Eczema

Eczema is a skin condition characterised by excessive dryness and itching.  The condition often flares-up, resulting in the appearance of red, scaly, bumpy, rough patches on the body.  It is common to see eczema in children who have allergies, hay fever, asthma or close family members with eczema.  The majority of children will outgrow the condition over time but until they do, their skin will require extra care daily and additional treatment when flare-ups occur.

Caring for a child with eczema

Keep the skin moist :  Since the skin of children with eczema is unusually dry, one of the most important things for you to do is to keep the skin well moisturised.  This will help to prevent flare-ups of the condition.  Twice daily, lotion such as  E45, Eucerin, Keri, Nivea or Vaseline, needs to be applied to the skin (even when the rash is not present!).  Applying lotion after a bath is helpful.  Pat the skin dry, then apply the lotion to the child’s entire body sealing in water the skin absorbed during the bath.

The whole principle of treating eczema is to avoid substances that break down the natural barrier layer - soaps, detergents, shampoos, and use substances that build it up - oils, moisturisers and barrier creams.

Some agents may cause senstitivity, and these should be avoided if possible

·        Fabric softners

·        Washing Powders – use high temperature wash and long rinse cycle, minimum amounts of non biological detergent

·        House dust mite – ensure bedroom as house dust mite free as possible, covers for pillow, duvet and mattress

·        Staphlaureus – a bacteria that commonly colonises broken skin.

 Tacrolimus (attached to Tacrolimus macrolide web page) 0.03% is a highly effective safe substitute and does not have the skin thinning and potential growth suppression effects of Hydrocortisone. It can safely be used on the face

Bathing : A bath or shower with lukewarm water will soothe the skin.  Many soaps irritate the skin of a child with eczema. If you need to use soap to cleanse the skin use minimal amounts and choose one that is super-fatted such a Dove. It may be better to use a bath oil substitute (Oilatium or Balneum) instead of soap.

Itching : Scratching further irritates eczema, causing the rash to become more severe.  Also, scratching opens the skin which can make infection more likely to occur.  Keep the child’s fingernails cut short.  It may be helpful to put cotton mitts or socks on the hands of infants at bedtime to prevent scratching.  Almost all children complain about itching more at nighttime, some children will have difficulty sleeping because of itching.  Keeping skin moist with lotion will help but there may be times when an antihistamine (anti-itch) medication such as Piriton (Chlorphenamine), is needed to give the child relief.  It can be given every six hours to relieve itching. 

The most common side effect of Piriton (Chlorphenamine) is drowsiness.  If your child seems to be too drowsy while taking the Piriton (Chlorphenamine), then cut back slightly on the dose.

Flare-ups : When the skin develops a rash as described in the first paragraph, consult your doctor.  A steroid cream may need to be applied to the rash to reduce inflammation.  Hydrocortisone cream 1% is most commonly used and is available without a prescription.  Hydrocortisone cream is a steroid cream.  This type of medicated cream should be applied to the skin sparingly, it does not need to be lathered on to be effective. In fact, overuse of steroid creams can cause serious problems.  The steroid cream is usually applied to the rash twice per day.  Do not use a steroid cream for longer than one week on the face or in the genital area, unless directed by your doctor. 

Continue to apply the moisturiser (E45, Eucerin etc) to the skin twice daily by alternating it with the steroid cream.  If the rash is not improving, contact your doctor to have the child re-evaluated.  Stronger steroid creams may need to be prescribed, but it is wise to start with the least potent medication first.

Call your doctor if :

.           Signs of skin infection appear: increasing redness, swelling, tenderness, pus

            drainage, red streaks on the skin, fever in association with these other signs.

.           The rash becomes worse, changes in its appearance or if new symptoms

            develop along with the rash.

.           If there is no improvement after one week of treatment.

Tuberculosis

Tuberculosis

Tuberculosis (TB) is a contagious infection, usually attacking the lungs although it can spread to other body organs (Miliary TB) and  is caused by mycobacteria (usually Mycobacterium tuberculosis).  Like many other illnesses it is passed from person to person through airborne droplets from coughs, but also in the mucus that the affected person may cough up (this may be bloodstained).  Children usually catch TB from another household member.  Less often outbreaks can occur in school or nursery.

Tuberculosis is common and a third of the world’s population suffer from it.  It has increased significantly in developing countries over the last eight years.  Someone with TB may not have any symptoms because the body’s immune defences can wall-off the bacteria.  However the bacteria are not completely killed and if anything happens to lower the body’s immune defences such as malnutrition, a severe illness, or a course of oral steroids, then infection can reactivate and TB infection can spread through the body.  The lungs are usually affected but in the later stages, bacteria can spread through the blood to the lymph nodes, brain and joints.

What to look for

Although extensive lung infection in TB can occur without any symptoms, of all the age groups, infants are most likely to show signs of illness with difficulty breathing, dry cough, fever, poor appetite and night sweats.  There may also be failure to thrive.  Older children may wheeze, have an abnormally fast breathing rate, lose weight or feel tired or short of breath.  

A child’s TB infection may be first discovered by a skin test (tuberculin, Mantoux, Heaf).  Countries such as America where BCG (immunisation against TB) is not performed, then the tuberculin test is done at a month, at 5 and at 14 years of age.  If at any time this test is positive, then the child should be assumed to have come in contact with TB and a six month course of anti-tuberculosis therapy should be given.

In countries where the BCG is given routinely, then this should produce a positive skin test (this will usually be 2-4mms).  If the skin test is strongly positive causing an area of induration and redness greater than 1cm, then BCG vaccinated children should be considered to have been infected and should receive a course of treatment.  At the same time as the course is given, a chest-x ray will be taken to look for evidence of TB. Other family members will also be tested and if found to be positive, will need to be treated with anti-tuberculosis medicine.

Call your doctor if

Any family member has been found to have a positive anti-tuberculin test or diagnosed as having TB.  Likewise if your child has wheezing, fever, night sweats, poor appetite or shortness of breath or has, for a long time, felt weak or tired.  Likewise if your child is failing to put on weight, this should be another reason to get your child checked over.

Immunisation

Under the age of 3 months the BCG – intradernal injection of live attenuated TB bacteria can be given without skin testing - after 3 months need to do a Mantoux skin test and return after 48 hours.

July 2011 News Letter

Dr Richard Primavesi

117a Harley Street

London

W1G 6AT

02072244668

There are 2 new important additions to the service I already offer to you.

1 Medical assessment of parents.

As you know I have been providing informal advice about medical conditions and giving immunizations to parents for many years now.

Due to many requests I have decided to formalize this as follows.

I am now happy to see parents who wish general medical advice on the same terms as I see their children.

Just as with your children in the case of yourselves I am able to make speedy referral to the appropriate adult physician if I do not feel able to give suitably informed advice or treatment.

As always the prime concern if your safety.

Out of hour’s service:

Again I have provided this service informally for the families I look after for many years.

From Sept 1^st 2011 I propose to make this more formal.

I will be contactable via the usual number ( 02072244668) for families wishing to use this service. My PA Kelly Anyogu will answer your call.

Due to being based at two sites – London Mon- Wed, Hampshire Thurs –Sun. I cannot guarantee to make a visit to your house if this is felt to be necessary but I can arrange for patients to be seen at 117A Harley St during all the week and at The Children’s Clinic, Hampshire Thurs – Sun.

Following the telephone consultation one of 3 decisions will be reached:

A No further action required.

B No further action required overnight, but to be seen first thing the following morning in clinic. (08:30 appointment kept free for emergency visits.

C To be seen in clinic that day before 9pm

D  Urgent assessment required in hospital. I will arrange for this process to be as smooth as possible by contacting the on call registrar in the hospital.

The cost of this service will be as follows:

£85:00 per telephone or text consultation.