Lumps,Bumps,and Things That Go Itch in Your Office!

History

T.G. is a 9-year-old black female who is in the 3rd grade at your school. She has had asthma since she was 3 years old. She is poorly compliant with her medication but currently has an Albuterol inhaler in the health office. She has not been in to your office recently for any medication, so you are surprised to get a call from her teacher asking you to assist in an evaluation of Attention Deficit Hyperactivity Disorder (ADHD) in T.G. You ask the teacher why she is concerned, and she tells you that T.G. is unable to sit still in class. She is constantly squirming in her seat and often keeps her hands under her desk. She does this all the time, but it seems to be getting worse. Now she does not seem able to concentrate in class or pay attention to her studies.

You ask T.G. to come to the school health office so you can look into the problem. When T.G. arrives, you see a pleasant little girl wearing a long-sleeved shirt with a high neck despite the warm day. When asked why she squirms in her seat, she tells you that she “itches” everywhere and that moving around helps her scratch. You ask her how long she has felt this way, and she states, “my whole life,” but it is worse this week with the warm days.

T.G. denies having any problems breathing, and her peak flow today in the office is normal. She tells you that she and her mother have just moved to a new apartment where they are sleeping on the couch because they do not have a bed. Her mother’s boyfriend is a smoker, but he only smokes outside according to T.G. She does not have a fever, cough, or any other systemic symptoms. Her only complaint is this very “itchy” rash.

You pull T.G.’s health card and note she has already missed several days of school this year. It is noted that she has asthma, eczema, allergic rhinitis, and occasional allergic conjunctivitis. Her immunizations are current, but she has not had a flu shot this year. No allergies are noted.

Physical Findings

On exam, you find T.G. to be a well-developed, healthy-looking black female. Her vital signs are: heart rate, 68; respiratory rate, 24, without wheeze; blood pressure, 110/71; and peak flow, 260. She is covered with a rash that appears on her cheeks, both arms over the extensor and flexural areas, and her chest, abdomen, back, and legs. The rash is thick, lichenified over her arms, and slightly scaly. (Figure 1 shows the appearance of this rash in black skin, and Figure 2 shows its appearance in lighter skin tones.) Generally, T.G.’s skin is very dry all over. She has a few eroded areas over her arms that indicate infection. The patches are hyperpigmented. Over the sides of her arms she has a few small erosions (Figure 3). Otherwise her exam is normal.

Differential Diagnosis

Discussion

T.G. is suffering from a severe case of atopic dermatitis (AD). The key to this diagnosis is her history of asthma, allergic rhinitis, and conjunctivitis. It is also helpful to note that she has had this “all her life,” but it gets better or worse during the year.

AD is a chronic, pruritic, inflammatory skin disease that is a major cause of school absenteeism, depression, and quality-of-life issues for the child, the care-giver, and the family (Habif, 2001, 2003; Hanifin, 2003; Nicol, 2003). The chronic scratching can disturb the sleep of the child, causing the child to have difficulty staying attentive in class, especially if she is being given sedating antihistamines to help with the itching. The need to scratch in class can also be distracting for the child and classmates sitting close by. The rash itself can be very unattractive and can lead to teasing by other children. Older children will often try to keep their skin covered even though it might cause them to get hot. Sweating makes the skin itch more; therefore, these children are miserable. Children with AD are at high risk for depression from being told they have ugly skin, from being teased, or because other children refuse to touch them or hold their hands. Missed days from school combined with poor attention can often lead to being behind in school, which can exacerbate the risk for depression. Like T.G., these children are often suspected of having ADHD.

Many children and their families do not understand this disease, how to use the medications, how often to apply them and for how long, and when to start and stop them. There also is confusion over the role allergies tend to play as a trigger for this disease. It is known that for a subset of these children, food allergens play a role in triggering flares (Sicherer & Sampson, 1999). The most common foods that cause flares are milk, eggs, peanuts, soy, wheat, and fish. Even when children test negative for a specific allergy to these products, these foods often exacerbate the rash.

The main treatment for these children is to keep the skin moisturized and maintain good skin hygiene. When a child is having a flare, he or she should take a 20-minute bath in warm (not hot) water twice a day. The child should stay in the bath until the fingers and toes are “pruney,” which indicates that the skin is hydrated. If the child is dirty, a mild moisturizing cleanser such as Dove, Neutrogena, or other mild cleanser that does not have a fragrance can be used. The skin should not be scrubbed with a washcloth. A moisturizing cream, ointment, or lotion should be applied to all of the body within 3 minutes of getting out of the tub and patting the skin lightly. This allows water to stay on the skin. There are many moisturizing creams, lotions, and ointments such as Lubriderm, Eucerin, Moisturel, and Aveeno. The child should find a product that does not feel sticky on the skin and leaves the skin feeling moist. Which product works best may vary by the time of the year because of the moisture in the air or the use of heat and air conditioning at home or school.

A child with a severe case of AD will often need to moisturize the skin during the day to keep it from itching. The child also will need to apply a topical corticosteroid medication such as Elocon or Cutivate twice a day for up to 14 days. Newer therapies that are nonsteroidal topical immunomodulator therapies are now available as an alternative to a topical steroid or an adjunct treatment. These products, Elidel Cream and Protopic Ointment, are used twice a day and are applied to dry skin to avoid stinging. They may be used on areas of thin skin around the eyes, nose, mouth, and neck on a daily basis without the side effects of steroid creams. New research supports the use of these medications as daily first-line treatment at the first sign of an AD flare to decrease future flares and reduce the amount of topical steroid therapy needed as a rescue medication during a flare (Eichenfield et al., 2002; Wahn et al., 2002).

Key Points for School Nurses