Pediatric Disorders of Eye, Ear, and Skin
Comprehensive Nursing Notes
Welcome to these comprehensive nursing notes focused on common pediatric disorders of the eye, ear, and skin. These notes are designed to help nursing students understand the pathophysiology, clinical manifestations, nursing assessment, and management of refractory errors, otitis media, and atopic dermatitis in the pediatric population.
Table of Contents
I. Refractory Errors
II. Otitis Media
I. Refractory Errors in Children
Refractory errors are the most common eye disorders in children, affecting how light is focused on the retina. Early detection and correction are crucial as untreated refractory errors can lead to amblyopia (lazy eye) and permanent vision impairment.
Did you know?
Approximately 20% of school-aged children have refractory errors that require correction. Early detection and intervention are critical for preventing long-term vision problems.
Types of Refractory Errors
| Refractory Error | Description | Clinical Features | Correction Options |
|---|---|---|---|
| Myopia (Nearsightedness) |
Light focuses in front of the retina due to elongated eyeball or steep corneal curvature |
• Clear vision for near objects • Blurry vision for distant objects • Squinting to see better • Headaches after visual tasks |
• Concave (minus) lenses • Contact lenses • Refractive surgery (for older children) |
| Hyperopia (Farsightedness) |
Light focuses behind the retina due to shortened eyeball or flat corneal curvature |
• Better vision for distant objects • Blurry vision for near objects • Eye strain and fatigue • Accommodative esotropia (eye turning inward) |
• Convex (plus) lenses • Contact lenses • Refractive surgery (for older children) |
| Astigmatism | Uneven curvature of cornea or lens causing light to focus at multiple points |
• Distorted or blurry vision at all distances • Headaches and eye strain • Difficulty focusing on fine details |
• Cylindrical lenses • Toric contact lenses • Refractive surgery (for older children) |
| Anisometropia | Significant difference in refractive error between the two eyes |
• High risk for amblyopia • Poor depth perception • May have symptoms of underlying refractive error |
• Different prescription lenses for each eye • Patching of stronger eye • Visual therapy |
Pathophysiology
Refractory errors occur when the eye’s shape prevents light from focusing directly on the retina. The pathophysiology varies based on the specific type of refractory error:
- Myopia: Usually results from an elongated eyeball or excessive corneal curvature. Genetic factors play a significant role, but environmental factors like extensive near work and limited outdoor time are increasingly recognized as contributors.
- Hyperopia: Typically results from a shortened eyeball or insufficient corneal curvature. Most infants are born with physiologic hyperopia that decreases with age as the eyeball grows.
- Astigmatism: Caused by irregular curvature of the cornea or lens, resulting in light focusing at multiple points. Can be congenital or acquired.
Key Developmental Consideration:
The pediatric eye continues to develop and grow until approximately age 8-10. This creates a critical period during which visual development can be affected by uncorrected refractory errors, potentially leading to amblyopia.
Clinical Manifestations
Children with refractory errors may not always complain about vision problems, making it important for healthcare providers and parents to recognize subtle signs:
Behavioral Signs
- Sitting close to television or holding books very close
- Squinting or closing one eye to see better
- Rubbing eyes frequently
- Tilting head or covering one eye when reading
- Poor school performance or difficulty concentrating
- Avoiding reading or close visual activities
Physical Symptoms
- Complaints of blurry vision
- Frequent headaches, especially after reading
- Eye strain or fatigue
- Dizziness or nausea after close visual work
- Excessive blinking or eye rubbing
- Eye misalignment (strabismus)
Age-specific manifestations are important to consider:
| Age Group | Common Presentations |
|---|---|
| Infants (0-1 year) |
• Difficulty tracking objects • Poor visual attention • Abnormal eye alignment |
| Toddlers (1-3 years) |
• Clumsiness or poor coordination • Difficulty with visual recognition of objects • Eye misalignment |
| Preschoolers (3-5 years) |
• Sitting too close to screens • Difficulty with shape/color recognition • Poor attention span for visual activities |
| School-age (6+ years) |
• Academic difficulties • Complaints of blurry vision • Headaches after visual tasks • Difficulty seeing whiteboard |
Nursing Assessment
A comprehensive assessment is essential for identifying refractory errors in children:
Health History
- Family history: Refractory errors often have a genetic component
- Birth history: Prematurity increases risk for myopia and other eye disorders
- Developmental milestones: Vision problems may affect developmental progression
- Academic performance: Vision problems often manifest as academic difficulties
- Screen time habits: Excessive near work may contribute to myopia progression
Physical Assessment
- Visual acuity testing: Age-appropriate methods such as:
- LEA symbols for preschoolers
- HOTV or Snellen chart for school-age children
- Alignment assessment: Hirschberg corneal reflex test and cover tests
- Ocular movements: Assess the six cardinal positions of gaze
- External eye examination: Check for structural abnormalities
Mnemonic: “VISION”
Key components of pediatric vision assessment:
- Visual acuity testing (age-appropriate)
- Inspect external structures
- Screen for eye alignment
- Inquire about symptoms
- Observe eye movements
- Note behavioral signs
Diagnostic Tests
Diagnosis of refractory errors involves several specialized tests:
| Diagnostic Test | Description | Nursing Considerations |
|---|---|---|
| Visual Acuity Testing |
• Tests the ability to see at various distances • Uses age-appropriate charts (LEA, HOTV, Snellen) |
• Ensure proper lighting • Test each eye separately • Document results for comparison |
| Retinoscopy |
• Objective measurement of refractive error • Uses light reflex to determine lens prescription |
• May require pupil dilation • Explain procedure to reduce anxiety • No special preparation needed |
| Photoscreening |
• Quick screening method using special camera • Detects refractive errors, strabismus, and media opacities |
• Good for young children (6 months+) • No need for verbal response • Useful for mass screenings |
| Cycloplegic Refraction |
• Uses eye drops to temporarily paralyze accommodation • Provides most accurate measurement of refractive error |
• Warn about temporary blurry vision and light sensitivity • Effects may last 24-48 hours • Sunglasses recommended after procedure |
Management
Management of refractory errors focuses on correcting vision and preventing complications:
Optical Correction
- Eyeglasses: First-line treatment for most children
- Plastic frames recommended for younger children
- Impact-resistant lenses for safety
- Consider elastic strap for infants/toddlers
- Contact lenses: Option for older children/teens
- Consider maturity and hygiene practices
- Daily disposables may be safest option
- Special considerations for sports
Additional Interventions
- Patching therapy: For amblyopia
- Patch stronger eye to strengthen weaker eye
- Duration based on severity and age
- Vision therapy: Eye exercises
- Improves visual skills and processing
- Usually performed by optometrist
- Myopia control strategies:
- Atropine eye drops (low-dose)
- Specialized contact lenses
- Increased outdoor time (protective effect)
Evidence-Based Practice:
Recent research has shown that increasing outdoor time to at least 1-2 hours daily may help prevent or slow myopia progression in children. This should be incorporated into patient education for all children, especially those at risk for myopia.
Nursing Care
Nursing care for children with refractory errors focuses on assessment, education, and support:
Nursing Interventions
- Screening: Participate in vision screening programs in schools and community settings
- Education: Teach proper care and cleaning of eyeglasses/contact lenses
- Compliance: Strategize with parents to promote consistent use of corrective lenses
- Follow-up: Emphasize importance of regular eye examinations
- Prevention: Counsel about vision-protective behaviors (outdoor time, breaks from screens)
Special Considerations
- Age-appropriate care: Adapt interventions based on child’s developmental stage
- School coordination: Collaborate with teachers to ensure child can see instructional materials
- Sports participation: Advise about protective eyewear and special considerations for activities
- Psychosocial support: Address potential teasing or self-esteem issues related to wearing glasses
Patient and Family Education
Education Checklist for Refractory Errors
- Explanation of condition: Use age-appropriate terms and visual aids
- Care of corrective devices: Proper cleaning, storage, and handling of glasses/contacts
- Signs of vision changes: When to seek reevaluation (headaches, squinting, etc.)
- Eye protection: Importance of protective eyewear for sports and hazardous activities
- Follow-up schedule: Typical recommendation is annual exams or as directed by specialist
- Preventive measures: Balanced screen time, outdoor activities, proper lighting for reading
Mnemonic: “CLEAR”
Patient education topics for refractory errors:
- Care of visual aids (glasses, contacts)
- Lighting for reading and close work
- Eye protection during activities
- Appointments for regular follow-up
- Rest periods for eyes during screen time
II. Otitis Media in Children
Otitis media is one of the most common childhood infections and a leading cause of healthcare visits and antibiotic prescriptions in the pediatric population. It refers to inflammation of the middle ear, which can occur with or without infection.
Did you know?
More than 80% of children will have experienced at least one episode of otitis media by their third birthday, with the peak incidence occurring between 6-18 months of age.
Types of Otitis Media
| Type | Description | Clinical Features | Management Approach |
|---|---|---|---|
| Acute Otitis Media (AOM) | Rapid onset of middle ear inflammation with signs and symptoms of infection |
• Ear pain (otalgia) • Fever • Irritability • Bulging, erythematous tympanic membrane • Otorrhea (ear drainage) if tympanic membrane ruptures |
• Antibiotics (based on age and severity) • Pain management • Observation-only approach in some cases |
| Otitis Media with Effusion (OME) | Fluid in the middle ear without signs or symptoms of acute infection |
• Often asymptomatic • Hearing loss (typically mild) • Feeling of ear fullness • Amber or blue-gray tympanic membrane • Air-fluid level or bubbles visible behind eardrum |
• Watchful waiting (most resolve spontaneously) • Management of underlying causes • Tympanostomy tubes for persistent cases |
| Chronic Otitis Media | Persistent inflammation of the middle ear lasting >3 months |
• Persistent or recurrent ear drainage • Hearing loss (may be conductive or sensorineural) • Tympanic membrane perforation • Potential for cholesteatoma formation |
• Antimicrobial therapy (topical or systemic) • Surgical intervention • Regular audiology monitoring |
| Recurrent Otitis Media | ≥3 episodes of AOM in 6 months or ≥4 episodes in 12 months |
• Repeated episodes of acute symptoms • Potential for persistent hearing loss • Impact on speech development if prolonged |
• Prophylactic antibiotics (limited cases) • Tympanostomy tubes • Address risk factors |
Pathophysiology
The pathophysiology of otitis media stems from several interconnected factors unique to pediatric anatomy and physiology:
Key Anatomic and Physiologic Factors
- Eustachian tube dysfunction: The primary factor in otitis media development
- In children, the eustachian tube is:
- Shorter (facilitates pathogen movement)
- More horizontal (impairs drainage)
- Less rigid (collapses more easily)
- Dysfunction leads to negative middle ear pressure, fluid accumulation, and impaired clearance of pathogens
- In children, the eustachian tube is:
- Immune system factors: Immature immune function in young children
- Respiratory infections: Often precede otitis media, causing eustachian tube swelling
- Bacterial colonization: Common pathogens include:
- Streptococcus pneumoniae (30-35%)
- Haemophilus influenzae (20-25%)
- Moraxella catarrhalis (10-15%)
- Viruses (respiratory syncytial virus, rhinovirus, etc.)
Pathophysiologic Sequence:
- Eustachian tube dysfunction (from URI, allergy, etc.)
- Negative pressure develops in middle ear
- Fluid accumulation (transudate)
- Bacterial colonization of fluid
- Inflammatory response
- Symptoms develop (pain, fever, etc.)
Clinical Manifestations
Clinical presentation varies by age, type of otitis media, and individual factors:
Infants and Young Toddlers
- Nonspecific symptoms:
- Irritability and crying
- Sleep disturbances
- Feeding difficulties
- Pulling or rubbing ears
- Systemic symptoms:
- Fever (may be high)
- Vomiting or diarrhea
- Observable signs:
- Otorrhea if tympanic membrane ruptured
- Decreased response to sounds
Older Children
- Localized symptoms:
- Ear pain (can verbalize)
- Feeling of fullness in ear
- Hearing difficulty
- Popping sensation
- Systemic symptoms:
- Fever (often lower than in infants)
- Headache
- Decreased appetite
- Behavioral changes:
- Inattention or difficulty concentrating
- Asking for repetition during conversation
- Turning TV/device volume higher
Warning Signs Requiring Immediate Attention:
- Severe pain unrelieved by analgesics
- Persistent high fever (>39°C or 102.2°F)
- Persistent vomiting or lethargy
- Swelling, redness, or tenderness behind the ear (mastoiditis)
- Facial weakness or asymmetry (facial nerve involvement)
- Severe headache with neck stiffness (meningeal involvement)
Nursing Assessment
A thorough nursing assessment is crucial for accurate diagnosis and appropriate management:
Health History
- Current symptoms: Onset, duration, severity, and associated symptoms
- Recent illness: Especially upper respiratory infections
- Past ear infections: Frequency, treatments, complications
- Risk factors:
- Daycare attendance
- Exposure to tobacco smoke
- Bottle feeding while supine
- Pacifier use
- Seasonal allergies
- Family history of ear infections
- Developmental history: Speech, language, and hearing milestones
Physical Assessment
- Vital signs: Temperature, heart rate, respiratory rate
- General appearance: Level of distress, activity, hydration status
- Ear examination:
- External ear: Assess for redness, swelling, discharge
- Otoscopic examination (provider):
- Position: Pull pinna down and back for infants, up and back for older children
- Tympanic membrane: Color, position, mobility, landmarks, perforation
- Associated systems:
- Respiratory: Nasal congestion, discharge, throat examination
- Lymphatic: Cervical lymphadenopathy
- Neurological: Assess for signs of complications
Mnemonic: “EARACHE”
Key elements of otitis media assessment:
- Examine tympanic membrane for redness and bulging
- Assess pain level and characteristics
- Recent upper respiratory infection or allergies
- Aural discharge (presence and characteristics)
- Check temperature (fever often present)
- Hearing changes (difficulty hearing)
- Evaluate risk factors and prior episodes
Diagnostic Tests
Diagnosis of otitis media primarily relies on clinical findings, but several diagnostic tools can assist:
| Diagnostic Test | Description | Nursing Considerations |
|---|---|---|
| Otoscopy |
• Primary diagnostic tool • Examines tympanic membrane for:
|
• Help position and comfort child • Ensure proper light source • May require gentle restraint • Remove cerumen if obstructing view |
| Pneumatic Otoscopy |
• Otoscope with bulb attachment • Creates air pressure to assess tympanic membrane mobility • Decreased mobility indicates fluid in middle ear |
• Explain puff sensation to older children • Monitor discomfort during procedure • Proper seal needed for accurate assessment |
| Tympanometry |
• Measures tympanic membrane compliance • Helps detect middle ear effusion • Types:
|
• Requires cooperation (difficult in young children) • Proper ear canal seal necessary • Results affected by crying, movement |
| Audiometry |
• Evaluates hearing loss • Types:
|
• Age-appropriate testing method • Quiet environment needed • May require referral to audiologist |
Note: Laboratory tests (culture of ear discharge) are typically only performed in cases of treatment failure, immunocompromised patients, or complications.
Management
Management of otitis media follows evidence-based guidelines that consider child’s age, symptom severity, and type of otitis media:
Pharmacological Management
- Antibiotics: Not always indicated
- Immediate antibiotics for:
- Severe symptoms
- Children <6 months
- Children 6-23 months with bilateral AOM
- Tympanic membrane perforation
- Common antibiotics:
- First-line: Amoxicillin (40-90 mg/kg/day)
- Alternative: Amoxicillin-clavulanate, cefuroxime, ceftriaxone
- Typical duration: 5-10 days (age-dependent)
- Immediate antibiotics for:
- Pain management:
- Acetaminophen (10-15 mg/kg)
- Ibuprofen (5-10 mg/kg)
- Topical analgesics (benzocaine drops)
- Decongestants/antihistamines: Generally NOT recommended
Non-Pharmacological & Surgical Management
- Watchful waiting:
- Option for mild-moderate AOM in children ≥24 months
- Most OME resolves spontaneously within 3 months
- Requires reliable follow-up plan
- Warm compresses: For pain relief
- Elevation of head: May help with drainage
- Surgical interventions:
- Tympanostomy tubes: For recurrent AOM or persistent OME
- Indications: ≥3 AOM episodes in 6 months or OME >3 months with hearing loss
- Ventilates middle ear, prevents fluid accumulation
- Adenoidectomy: May be considered for recurrent or chronic otitis media
- Tympanostomy tubes: For recurrent AOM or persistent OME
Evidence-Based Practice:
The American Academy of Pediatrics recommends “watchful waiting” as an option for selected children with non-severe AOM, using a safety-net antibiotic prescription approach where parents fill the prescription only if symptoms worsen or don’t improve within 48-72 hours.
Nursing Care
Nursing care for children with otitis media focuses on symptom management, education, and prevention:
Nursing Interventions
- Pain management:
- Administer or teach administration of analgesics
- Apply warm compress to affected ear
- Position child with affected ear up when lying down
- Medication administration:
- Teach proper antibiotic administration
- Emphasize completion of full course
- Educate about potential side effects
- Monitoring:
- Fever and pain response to interventions
- Signs of complications
- Hearing changes
- Assessment for complications:
- Mastoiditis: Pain/swelling behind ear, protrusion of pinna
- Meningitis: Severe headache, neck stiffness, altered mental status
- Facial nerve paralysis: Facial asymmetry, inability to close eye
Patient and Family Education
Education Checklist for Otitis Media
- Disease process: Explain the condition in simple terms
- Medication administration:
- Proper dosing and timing
- Importance of completing full course of antibiotics
- Storage requirements (refrigeration if needed)
- Signs requiring medical attention:
- Persistent fever >48 hours after starting antibiotics
- Increased pain or drainage from ear
- Swelling behind ear or facial asymmetry
- Changes in balance or severe headache
- Prevention strategies:
- Breastfeeding when possible
- Avoid bottle feeding in supine position
- Eliminate tobacco smoke exposure
- Proper hand hygiene
- Vaccination (pneumococcal, influenza)
- Follow-up care: Importance of completing follow-up visits
Mnemonic: “PREVENT”
Prevention strategies for otitis media:
- Position upright for feeding
- Reduce exposure to tobacco smoke
- Encourage breastfeeding
- Vaccination (pneumococcal, influenza)
- Eliminate pacifier use after 6 months
- Nose and hand hygiene
- Treat allergies and URIs promptly
III. Atopic Dermatitis in Children
Atopic dermatitis (AD), commonly known as eczema, is a chronic, inflammatory skin condition characterized by intense itching and recurrent eczematous lesions. It typically begins in infancy or early childhood and is often the first manifestation of the “atopic march” that may progress to food allergies, allergic rhinitis, and asthma.
Epidemiology:
Atopic dermatitis affects 15-20% of children worldwide, with approximately 60% developing symptoms in the first year of life. The prevalence has increased 2-3 fold in industrialized countries over the past few decades.
Pathophysiology
Atopic dermatitis results from a complex interplay of genetic, immune, and environmental factors:
Key Pathophysiologic Mechanisms
- Skin barrier dysfunction:
- Genetic mutations in filaggrin gene (FLG) and other skin barrier proteins
- Decreased ceramides and natural moisturizing factors
- Increased transepidermal water loss
- Enhanced penetration of allergens, irritants, and pathogens
- Immune dysregulation:
- Th2 cell predominance (acute phase)
- Increased production of pro-inflammatory cytokines (IL-4, IL-13, IL-31)
- Elevated IgE levels in most patients
- Chronic phase: Mixed Th1/Th2 response with tissue remodeling
- Microbiome alterations:
- Decreased skin microbiome diversity
- Staphylococcus aureus colonization (found in >90% of AD patients)
- S. aureus exotoxins act as superantigens and worsen inflammation
- Neurogenic inflammation:
- Increased nerve fibers in affected skin
- Enhanced release of pruritogenic mediators
- Perpetuation of itch-scratch cycle
The Itch-Scratch Cycle:
The hallmark of atopic dermatitis is intense pruritus (itching) that triggers scratching, which further damages the skin barrier, increases inflammation, and worsens pruritus. Breaking this self-perpetuating cycle is a major treatment goal.
Clinical Manifestations
Clinical manifestations of atopic dermatitis vary based on age and disease phase:
| Age Group | Distribution Pattern | Characteristic Findings |
|---|---|---|
| Infants (0-2 years) |
• Cheeks, forehead, scalp • Extensor surfaces of extremities • Trunk • Usually spares diaper area |
• Erythematous papules and vesicles • Weeping, crusting lesions • More acute/subacute presentation • Often resolves by age 2 |
| Children (2-12 years) |
• Flexural areas (antecubital and popliteal fossae) • Neck, wrists, ankles • Periorbital region • Hands and feet |
• Dry, scaly patches and plaques • Lichenification (skin thickening) • Excoriations from scratching • More chronic presentation |
| Adolescents (12+ years) |
• Flexural areas • Face and neck • Hands • May become more widespread |
• Prominent lichenification • Severe dryness • Persistent post-inflammatory hyperpigmentation • Chronic pruritus |
Common Clinical Features Across Age Groups
Skin Findings
- Intense pruritus (cardinal symptom)
- Xerosis (dry skin) even in non-lesional areas
- Erythema (redness)
- Edema and papulation in acute phase
- Excoriations from scratching
- Lichenification in chronic disease
- Hyperpigmentation or hypopigmentation
Associated Features
- Atopic features:
- Personal/family history of asthma or allergic rhinitis
- Food allergies
- Dennie-Morgan infraorbital folds (extra fold below lower eyelid)
- Pityriasis alba (hypopigmented patches)
- Keratosis pilaris (“chicken skin”)
- Hyperlinear palms
- Sleep disturbances due to pruritus
Complications to Monitor:
- Skin infections:
- Bacterial: S. aureus (impetiginization)
- Viral: Eczema herpeticum (HSV)
- Fungal: Dermatophyte infections
- Psychosocial impact: Emotional distress, social withdrawal, bullying
- Growth effects: Sleep disruption can affect growth and development
- Ocular complications: Atopic keratoconjunctivitis, cataracts
Nursing Assessment
A comprehensive nursing assessment is essential for proper management of atopic dermatitis:
Health History
- Symptom evaluation:
- Age of onset and progression
- Severity and frequency of flares
- Pruritus intensity (use age-appropriate pain scales)
- Impact on sleep and daily activities
- Trigger identification:
- Environmental: Heat, humidity, wool clothing, harsh soaps
- Allergic: Foods, aeroallergens, contact allergens
- Stress or emotional triggers
- Seasonal patterns
- Current management:
- Skin care routine
- Medications (topical and systemic)
- Complementary therapies
- Effectiveness of current regimen
- Family history: Atopic conditions, other skin disorders
Physical Assessment
- Skin examination:
- Distribution and morphology of lesions
- Stage (acute, subacute, chronic)
- Secondary changes (lichenification, excoriations)
- Signs of infection (crusting, pustules, weeping)
- Disease severity assessment:
- Percentage of body surface area affected
- Validated tools: SCORAD, EASI, or PO-SCORAD scales
- Associated findings:
- Growth and development
- Signs of other atopic conditions
- Evidence of psychosocial impact
Mnemonic: “SCRATCH”
Key components in atopic dermatitis assessment:
- Severity and distribution of lesions
- Complications (infections, sleep disruption)
- Risk factors and triggers
- Associated atopic conditions
- Treatment history and response
- Care routines for skin
- Hygienic practices and environment
Diagnostic Tests
Atopic dermatitis is primarily a clinical diagnosis. However, certain tests may be helpful in specific scenarios:
| Diagnostic Test | Purpose | Nursing Considerations |
|---|---|---|
| Skin Cultures |
• Identify bacterial, viral, or fungal infections • Guide antimicrobial therapy |
• Obtain before initiating antibiotics • Use sterile technique • Document site and appearance |
| Allergy Testing |
• Identify potential triggers • Types:
|
• Not routinely recommended for all patients • Stop antihistamines before testing • Prepare family for potentially lengthy process • Results require clinical correlation |
| Skin Biopsy |
• Rarely needed • Used to rule out other conditions that mimic AD |
• Explain procedure to child and family • Provide post-procedure care instructions • Used only in atypical or refractory cases |
| Serum IgE Levels |
• Often elevated in atopic dermatitis • Not diagnostic but may support diagnosis |
• Not necessary for all patients • Prepare child for blood draw • Normal levels don’t exclude diagnosis |
Differential Diagnosis:
Several conditions may resemble atopic dermatitis and should be considered during assessment:
- Seborrheic dermatitis
- Contact dermatitis (allergic or irritant)
- Scabies
- Psoriasis
- Tinea infections
- Immunodeficiency disorders with eczematous features
Management
Management of atopic dermatitis follows a stepped approach based on disease severity:
Basic Management (All Patients)
- Skin hydration:
- Bathing: Brief (5-10 min), lukewarm water, gentle cleanser
- Moisturization: Apply within 3 minutes of bathing
- Emollients: Creams and ointments preferred over lotions
- Frequency: At least twice daily and after bathing
- Trigger avoidance:
- Avoid irritants: Harsh soaps, wool, synthetic fabrics
- Temperature control: Avoid overheating
- Identified food triggers (if applicable)
- Itch management:
- Keep nails trimmed
- Cool compresses
- Distraction techniques
Pharmacological Management
- Topical anti-inflammatories:
- Corticosteroids: Varying potencies based on location and age
- Low potency: Face, neck, intertriginous areas
- Medium-high potency: Extremities, trunk
- Calcineurin inhibitors (tacrolimus, pimecrolimus): Second-line, steroid-sparing
- Phosphodiesterase-4 inhibitors (crisaborole): Newer option for mild-moderate AD
- Corticosteroids: Varying potencies based on location and age
- Systemic therapies (severe cases):
- Antihistamines: Primarily for sleep disturbance (sedating types)
- Oral corticosteroids: Short-term for severe flares
- Immunosuppressants: Cyclosporine, methotrexate, azathioprine (specialist use)
- Biologics: Dupilumab (IL-4/IL-13 inhibitor) for moderate-severe AD ≥6 years
- Antimicrobials:
- For documented infections only
- Not recommended for routine use
Advanced and Complementary Therapies
- Wet wrap therapy: For severe flares and recalcitrant disease
- Apply medication and moisturizer
- Cover with damp gauze/clothing, then dry layer
- Leave for several hours or overnight
- Phototherapy: UVB light treatments (specialist setting)
- Probiotics: Limited evidence, but may help some patients
- Vitamin D supplementation: May improve symptoms in deficient patients
Evidence-Based Practice:
The “soak and seal” method has strong evidence for improving skin hydration. Have the child soak in a lukewarm bath for 5-10 minutes, pat (don’t rub) skin partially dry, apply medication (if prescribed) to damp skin, then immediately apply a thick layer of moisturizer to “seal” in the moisture.
Nursing Care
Nursing care focuses on assessment, education, and supporting the child and family in managing this chronic condition:
Nursing Interventions
- Comprehensive assessment:
- Regular evaluation of disease severity
- Monitoring for complications
- Assessing impact on quality of life
- Skin care education:
- Demonstration of bathing and moisturizing techniques
- Proper application of topical medications
- Return demonstration by caregivers
- Itch management strategies:
- Distraction techniques appropriate for age
- Cool compress application
- Relaxation techniques for older children
- Infection prevention:
- Signs of infection to monitor
- Proper hand hygiene
- Avoid sharing personal items
- Psychosocial support:
- Addressing sleep disturbances
- Coping with visible skin condition
- Referral to support groups if appropriate
Patient and Family Education
Education Checklist for Atopic Dermatitis
- Disease process: Chronic, relapsing nature with potential improvement with age
- Daily skin care routine:
- Bathing practices (frequency, temperature, duration)
- Appropriate cleansers (fragrance-free, hypoallergenic)
- Moisturization schedule and technique
- Avoidance of scratching
- Medication administration:
- Proper application of topical medications
- Use of fingertip unit method for measurement
- Potential side effects and monitoring
- Frequency and duration of treatment
- Flare management:
- Recognition of early signs
- Stepped approach to treatment intensification
- When to seek medical attention
- Environmental modifications:
- Humidity control (cool mist humidifier in dry conditions)
- Dust mite reduction strategies
- Clothing choices (cotton, loose-fitting)
- Laundry practices (fragrance-free, double-rinsing)
- School/daycare considerations:
- Communication with teachers/caregivers
- Medication administration at school
- Addressing potential teasing/bullying
Mnemonic: “MOISTURIZE”
Key components of atopic dermatitis management:
- Moisturize frequently (after bathing and 2-3 times daily)
- Ointments and creams (preferred over lotions)
- Identify and avoid triggers
- Short, lukewarm baths/showers
- Topical medications as prescribed
- Use gentle, fragrance-free products
- Reduce scratching (keep nails short)
- Infection prevention and monitoring
- Zzzz (address sleep disturbances)
- Education and emotional support