allergy testing has many pitfalls, and results need to be considered in conjunction with the clinical presentation. Not all food reactions are detectable with these tests, particularly when salicylates and other food additives are involved. Referral is strongly recommended before any major action, either dietary or environmental, is put into practice.
Generally, the prognosis of AD is good, with most children substantially improving by the time they start school and remitting by the end of primary school. A minority still suffer from the condition as teenagers, but it continues into adult life in only a few. Treatment resistance is often due to noncompliance, but infection, allergy or the onset of a new skin condition such as psoriasis should be considered.
Certain environmental situations may bring out the tendency for AD later - for example, an occupation or hobby where there is heavy aeroallergen or irritant exposure, or an outdoor sport in a patient who is allergic to grass. Certain geographical areas suit some patients better than others, no doubt related to humidity and aeroallergen levels.
Until remission occurs, parents need to maintain all environmental modification precautions and ensure treatment is given regularly. It is important in young children, and even in many teenagers, never to leave treatment up to the child. It is a bit like teeth cleaning: unless the parent nags, it often does not happen.
AD is a common paediatric presentation in primary care and GPs maintain key long-term relationships with both the child and their parent or carer. Educating parents and carers about the safety of gold standard therapy and the importance of day-to-day skin maintenance measures and environmental modifications is central to treatment success and maintaining remission. The GP’s assistance in negotiating many of the associated considerations, such as minimising the cost of treatment and suggesting simple solutions for when the child is at school, make the world of difference to the wellbeing of children with AD. MT