Eczema

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 five. 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 for eczema?

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 soap. Antibacterial soaps, hand sanitizer, and repeated washing and drying can make eczema worse. When needed, use as little soap as possible and only on dirty skin. Even water without soap can dry the skin if used frequently. 
  
• Apply cool compresses. Covering affected areas with a cool, wet washcloth can ease itching.
  

If your child has moderate to severe eczema that does not respond to preventive measures and moisturizers, she may need topical and oral medication. Topical steroids (ointments, creams, or lotions) of various strengths can be applied to the affected areas.

• Low dose steroids. Low dose steroid ointments such as hydrocortisone are usually reserved for areas with thin skin, such as the face, neck, and groin. Available over-the-counter, low dose steroids can be applied to a wide area.
  
• Higher dose steroids. Higher potency topical steroids are also available and are usually reserved for the most severe cases. These high potency steroids are used for a limited amount of time in an effort to reduce the risk of skin thinning, absorption of the steroid into the blood stream, and enlargement of local blood vessels (telangectasias). Once the rash is controlled, use of topical steroids can be reduced to every-other-day or even twice-a-week.
  
• Oral steroids. In the most severe cases, oral steroids such as prednisone may be needed to control flare-ups. Oral steroids should be used sparingly since they come with many side effects.
  
• Oral antihistamines. Controlling the itch is essential and antihistamines are generally needed everyday in chronic cases, both mild and severe. Controlling the itch reduces skin trauma, skin breakdown, and the need to add steroids to the treatment program. Check with your doctor on the proper dosage for your child. Longer-acting, non-sedating anti-histamines such as Allegra or Zyrtec are more suitable treatment options. Long-acting anti-histamines last 24 hours so they are easier to use and are therefore more effective. Benadryl, a commonly used antihistamine for eczema, is usually not the best choice. It has a short duration of effect, lasting only 4–6 hours, and therefore needs to be administered more frequently. Plus Benadryl is more likely to cause sedation and irritability. Over-the-counter cough and cold medicines are not recommended in children under the age of 4. Parents should speak with their child’s health care provider before giving their child medication, including those available over-the-counter (without a prescription).
  
• Oral antibiotics. If your child’s skin appears to be infected (open, weeping lesions) she may need an oral antibiotic. Talk with your child’s health care provider to determine which treatments are best.
  

Are there non-medicinal treatments for eczema?

Studies show that high-risk infants (those born to parents with eczema or allergies) benefit from breastfeeding. Breastfeeding for at least four months has been shown to help reduce a high-risk infant’s chance of developing eczema. If breastfeeding is not an option, your baby’s doctor may suggest giving your baby an extensively hydrolyzed (predigested) formula rather than non-hydrolyzed or partially hydrolyzed formulas to reduce the risk for eczema. Extensively hydrolyzed formulas contain amino acids (the building blocks of protein) rather than complete proteins. Partially hydrolyzed formulas were previously thought to be less “allergenic” (capable of causing an allergic response), however, some data suggest that this may not be true, so talk with your child’s health care provider before using any formula.

Because children with eczema don’t have a normal skin barrier, they often have more bacteria on the surface of their skin compared to non-affected children. These bacteria secrete irritating substances that may help drive the disease. To kill off this bacteria, your child's health care provider may suggest a bleach bath. If properly diluted and used as directed, bleach baths may help lessen symptoms if used in combination with other eczema treatments. For best results:

• Consult your child's health care provider before trying a bleach bath
• Put ¼–½ cup of bleach into a full-sized bathtub (approximately 40 gallons). If you are not filling the tub to the overflow drainage holes, you will need to add less bleach. 
• Soak from the neck down or just affected areas of skin for about 10 minutes.
• A wet towel with the dilute bleach solution can be used to dab your child’s cheeks and neck. Be careful to avoid contact with the eyes or mouth.
• After soaking, gently pat your child's skin dry, then immediately apply moisturizer.
• Bleach baths 2–3 times a week are usually sufficient, taking them too often or using too much bleach can dry out the skin. Always apply moisturizer immediately after a bleach bath. 
• Do not give your child a bleach bath if they have any type of open wound (cracks, sores, cuts, etc.,) on their skin, these must be healed completely. 

Will my child outgrow eczema?

Not all patients with eczema are actually “atopic” or allergic, but those who are, can be more difficult to manage. In the past, the medical community thought that the majority of children with eczema would outgrow the disease, but more recent data show that over one-half of children with eczema still have the disease at age 7. Symptoms can disappear for months or years, but 40 percent of children with eczema experience flare-ups as adults. It is important to note that even after the eczema improves or “resolves,” the skin will remain dry and more sensitive to irritants than normal skin, and that continued use of hypoallergenic lotions and other skin products are recommended to reduce the potential for flare-ups.

When should I call the doctor?

Since children with eczema are more prone to skin infections, parents are urged to call the doctor right away if their child develops any of the following:

• Fever
  
• Fluid- or pus-filled bumps on the skin
  
• Redness or warmth in the affected areas
  
• Worsening of symptoms
  
• Symptoms that don’t respond to treatment
  

How will eczema affect my child’s day-to-day life?

Thankfully, eczema is not contagious, so there is no need to isolate your baby or child from family and friends. The symptoms are usually mild and easy to control with the measures mentioned above, so there is little impact on your child’s day-to-day life. In most cases, with a little bit of care, individuals with eczema can have normal looking skin. However, if symptoms persist or are severe, help is available. A board certified allergist or dermatologist can determine the cause(s) of the disease and give you a complete solution, rather than simply treating the symptoms.