Treating Dermatitis in Children

The Role of Topical Corticosteroids

By Sally Peters

Terms for common pediatric skin conditions abound in the lay public. Most everyone has heard of "cradle cap" (seborrheic dermatitis), "eczema" (atopic dermatitis) and "ringworm" (of the scalp, tinea capitis). Other commonly known pediatric skin conditions include acne and warts. Conditions lesser known by the lay public can include molluscum contagiosum and alopecia areata. This article centers on two types of dermatitis particular to children that can be treated with topical steroids, atopic dermatitis and seborrheic dermatitis.

Atopic Dermatitis

Considered to be a fairly common skin disorder, atopic dermatitis affects 1 of every 10 children. The skin disorder belongs in an "allergic triad" that includes asthma, allergic rhinitis and atopic dermatitis. These conditions are related genetically, and often a child who develops atopic dermatitis has a history of asthma or hay fever. The disease usually presents in infancy or early childhood, and the majority of cases usually develop before age 6.

Atopic dermatitis has no primary lesion, and secondary characteristics can be highly individualized. This can present problems in diagnosis, and atopic dermatitis is often confused with seborrheic dermatitis in infancy. Before making a diagnosis, the nurse practitioner should see the patient several times.

Atopic dermatitis is primarily characterized by intense itching. This can pose a problem in children, who tend to scratch more frequently. Scratching can exacerbate the rash. Atopic dermatitis is also characterized by edema, papules, erythema, excoriation, serous discharge and crusting. The lesions usually appear on the head, scalp, arms and legs.

Though atopic dermatitis is considered a chronic and relapsing illness, diligence on the part of health care providers and parents can help contain the disorder to some extent. Most cases of atopic dermatitis will spontaneously regress by age 5, and a higher percentage will disappear by age 15.

Treatment of atopic dermatitis hinges on maintaining moisture balance in the skin. Most clinicians recommend a daily bath to keep the skin hydrated. After a bath, parents can apply a moisturizing occlusive to their child's skin to help prevent moisture loss. Good moisturizers include Eucerin Cream, Curel and AquaPhor ointment.

Tar solutions have fewer side effects than topical steroids, but also have a slower anti-inflammatory effect. Tar solutions may stain hair or clothing and have a relatively strong odor.

Topical corticosteroids are used to control acute cases of atopic dermatitis. Use caution when choosing the strength and vehicle. Occlusive dressings should never be used with children because their skin is thin and highly permeable.

Seborrheic dermatitis

Known as "cradle cap" in neonates (infants younger than 1 month old), seborrheic dermatitis exhibits as thick, yellow, crusting lesions that appear on the scalp. Heavy crusts often form behind the ears, and red facial papules may be present as well. Newborns may also have concomitant diaper rash.

The cause of seborrheic dermatitis is unknown, and its course waxes and wanes. Some researchers have identified a particular yeast that occurs in hair follicles (Pityrosporum ovale) as a possible cause for the disease. Older children with seborrheic dermatitis may develop thick, scaly plaques on the scalp that can measure 1 cm to 2 cm in diameter.

Seborrheic dermatitis can be treated with topical corticosteroids, but it also responds to treatment with zinc pyrithione, selenium sulfide, sulfur, salicylic acid and tar preparations. Infantile seborrheic dermatitis responds to treatment with a mild baby shampoo and hydrocortisone cream. Thick, scaling lesions on an infant's scalp can be treated by gently rubbing salicylic acid in mineral oil or corticosteroid gel onto the scalp with a soft toothbrush. The scales can then be washed away with thorough shampooing.

Topical Corticosteroids

Topical corticosteroids, when used properly, are the most effective anti-inflammatory agents available for eczematous skin conditions. Corticosteroids reduce inflammation by promoting vasoconstriction of the blood vessels in the skin. These medications can reduce the redness and itching associated with the inflammation of some disorders, though corticosteroids should not be used with skin conditions like acne, rosacea and some fungal infections.

Speaking at the National Primary Care Nurse Practitioner Symposium last summer, Noreen Heer Nicol, MS, RN, FNP, director of nursing at the National Jewish Center for Immunology and Respiratory Medicine in Denver, said that topical corticosteroids can be used to reach several objectives, including: restoring hydration, alleviating symptoms, reducing inflammation, protecting the skin, reducing scale and callus, cleansing and debriding and eradicating causative organisms.

Corticosteroids are available in several vehicles, including creams, gels, ointments, lotions, powders, aerosols and tapes. Corticosteroids also come in several strengths. Finding the right vehicle and strength is imperative for safety and efficacy.

High concentrations of corticosteroids may also be delivered through intralesional injection. This method is used most often for chronic or resistant lesions. Triamcinolone acetonide is the corticosteroid most often used for injection. Side effects can result with this delivery method, most often dermal atrophy, which is usually reversible. To decrease the risk of side effects, triamcinolone acetonide may be diluted with sterile saline and administered at concentrations of 2.5 mg/mL to 10 mg/mL.

Side effects can occur with the use of corticosteroids, especially the stronger strengths. Nicol says possible side effects include: skin atrophy, striae, increased skin fragility, hypopigmentation, secondary infection, acneform eruption, folliculitis, miliaria, hypertrichosis and, with high-potency products, systemic side effects.

Application Techniques

Clinicians count on adults with skin diseases to be responsible about applying corticosteroids at home. In young children with skin diseases, parents are likely to be responsible for applying the corticosteroids. For this reason, health care providers must review application techniques with whomever will be responsible for applying the preparation.

Most clinicians recommend that topical steroids be applied in a thin layer over the affected area. The preparations should only be applied to lesions; unaffected areas should be avoided. Creams, gels and lotions should be applied sparingly and rubbed in until no longer visible. Powders should be dusted lightly over the affected area in a thin shield.

The medications can be applied with bare hands; Nicol recommends thoroughly washing hands after application. Some patients may prefer to use thin latex gloves when applying the medication. A tongue depressor may be used to scoop medication out of a tub if the patient does not want to dip his hands in, Nicol says.

One technique used to measure the amount of medication that should be applied is "fingertip units." In this method, parents may use the child's fingertip as an indicator of how much medicine should be applied to an area. One FTU reaches from the tip of the child's index finger to the first skinfold at the joint. Each FTU weighs about .5 grams. It usually takes 30 grams of medicine to cover an adult, and when using medicine on a child, the gram amount should be determined by the child's size.

Patricia Crader, RN, who works with dermatology outpatients in a hospital and office setting at Washington University School of Medicine at St. Louis, notes that emollients can help decrease scaling and that these products can be used along with corticosteroids. Educate parents about proper bathing and the use of soaps and moisturizers, along with correct application of corticosteroids, she says.

Choosing a Strength

Topical corticosteroids are classified in groups from Group I to Group VII, with Group I being the most potent. Common products in Groups I through VII are listed here. Side effects occur most often with medicines in Groups I through V.

* Group I--clobetasol proprionate (Temovate), halobetasol proprionate (Ultravate)

* Group II--amcinonide (Cyclocort), betamethasone diproprionate (Diprosone)

* Group III--fluticasone proprionate (Cutivate), fluocinonide (Lidex)

* Group IV--triamcinolone acetonide (Kenalog), fluocinolone acetonide (Synalar)

* Group V--hydrocortisone butyrate (Locoid), hydrocortisone valerate (Westcort)

* Group VI--alclometasone diproprionate (Aclovate), desonide (DesOwen)

* Group VII--hydrocortisone acetate (Hytone).

Most clinicians agree that when therapy is begun, providers should prescribe the lowest dose effective for treatment. Nicol says the strength of the corticosteroid used may be determined by the amount of inflammation, the location of the dermatitis and the depth of the lesions. Different strengths may be used on different body areas, since skin on some parts of the body is thinner than others.

Nicol notes the importance of referral in choosing and using topical steroids. Clinicians unfamiliar with the medications should immediately refer. In addition, NPs should refer if the medications don't improve a patient's conditon. Clinicians who are well-versed in corticosteroids and their side effects should start by using a reasonable strength topical steroid from groups IV through VII. If the lesions do not respond to the treatment, the nurse practitioner should refer. In the meantime, the nurse practitioner may continue to treat the patient's skin disease for a short time with small amounts of corticosteroids, Nicol says.

Hydrocortisone cream, considered the mildest of the topical steroids, is available over-the-counter under brand names like Hytone and Cortaid in strengths of .5% to 1%. Nicol says these hydrocortisone creams can be very effective, though researchers found in a study that desonide ointment, a well-known class VI steroid available by prescription, was more efficacious and produced more rapid improvement than hydrocortisone 1% in a 6-month study (Jorizzo Joseph et al. Multicenter trial for long-term safety and efficacy comparison of 0.05% desonide and 1% hydrocortisone ointments in the treatment of atopic dermatitis in pediatric patients. J Am Acad Dermatol. 1995;33:74-7).

Choosing a 'Vehicle'

The term vehicle refers to the preparation type. NPs should choose a vehicle based on the location and severity of the lesions. Choosing the right vehicle is as important as choosing the right strength.

Ointments are the most occlusive of the corticosteroid vehicles. Ointments and creams are usually the easiest vehicles to use on children. Ointments tend to be greasy and are better for use on dry skin. Creams are often less greasy than ointments, but can sting.

Gels, which usually contain alcohol, can be drying and are good for use in oily areas like the scalp and for weeping lesions. Lotions and aerosols are also good for use on the scalp. Medicated tape is best used on small areas of the body. *