Different than winter dry skin, but often worse in the winter, is a medical condition common among infants and children called atopic dermatitis (AD) or eczema. In this month’s Pediatrics, the journal of the AAP, eczema treatment was discussed in depth. We felt a summary might help our patients and families better understand this often frustrating condition.
Atopic dermatitis is a chronic condition that has been referred to as ‘the itch that rashes’. It is comprised of intense itchiness of the skin and red, raw rashes that appear in areas that are scratched. The skin becomes very inflamed and often hurts. As the skin barrier is the major protectant against invasion of bacterial and viral invaders, areas disrupted by rash are often prone to infection.
In infancy, the most common places to see eczema (AD) are the cheeks, scalp, trunk and extremities. In early childhood, it is common in skin folds, such as the bend of elbows or back of knees. Adolescents and adults often break out on hands or feet. Flares of AD have an impact on the entire family, as children experiencing these flares are often cranky, do not sleep well and may be teased about their rashes by peers. The encouraging news is that most children will outgrow the symptoms, or AD will become milder over time.
Many factors contribute to AD, such as family history, disruption of the protective skin barrier or immune dysfunction. The relationship between food allergies and eczema is complicated, but often over-emphasized. It’s confusing, but experts believe food allergies are MORE COMMON in children who have AD, rather than CAUSING the eczema. In other words, the allergy may be there, but removing the allergen won’t necessarily improve the rash. It is estimated that 90% of parents inappropriately blame foods as the sole source of their child’s rashes. Often this leads to elimination diets that often leave kids lacking in essential nutrients or proteins. The one exception, experts note, may be egg allergies. Nearly 50% of infants with egg allergies had documented improvement in skin when an egg-free diet was followed. Please check with us before eliminating foods from your child’s diet, especially infants and young children.
Eczema treatment should focus primarily on the skin. The AAP proposes a 4 step approach:
Getting hydration to the skin is critical to repairing and maintaining the skin. The best moisturizers for patients with AD are those that are a labeled ‘fragrance free’ and have the least number of preservatives. Ointments are the most moisturizing, followed by creams, then lotions. When it comes to soap, remember that lather comes from detergents, which are drying and irritating to the skin. Look for a non-lathering soap for sensitive skin. Avoid irritants in laundry products and scratchy fabrics. Look for laundry soaps with no dyes or perfumes. Skip the fabric softener, even in the winter. It not only leaves a gummy film in your dryer, it irritates the skin. Look for soft, breathable fabrics, such as 100% cotton.
Flared, itchy skin often won’t improve with emollients alone. Topical steroids are used to decrease inflammation and are safe when used sparingly and appropriately. Often, low potency steroids shuch as 1% hydrocortisone, available over the counter, are a good first line treatment. If these aren’t helpful, we will sometimes prescribe more potent steroid preparations. It is important to remember that these medicines should be used only on the inflamed or ‘flared’ areas of skin, not as an all- over treatment. A good rule of thumb is that a dab of medicine the size of a pearl should be sufficient to treat all affected areas. You shouldn’t be able to see the medicine, once it has been appropriately applied.
Thirdly, itch control is important. Often, parents may not appreciate how much their child is scratching because it is usually worse at night. Of course, keeping the skin in good shape may alleviate some itch, but may not be enough. Oral anti-histamine, readily available in over the counter forms, may often be useful to reduce the sensation of itching. Topical antihistamine creams are not effective and can be dangerous. Please consult our providers to find a preparation that would be the right choice for your child.
Finally, bacteria living on the skin may play a role in both the flares of eczema and in ‘super-infection’ or infections occurring in already irritated skin. Please contact our office right away if you notice pustules, oozing or a yellow crusting around eczema lesions, as these may be a sign of secondary infection and may need antibiotics. In addition, children with eczema are also prone to other types of skin infections, or experience more severe skin symptoms with common childhood infections. One such viral skin infection, molluscum contagiosum is more frequent and may be more widespread in children with AD. We are able to treat some patients with molluscum in our office.
Dilute bleach bathes may help those patients who experience frequent infections and flares of AD. Adding 120 mL or ½ cup of household bleach to a full bathtub of water and bathing for 5-10 minutes once to twice weekly, has been shown to help. Please seek our advice on whether this is an appropriate treatment for your child.
Eczema is often frustrating and challenging for affected families. Fortunately, there are many ways to help ease the suffering of this chronic condition. Please call our office for an appointment to discuss your child’s skin care and treatment options.
Tollefson, MM , Bruckner AL, Atopic Dermatitis: Skin-Directed Management Pediatrics, December, 2014 http://pediatrics.aappublications.org/content/134/6/e1735.full.html