Atopic Dermatitis in the Pediatric Population

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Use and Analysis of Background Literature

Atopic dermatitis (AD) refers to a chronic skin disorder that causes morbidity. Globally, among all skin diseases, AD poses the greatest health burden. In the United States, the prevalence of AD among the pediatric population is 10.7% and relatively lower among adults at about 3% (Silverberg, 2014). AD mostly affects children aged between one and five years. Moreover, the number of primary care visits for children having AD is increasing. Therefore, it is prudent to devise effective therapy interventions for AD in children. There are various treatment approaches for AD that have been outlined in the literature, including antipruritic drugs, phototherapy, and systemic and topical agents. Due to the fact that AD is linked to a complex interaction involving environmental exposures and immune system dysfunction, its treatment requires a mix of approaches (American Academy of Pediatrics, 2016). However, the U.S. Food and Drug Administration has only approved a few medications for AD, which poses a need for developing novel and more effective approaches to treat AD (Silverberg, 2014).

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In the United States, numerous guidelines for managing AD in pediatric patients exist. Clinical practice guidelines are important decision-making tools for clinicians for the management of pediatric conditions (Engorn & Flerlage, 2015). It is widely accepted that skin-directed AD management is important. Evidence supports the theory that AD is caused by abnormalities in the skin barrier. Therefore, the first treatment approach for managing AD is the use of skin-directed therapies. This approach consists of four primary components, including maintaining skincare to ensure a healthy and functional skin barrier, using topical anti-inflammatory medications for suppressing the inflammatory responses associated with AD; controlling itching; and the management of infectious triggers, and recognizing and treating infection-related burns (American Academy of Pediatrics, 2016). Each of these components addresses a particular AD manifestation.

The first protocol relates to maintaining skin care and has been touted to be the basis of managing AD (Silverberg, 2014). Maintaining skin care has the goal of repairing and maintaining the functionality of the skin barrier. This requires instructing patients to develop skin care habits and performing them on a daily basis (Bajaj, Hambidge, Nyquist, & Kerby, 2011). Evidence suggests that maintaining skin care can help to lower the severity and frequency of AD skin flares. The core aspects of skin care maintenance include avoiding the triggers and irritants and maintaining the hydration of the skin (Marcdante & Kliegman, 2014). Soaking baths on a daily basis followed by the application of a skin moisturizer has been recommended. In addition, using lukewarm water and a limited bath duration can help to prevent the skin dehydration (Engorn & Flerlage, 2015). Cleansing by mild synthetic detergents that lack fragrance can also be used to eliminate bacteria from the surface of the skin. Besides bathing, skin hydration can also be maintained by lubricating the skin, which is commonly known as moisturization, which helps in repairing skin barrier and lessens the amount of pharmacologic interventions needed (Marcdante & Kliegman, 2014). Moisturization should be performed at least one daily and on the entire body.

The second treatment protocol for managing AD involves the use of topical anti-inflammatory medications. The eczematous dermatitis witnessed in AD is because of the inflammatory immune response. Using moisturization alone cannot effectively eliminate the AD flares. In such cases, treatment is needed, and its main aim is to suppress the inflammatory response (Engorn & Flerlage, 2015). The recommended first-line medications are topical steroids, which are utilized for treating active AD. These medications have been used for the past four-five decades (American Academy of Pediatrics, 2016). These medications are also safe and effective when used appropriately. However, their inappropriate use results in likely risks of adrenal suppression. Wet therapy can also be used together with topical steroids in controlling AD by increasing the penetration of topical steroids into the skin, reducing itching, and effectively deterring scratching. Whereas conventional management of AD focuses on the treating of active AD and its flares using topical steroids, emerging evidence shows that using these medications in patients not having active AD might be beneficial (American Academy of Pediatrics, 2016).

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The third guideline for managing AD among pediatric patients is itch control. AD is often typified by pruritus and an itch that is likely to rash. AD patients experience significant itching. Usually, parents are not aware of the degree to which their child scratches him/herself, since itching worsens during night time (Marcdante & Kliegman, 2014). Controlling itching is a challenge even in situations when the skin of the patient is showing considerable improvement. Managing itching initially places an emphasis on minimizing triggers, as well as continued skin-directed management to restore the skin barrier and suppress the inflation. A supplementary adjunctive systemic therapy can be used for managing the itch (American Academy of Pediatrics, 2016). Reducing the sensation of itching can be done by using oral antihistamines, which subsequently lowers scratching and the skin trauma among patients with AD flares.

Another important component of AD treatment protocol is the management of infectious triggers (Marcdante & Kliegman, 2014). Viral and bacterial skin infections have been linked to skin flares among children having AD. Patients with poorly controlled AD are at a higher risk of developing cutaneous infections. About 90% of AD patients are colonized with the S aureus (American Academy of Pediatrics, 2016). This poses the need for providing antibacterial treatment for such patients. Also, it is recommended that the primary care provider should obtain skin cultures, especially in the draining lesions and pustules, prior to the treatment, in order to determine the causative pathogen. Patients with AD might also have streptococcal infections that are characterized by fever, painful erosions, and pustules. Streptococcal infections and S aureus can be treated using intravenous, oral or topical antibiotic therapy based on the severity of the infection. The first choice antibiotic medication for streptococcal and S aureus infections is Cephalexin, which should be accompanied by topical anti-inflammatory, moisturization, and bathing therapies to ensure the repair of the skin barrier (American Academy of Pediatrics, 2016). Dilute bleach baths are useful for managing patients having recurrent AD flares (Engorn & Flerlage, 2015). Also, AD patients are at a higher risk of getting viral skin infections, which should be appropriately treated.

Overall, it is evident that the AD treatment guidelines place a considerable emphasis on skin-directed management, as the first line treatment for children having AD, which comprises of maintaining skin care and using topical steroids for the case of active disease. The appropriate use of topical steroids has been reported to be effective and safe when utilized appropriately in children. Moreover, recognizing and treating AD early and its associated complications and triggers can improve the outcomes for patients.

Use and Analysis of Current Literature

Various research studies have been conducted in an attempt to develop more effective treatment for AD. Saki, Jowkar, and Alyaseen (2013) performed a double-blind bilateral comparison study that sought to compare the effect of sertaconazole cream and hydrocortisone ointment with respect to AD treatment methods. The sample comprised of 45 patients who smeared sertaconazole 2% cream two times a day one side of their body and hydrocortisone 1% on the other side of their body for duration of 30 days. The findings of the research did not show any significant differences between these two drugs in terms of reducing pruritus, xerosis, lichenification, scratch marks, crust, swelling, and erythema. However, the researchers found that sertaconazole performed better in reducing the overall score and those patients had more knowledge regarding sertaconazole when compared to hydrocortisone. Saki et al. (2013) concluded that sertaconazole was significantly better with respect to reducing the total score of AD and that it could be an efficient and safe approach for treating AD. The results of this study are consistent with the AD guideline that requires patients to smear their topical steroids twice per day.

Healy, Bentley, Fidler, and Chambers (2011) designed a study with the aim of determining the cost-effectiveness of tacrolimus ointment in maintaining the treatment regimen when compared to the standard reactive regimen for managing moderate to severe AF among children and adults. The researchers collected data over one year from children and adults, receiving 0.03% and 0.1% tacrolimus respectively. Their findings showed that for children and adults having moderate to severe AD, using tacrolimus twice per week was more effect and less expensive when compared to the standard regimen. Thus, they concluded that the tacrolimus ointment is beneficial for managing moderate to severe AD, which is consistent with the guideline provided by the American Academy of Pediatrics (2016), which considers the tacrolimus ointment as the second-line therapy for moderate to severe AD. Similar findings were reported by Siegfried, Jaworski, and Hebert (2013), who showed that topical tacrolimus ointment is safe and effective treatment option for AD.

Wu, Li, and Peng (2012) compared the impacts of fructooligosaccharides (synbiotic) and Lactobacillus salivarius with fructo-oligosaccharide alone (prebiotic) with respect to the treatment of children having moderate to severe AD. The sample comprised of 60 children aged between 2 and 14 years having moderate to severe AD who were randomly placed into a treatment group (symbiotic) and control group (prebiotic). They were provided with one capsule on a daily basis for the duration of eight weeks. The findings of the research indicated that combining fructo-oligosaccharide with L. salivarius resulted in superior outcomes to using prebiotic alone when treating moderate to severe AD in children. A limitation of their research is that patients were not followed for an adequately long period of time. This finding is consistent with the protocol recommending a combination of treatment approaches.

A study by Kapoor, Hoffstad, Bilker, and Margolis (2009) had the aim of describing the natural history of the usage characteristics of topical treatment for patients having AD. Kapoor et al. (2009) used the longitudinal design with 4105 children having mild to moderate AD. The study spanned three years. The results of the study showed that, after at least six months, the majority of the patients had the ability to completely control their disease without using topical medication, whereas all participants were using pimecrolimus during the beginning of the study, less than 40% of them continued using this medication after three years. These findings also highlight the difficulty of adhering to treatment among pediatric patients with AD. The researchers used their findings to recommend community-based use of topical pimecrolimus in the treatment of AD. This study had design limitations, stemming from self-reported data by parents and caregivers. Poor adherence is a prevalent issue that leads to poor clinical outcomes, especially among pediatric population. Sticker charts are commonly used as means of increasing motivation to medication adherence. Luersen, Davis, Kaplan, Abel, Winchester, and Feldman (2012) performed a systematic review to examine the use of sticker charts in improving treatment adherence among children. Their review showed that the effect of sticker charts was sustained for months, following the initial intervention. They concluded that using sticker charts can help encourage treatment adherence among children with AD and enhance their clinical outcomes. The limitation of their review is that the only variable manipulated was sticker charts and that only five randomized controlled studied were incorporated in the review.

Mengeaud, Phulpin, Bacquey, Boralevi, Schmitt, and Taieb (2015) acknowledged that whereas emollients have been recommended to help manage AD, emollient maintenance therapy regimens are yet to be validated. To this end, they conducted a global multi-center trial to evaluate the impacts of a three-month maintenance regimen using a sterile emollient cream that is free of preservatives and contains oat plantlets. The sample for the research consisted of children aged six years having moderate AD. The intervention included applying emollient twice per day for three months. The results showed considerable reductions in the number of skin flares, which also resulted in reduced use of topical corticosteroid. These results are consistent with the guideline requiring the use of moisturization for lessening the amount and potency of pharmacologic interventions in AD treatment. The limitation of their research stemmed from the possibility of investigator and patient biases.

The use of phototherapy is another treatment approach that can be used among patients having AD. To this end, Garritsen, Brouwer, Limpens, and Spuls (2014) conducted a systematic review that sought assess the effect of phototherapy in AD patients. The systematic review was based on an electronic search in various databases for randomized controlled studies on the use of phototherapy for AD treatments. The findings showed that the most effective phototherapy involves using ultraviolet and narrowband, which had no side effects. They concluded that phototherapy is a valid treatment method for AD. The existing clinical guidelines for AD have not mentioned the use of phototherapy as an approach for managing AD. A limitation of this review is that researchers only included randomized controlled studies and no cohort studies.

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Implications for the Advanced Practice Nursing Role

The information gathered from the research has important implications for the role of the advanced practice nurse. Through this information, I have acknowledged that AD is a key pediatric issue that requires a combination of various treatment modalities to enhance clinical outcomes for patients with AD. Therefore, based on this information, I will be able to develop treatment plans for pediatric patients having AD by incorporating the four treatment approaches, including maintaining skin care to ensure a healthy and functional skin barrier; using topical anti-inflammatory medications for suppressing the inflammatory responses associated with AD; controlling itching; and the management of infectious triggers, and recognizing and treating infection-related burns. The information gained from the latest evidence-based research will help to incorporate the most effective interventions when developing treatment plans for children with AD.

This is going to enhance my practice as a Pediatric Nurse Practitioner through becoming aware of some of the challenges in pediatric care, especially the adherence to medication. The evidence shows that medication adherence is a key issue for AD patients, and this can be addressed using sticker charts. The evidence also reveals that some treatment approaches are still under development, such as phototherapy. The information obtained from the evidence clearly distinguishes the treatment approaches that are most effective, which is an important consideration when developing treatment plans. Thus, this information will contribute to safe and effective pediatric practice, which will improve patient outcomes.

The findings also have implications for my role as a Pediatric Nurse Practitioner, especially through educating and counseling patients and their families. Even when excellent treatment plans are developed, AD is likely to recur. The primary care provider should establish realistic expectations concerning the outcomes in order to enhance patient compliance. The American Academy of Pediatrics (2016) recommends primary care providers to discuss AD prognosis with patients since the majority of children are likely to outgrow the severity or symptoms associated with the disease. Pediatric patients whose parents are educated comprehensively concerning AD including its care report better improvements in terms of the severity of AD when compared to the patients whose parents are not educated on AD.

Based on these findings, I will provide written action plans to patients and their families, in order to enhance adherence among children having AD. These action plans are helpful if they outline the specific indications for various medications and products. Implication for nurses is to engage in family and patient counseling and education concerning the pathogenesis, treatment, and prognosis of AD.

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