As many as 1 in 10 U.S. children have atopic dermatitis (“eczema”), a recurrent and distressing condition characterized by recurrent cycles of red, rough, and itchy skin. According to the American Academy of Pediatrics’ (AAP) 2014 clinical report, caring for the skin is the primary step in preventing and managing flare-ups of eczema.
Sometimes called “the itch that rashes,” eczema is a persistent, recurrent, and often widespread rash. It has been linked to environmental factors, genetic predisposition, and immune dysfunction. Atopic dermatitis is more than “just” an itch, though; the effects on quality of life “cannot be underestimated,” the AAP doctors write, and include: fatigue and sleep deprivation, activity restriction, depression, and social repercussions (fewer friends, fewer organized activities). For parents and caregivers, the effects can include: cost of treatment, time of skin care (estimated to be up to three hours per day), fatigue and lack of sleep, and feelings of hopelessness, guilt, and depression.
Given the strength of these concerns, it’s no wonder that current recommendations emphasize preventive care and early treatment. Skin-directed therapy relies on four strategies:
- maintenance skin care, to repair and maintain healthy skin
- topical anti-inflammatory medications (as directed), to suppress an inflammatory response
- itch control
- managing triggers and recognizing/treating flares
The approach to these strategies should be provided in a written action plan for parent’s future reference. While eczema may recur even when parents follow their child’s care plan without fail, a clear action plan and realistic expectations can improve outcomes and reduce frustration.
Your child’s skin care plan
Onset of eczema typically occurs before age 5, and many children experience an easing of symptoms and reduction of outbreaks as they grow older, although increased skin sensitivity may remain. Whether eczema is present for one year, five years, or longer, quality of life is sure to be improved with a clear plan of action. If you have noticed eczema affecting your child, make sure to talk with your child’s pediatrician about these recommended skin care strategies:
- Maintenance skin care. How often to bathe the child with eczema has been unclear over the years. According to the AAP’s clinical report, the child can bathe daily for 10–15 minutes in lukewarm water. (Adjust the bath schedule to every 2-3 days if the child does not enjoy a bath, or if you feel it irritates his skin.) Use a gentle, non-soap cleanser only on dirty parts, and apply it at the end of the bath to limit exposure. After bathing, pat your child with a towel (rubbing increases itching), but leave the skin damp. For the entire body and face, apply a moisturizer. An ointment (preferred) or a cream (rather than a lotion) is recommended. Note that some creams contain alcohols that can increase drying of the skin which increases itching. If you can, try to keep your child from getting excessively dirty, as this can increase skin irritation and subsequent symptoms.
- Topical anti-inflammatory medications. After the bath, apply prescription medications as directed to any areas that are “red, rough, and itchy.” (Note that your doctor may prescribe different medications for different areas of the body. Use a cotton swab or wash your hands before applying each medication to reduce the chance of medication mixing.) Prescription medications should be applied no more than twice daily. Continue the medication until symptoms resolve; if symptoms persist two weeks, consult with your child’s doctor. There are a wide variety of medications available to treat atopic dermatitis, and your physician may decide to switch your child’s prescription. It’s common for caregivers to experience “steroid phobia” that leads to under treatment. While misuse of any prescription medication can have unintended side effects, topical steroids have been shown to be safe—and most are not as strong as parents believe them to be. Topical steroids used for treatment of atopic dermatitis are classified in seven classes, ranging from “low potency” to “super potent.” Those in the “super potent” class are 1,800 times more potent than the first line of treatment preparations in the “low potency” class. (Table 2 shows the ranking of topical steroids by class, or you can ask your child’s doctor which is safest for your child.) Your child’s doctor will likely prescribe a low potency steroid at first in an effort to reduce the risk of side effects.
- Itch control. Antihistamines can help to reduce itching, especially at bedtime. Scratching actually increases the itching, and can result in significant skin damage, so it is imperative to control the itching as much as possible. Consider giving an antihistamine 30 minutes before bedtime and/or in the morning, as needed, for itching. Talk with your child’s doctor about the benefits and risks of sedating antihistamines (such as Benadryl) and non-sedating antihistamines (such as Zyrtec or Allegra). You will want to discuss possible side effects, as well as how long the relief from the medicine lasts (for example, relief from certain medications may diminish in as little as four hours while effects from other medications may last a full day). Antihistamines can be purchased over-the-counter at your local pharmacy and many have been approved for use in children as young as 6 months of age, but parents should speak with a physician about appropriate dosing, which should be based on your child’s age and weight.
- Managing triggers. When possible, try to identify those factors that trigger your child’s eczema. Common triggers include: foods; airborne or environmental allergens; infections (viral or bacterial); harsh soaps and detergents; fragrances; rough or non-breathable fabrics in clothing; sweat; excess saliva; and stress. Also, watch for signs such as “oozing, drainage, pus bumps, and yellow crusts,” which can signal skin infection and require a trip to the doctor. Seeing a board certified allergist may help you identify the triggers in your particular child.