Paediatric Dermatology for GPs – Key Questions Answered
Did you attend our virtual event covering Women’s Health, Dermatology and Long Term Conditions from 21 – 23 November 2023? Dr Sue Ann Chan answers some of the key questions about Paediatric Dermatology for GPs that we didn’t have time to answer on the day.
Paediatric Dermatology for GPs – Key Questions Answered
What would you use between 1 month- 2 years old children with eczema?
Usually topical steroids – HC 1-2.5% , Eumovate, Timodine. I rarely use immunomodulators in infants / toddlers.
Can Tacrolimus 0.1% be used around the eyes of adults?
Yes. Its designed for facial, periorbital use as it doesn’t cause atrophy.
Can tacrolimus be prescribed by GPs or is it a secondary care only drug?
GPs can prescribe the medications. If unsure, we are happy to guide (consider A+G).
Protopic and Elidel in Dorset are Amber drugs which are usually started by consultants. Do you recommend GPs starting them in primary care?
You can. However, if unsure and would like to discuss, A+G is a good portal for discussion and clinical images.
We used ScratchSleeves for my son 15 years ago and the company were so helpful. He wore it until he was 3 years old and it really helped us as parents to get a break from the scratching (it has silk on the hand part). They also have clothing products for night time (toe scratching).
Thank you for the kind comment. Great tip I will share with patients too.
Please advise regarding application of emollients and topical steroids – Which one should go first?
It’s up to the parent. I always advise steroids first then emollient. Some of my colleagues would advise opposite.
What should we tell parents about side-effects of topical immunomodulators short and long term. How long should they be used for and what duration of break is required before reusing or switching to topical steroids?
I would usually advise them to use it twice a day initially once the superficial infection has settled (e.g. bacterial or viral infections over patches of eczema). When the dose is dropped to once a day, I would recommend keeping the night dose. Sun protection is important when using protopic. I would not recommend using protopic elsewhere apart from face and neck areas.
Can vitamins be absorbed topically?
Yes – vitamin A is a good example. Vitamin C topical has also been proven to be effective for anti-ageing purposes and improves pigmentation as well.
Would you recommend doublebase once a day gel for school age children where compliance might be an issue?
If compliance is an issue, I would probably recommend something thicker. Doublebase comes in a gel formula so it’s slightly lighter.
An infant who is dribbling is getting a recurrent rash just over and under the chin and need steroid cream every couple of weeks. The mum is concerned that the skin over the chin is getting transparent and possibly thinning, what would you advise them?
Unfortunately this is indeed a very common issue we see in paediatric clinics. I rarely prescribe steroid sparing ointment for infants (too young). Consider daktakort ointment when needed and using practical measures e.g. regular bib changes and Vaseline ointment around the mouth as barrier ointment.
Are the therapeutic garments on NHS prescription?
It used to be, now I think it depends on the practice (I am not sure) – was hoping to have a discussion about this too.
Do you have any brief advice on steroid withdrawal condition/syndrome?
It has become a very popular ideology amongst patients (Professor Moss has written an article about it). For older adults, I tend to consider systemic therapy earlier (depending on the extent of disease as well).
You can only get hand foot and mouth once right?
I have seen children getting HFM and also chicken pox more than once / twice.
Is there a role of allergy testing for children with eczema?
Yes – if you think there is a systemic element to it – diarrhoea, not putting on weight, dropping centiles, type 1 allergy symptoms e.g. angioedema, swollen lips / eyes; persistent history provided by parents, then a food diary is important.
What is the advice for allergy testing in general practice? RAST testing? I often advise a dietary exclusion but they often want a referral?
Eczema caused by food allergy is often non responsive to even very potent topical steroids (just like a bad drug eruption; would only stop once the drug is being stopped). RAST can be done but can often confuse patients and clinicians, especially if results are inconclusive. Consider immunology referral.
Eczema coxsackium – should we refer for admission to paediatrics as it is for eczema herpeticum?
Yes. If the paediatrics team require dermatology input, they would normally ring us. We have lost all admitting rights.
Comments on foods as triggers to troublesome eczema
Similar to the question above. I would suggest a food diary and if the eczema does not respond to topical steroids and remains persistent, refer to dermatology / immunology.
What to give children with flaky scalp / scalp which looks like seb derm as ketoconazole unlicensed under 12 yrs old. Or do we give Ketoconazole off license?
Consider dermax shampoo daily, or capasal shampoo 3x/week. Any shampoo prescribed, would be important to explain how to use – massage into scalp, leave on scalp for 10 min prior washing off – that is 3 Christmas songs.
How should we use ketoconazole shampoo?
As above – if used correctly 3x/week it can be effective. If the child has active tinea capitis, daily use is good.
With terbinafine oral do you need to check LFT?
For me, if the child has underlying long term medical conditions, yes would normally check OR if the child takes other regular medications. If the child requires more than one course I would also check. Otherwise, I don’t check it regularly. The scoring here is similar to Neurofibromatosis.
Please can we know what the plan was for the last case?
Yes the baby has a large facial haemangioma. She was discussed in the paediatrics vascular MDT and has commenced on oral propranolol. Full investigation for associated syndromes performed. Also under paediatrics now at BCH.
Do you have any brief advice on steroid withdrawal condition/syndrome?
This syndrome is rarely seen in children themselves. However, the parents can often have this ideation and can often influence the child. It has to be reviewed case by case. E.g. if the child is >12 years old and has really extensive AD, I would have a lower threshold to offer a systemic therapy – would always work with patient and parents for joint decision making.
Lots of parents ask for ‘Allergy testing’ for dermatitis. Just to clarify, what is the purpose of Patch testing i.e. how will it alter management of the dermatitis?
If the child is allergic to an ingredient in the cream / ointment for example, we can avoid the offending allergen and the child improves dramatically. Commonly – nickel, latex, Methylisothializone (MI) etc.