Eczema: The “Itch That Rashes”

by Dr. Keith I. Lenchner
July 31, 2012

“Nobody in the house is sleeping,” declared a Mom with a distressed look on her face and a crying 1-year-old cradled in her arms. Her son’s cheeks, arms, legs, and belly were covered with a red, weeping, crusted rash, and thick yellow mucous was dripping from his nose.  “He scratches all night and the creams aren’t working,” she added. A brief discussion revealed that her son had developed the rash soon after birth and was diagnosed with eczema. It had worsened (along with the runny nose) over the last few weeks, and the moisturizers and ointments previously used to control the rash and itching were no longer working. She was desperate for a solution.

What is eczema?
Eczema is a general term that refers to inflammation of the skin. “Atopic dermatitis” is often used interchangeably with “eczema.” It describes a chronic and reoccurring skin condition that starts in childhood and results in dry, rough, red, crusted, itchy patches on the skin. These patches can occur anywhere on the body, but classically appear on the face, scalp, hands, and feet of young children. Older children and adults usually develop patches behind their knees, in the bend of their arms, and on their neck, hands, and feet. If the outbreak is severe, the rash can occur anywhere (and often does!).

About 1 out of every 10 kids develops eczema. The majority of children outgrow the disease by age 10. However, symptoms can occur off and on into adulthood.

Red, itchy, scaly skin is nuisance enough, but children with eczema are also more prone to developing other allergic diseases such as asthma and allergic rhinitis (chronic runny nose). In fact, eczema, asthma, and allergic rhinitis are often seen in the same patients and are referred to as the “allergic triad.” The serial development of eczema followed by asthma and finally allergic rhinitis is referred to as the “allergic march.”

What are the causes of eczema?
It’s unclear why some children develop eczema and others don’t. Genetics clearly play a role based on data showing that children with a family history of allergic disease have a higher risk of eczema. In fact, in 70–80 percent of eczema cases involving identical twins, both have the disease. Experts theorize that some children lack key proteins (like filaggrin) that give the skin its protective barrier function. The end result is “leaky” skin that dries out easily and fails to keep out allergens that come into contact with the skin such as foods, pollens, animal dander, dust mites, and molds.

What are the symptoms of eczema?
Itchy, red, blistered skin is the classic sign of eczema. As the condition worsens and becomes more chronic, the skin can get thick, dark, and scaly and in severe episodes it can crack and bleed. Symptoms often appear within the first few months of life, and usually before a child turns 5. The rash generally starts on the cheeks, forehead, and scalp and spreads to the arms, legs, and trunk. The dry skin makes secondary infections with bacteria (staph or strep), yeast (candida), or viruses (herpes simplex, molluscum contagiosum) more likely to occur.

In infants, the rash usually appears on the face, head, and neck, but seldom develops in the diaper area. A rash in the diaper area can be a sign of a yeast infection, especially if the rash appears in the creases at the top of the legs.

Occasionally, the rash will appear around the eyelids. This is more common in adults and is often an allergic reaction to an ingredient in a shampoo, cleanser, cosmetic, lotion, or perfume rather than a sign of eczema. Severe eye involvement is rare, but it can cause itching, burning, and drainage (atopic keratoconjunctivitis) that can ultimately lead to cataracts or corneal lesions and deformity (keratoconus). Severe eye involvement may require an evaluation by an ophthalmologist (eye doctor).

How is my child diagnosed?
Eczema is sometimes confused with other skin conditions such as cradle cap (seborrheic dermatitis), psoriasis, and contact dermatitis (irritation that occurs when the skin comes into contact with an harsh substance). Most doctors will diagnose a child with eczema based solely on clinical history and skin appearance. Usually no laboratory tests, skin biopsies, or skin tests are required. However, because food allergy can contribute to eczema in up to 35 percent or more of children, parents of a child with moderate to severe eczema may want to consider having their child allergy tested by a board certified allergist.

What is the treatment?
Although 10–20 percent of children experience eczema, eczema usually improves with age, so time is often the best treatment. The best way to treat eczema outbreaks is to avoid known triggers (allergens or irritants), keep the skin moist and intact (free of cracks), and treat secondary infections (bacterial, viral, fungal). Eczema is often described as the “itch that rashes.” The following strategies can help prevent skin trauma and disease flare-ups.

• Use soft, breathable clothing. Avoid dressing your child in clothing made from coarse fabrics or clothing that is tight-fitting, which irritates the skin and increases itching. Consider dressing your child in lightweight cotton clothing.  Prewash all new clothing to remove any chemicals that may have been applied to the clothing during manufacturing. When washing the clothing, use a hypoallergenic soap free of additives and softeners that can also irritate the skin.
• Keep nails short. Clipping your child’s nails or covering her hands with socks, gloves, or mittens can protect against nighttime scratching.
• Keep skin moist. Sweat, dry air, and heat tend to aggravate eczema, which explains why symptoms often worsen in summer and winter. During these seasons, fragrance-free moisturizers (like Aquaphor, Eucerin, or Cetaphil) should be applied several times a day and within minutes of bathing to help lock in moisture. Read labels carefully, and avoid moisturizers and lotions that contain alcohol, which dries the skin even more.
• Avoid hot water. Use lukewarm (tepid) or warm water when bathing your child. Avoid excessive scrubbing. Gently pat your child’s skin dry with a towel.
• Avoid harsh cleansers and soaps. Even water, alone, can dry the skin if used frequently. Repeated washing and drying and use of antibacterial soaps or hand sanitizers can make eczema worse.
• Apply cool compresses. Covering affected areas with a cool, wet washcloth can ease itching.