LEARNING OUTCOMES

By the end of this section you should be able to:

RATIONALE

Children’s nurses are frequently involved in the care of children with many skin conditions, including atopic eczema; in general wards when the child is admitted for another condition; in out-patient departments and in the dermatology ward.

The healthy child may suffer from dry skin conditions or infections. The majority of dermatological conditions can be exacerbated by the dry hot atmosphere of the hospital ward. A hospital admission, whether for management of the skin condition or for another reason, provides an ideal opportunity for intensive skin care and for assessment and review, enhancing parental education, and building on and reiterating knowledge.

Painful and irritated skin has a profound effect on the child’s self-image, mood and peer acceptance. Those who will require additional skin care over and above routine cleansing include:

FACTORS TO NOTE

EQUIPMENT

CRADLE CAP/SEBORRHOEIC DERMATITIS

This is characterised by erythema and a yellow scale on the scalp, which can spread to eyebrows. Generally affecting infants under 3 months of age, occurring on the scalp (cradle cap), eyebrows, face and limb flexures, it can also favour the nappy area. Unlike atopic eczema, it is not itchy or painful but can look unsightly, causing distress to parents. It will generally clear on its own with mild emollient therapy such as an emollient bath daily and a light emollient cream. If it does not clear, the infant should be referred to a dermatologist/paediatrician for further assessment.

For cradle cap, olive oil can be applied to the scalp and gently massaged in to loosen the scales and encourage them to separate. The oil can be left in for 30 min to overnight, depending on the severity of the cradle cap. A soft baby brush can then be used to gently remove the loosened scales. Temptation to remove adherent scales by picking must be resisted as hair loss may result (Gill 2003).

The oil should not be left on the scalp, so a medicated or mild infant shampoo can be used to remove it.

NAPPY RASH

Nappy rash is a relatively common condition of infancy. It can be caused by irritation from faeces and urine or fungal contamination. Infant skin is generally more fragile and therefore more prone to physical and chemical injury/irritation as the dermis is immature due to decreased collagen and elastic fibres, as well as immature blood and nerve supply. The normal pH of skin is acidic; moisture in the nappy area increases the pH, making the skin more permeable (Turnbull 2003). Children suffering from gastroenteritis or malabsorption syndromes frequently pass watery stools, which may be acidic and cause damage to the nappy area. These children may require more frequent nappy changes and application of occlusive ointments such as petroleum jelly; this will go some way to reducing contact with irritants. Exposure of the excoriated skin will help minimise nappy rash (Turnbull 2003).

The carer must be educated on prevention of nappy rash by frequent changing and gentle cleansing followed by application of a barrier cream/ointment, such as zinc and castor oil cream or petroleum jelly. The use of fragranced cleansing wipes should be discouraged in the presence of nappy rash, as they will only serve to irritate the skin.

When there is no improvement using simple measures, secondary infection such as with Candida albicans (thrush) should be suspected and a swab obtained for culture before commencing prescribed treatments (Turnbull 2003). If nappy rash is severe and persists despite all measures, the infant should be referred to a dermatologist/paediatrician for diagnosis.

ECZEMA HERPETICUM

This is caused by the herpes simplex virus (HSV) and many eczematous children have an abnormal response to HSV, which can result in dissemination of the herpes and subsequent toxaemia (Harper 1990).

It is recognised as small clusters of clear fluid-filled vesicles, which can take on a punched-out appearance. The child may be generally unwell with pyrexia and malaise.

This is a dermatological emergency and the child should be seen by a GP or emergency department immediately and all parents should be alerted to this condition and advised to keep the child away from those with cold sores. Healthcare workers with cold sores should not care for the child with eczema and should refrain from work until clear. The child will require adjustment to the topical therapies and treatment with antiviral medication.

IMPETIGO

This is a highly infectious disorder caused by Staphylococcus aureus and/or group A streptococci. It is characterised by small blisters that burst easily, releasing a yellow exudate, which in turn forms a pale honey-coloured crust.

The infectious nature of this condition necessitates the child being kept off school or nursery. Sites around the nose and mouth are most commonly affected (Doherty 2001). If the infection is extensive, then systemic antibiotics are indicated and they should be prescribed immediately and not withheld until microbiology results are available.

Topical antibiotics are only of use if the infection is identified early enough and the impetiginised area is localised; however, one must be aware that in some instances such as eczema the possibility of multiresistant strains should be a consideration.

Crusts can be removed by the use of warm saline soaks or a weak solution of potassium permanganate as per pharmacy instruction.