Multi-pronged strategy controls recalcitrant dermatitis in children

Key Points

New Orleans - Dermatitis in children can be challenging to treat, particularly when commonly used treatment regimens fail. According to one expert, a multi-pronged treatment strategy is the best approach to help clear symptoms and control disease.

"Choosing an appropriate treatment strategy very much depends on the type of dermatitis you are dealing with and the cause of the disease," says Moise L. Levy, M.D., chief of pediatric dermatology, Dell Children's Medical Center, Austin, Texas; clinical professor of dermatology and pediatrics, Baylor College of Medicine, Houston; and clinical professor of dermatology, UT-Southwestern Medical School, Dallas.

Dr. Levy spoke about recalcitrant dermatitis in children at the 69th annual meeting of the American Academy of Dermatology in February. "However, first and foremost, therapies must be directed at providing an adequate barrier to minimize fluid loss, temperature loss and the risk of infection, particularly in younger patients."

Most cases of dermatitis in infants and younger children will usually be atopic dermatitis/eczema, Dr. Levy says. Here, early onset of a pruritic inflammatory eruption or rash in a typical distribution in an otherwise-healthy child will be indicative of the diagnosis.

Other forms of dermatitis can include seborrheic dermatitis, but the distribution here can be different and may frequently involve the diaper and scalp areas, more so than in the eczema or atopic dermatitis patient.

Location of symptoms is not the only parameter than can help the clinician arrive at the correct diagnosis. Dermatologists must try to assess concern (or lack thereof) for either immune or metabolic problems. They may even perform a skin biopsy in order to help confirm or disprove a suspected diagnosis.

Laboratory tests can be useful as well, including a routine blood count, metabolic profile (liver function), nutritional status (such as albumin) and immunoglobulins.

According to Dr. Levy, these diagnostic parameters can prove very helpful in identifying the correct diagnosis, as well as uncovering a potential immune problem or other inherited condition, such as a form of one of the congenital ichthyoses or even Netherton syndrome.

Depending on these diagnostic evaluations, the clinician may need to refer the patient for more specific genetic or immune testing.

"In an otherwise-healthy child, the clinician should be wary if the child is not responding to standard therapies prescribed for the suspected diagnosis or if the patient is not thriving," Dr. Levy says. "Here, lack of compliance or unusual infections could be considered in the differential diagnosis. Also, the clinician might also consider that perhaps a 'routine' skin disease may not be the accurate diagnosis."

According to Dr. Levy, therapeutic strategies will usually be directed at repairing the skin barrier, managing any inflammatory component seen in the patient with either a topical corticosteroid or calcineurin inhibitor and managing infection with topical or systemic agents.

Therapy may also include managing more complex issues such as potential metabolic or immune disease. Medications for these conditions can and should be prescribed and applied in parallel with all of the diagnostic measures and tests the patient is undergoing.

Other considerations

Should tried therapies not appear to work, the clinician may also suspect a lack of compliance to treatment protocol. According to Dr. Levy, many clinicians assume that parents or guardians will apply therapy appropriately in patients, but this may not always be the case.

Additionally, patients with chronic skin conditions may develop a true allergy or contact dermatitis to one of the products used for routine maintenance of the disease, which could additionally be considered as a reason for failed therapy.

"After standard therapeutic approaches to routine disease do not appear to work, the clinician should try to think more broadly, as there could be several factors that can impact treatment failure," Dr. Levy says.

Disclosures: Dr. Levy reports no relevant financial interests.