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Severe, Refractory Eczema in Children (June 2011)

Q: I have a 3 year old patient with severe eczema. While his IgE is not very high, he did have low-grade IgE antibodies to a variety of common foods. The parents are fanatic about avoiding all of them. As the eczema gets worse, more foods have been removed from his diet. He is using all of the standard treatments including steroid creams, antihistamines for itch, bleach baths, wet wraps. I haven’t given long-term oral steroids or cyclosporine due to concern about side effects and his young age, but it is getting to the point where that may need to be considered. What should I do?

A: This is a very difficult situation that comes up periodically. What do you do when all of the standard approved treatments have been tried and the patient is still suffering? In this case I am concerned about the potentially deficient diet. If this patient has not seen a nutritionist, he should do so immediately. It is important that foods be added back into his diet as soon as possible. If the parents are reluctant to do this, offer oral challenges in the office. It may turn out that all of them cause the skin to itch a little, but that may be a better alternative than an extremely limited diet. Food avoidance is always a trade-off between the risk of not eating the food and the risk of the reaction from eating it. For a 3 year old, malnutrition is a serious risk.

I would certainly check this child’s zinc level. Zinc deficiency is associated with worsening eczema and merits checking in most patients who have eczema of any significance. Vitamin D deficiency is also associated with an increased inflammatory state, though its role in eczema is not clear.

If he has a secondary infection, it should be treated. It may also be necessary to admit him to the hospital for a few days to determine how refractory the eczema really is. Close cooperation with a dermatologist is also important.

More exotic treatments such as UVA, cyclosporine, QOD steroids, IVIG and even anti-IgE therapy may be necessary if the eczema is truly refractory. There are even anecdotes about the use of SLIT, though these are poorly documented. In such a young child, these options need to be approached with caution, complete transparency and of course, the consent of the parents.

 

 
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