Eczema is a common skin condition affecting 3 - 5% of children. It is due to a combination of two problems.
1. The surface of the skin has an altered protein (filaggrin) which is unable to hold as much moisture - this results in cell shrinkage, allowing irritants to get 'under the skin'.
2. The second problem is increased sensitivity to these irritants, resulting in inflammation. There is an aggressive immunological reaction which is abnormal.
These two problems lead to the key elements of eczema - dryness and inflammation. These are the two areas that need to be managed with any treatment.
Approximately 85% of children grow out of eczema before they reach 5 years of age. Eczema is more common in those under 12 months and is also called atopic dermatitis. There is no cure for eczema and this page is designed to give you some advice on the best way to manage it. The itching of eczema can be very disrupting to the family and lead to sleep problems and thickening of the skin called lichenification.
Myths surrounding eczema
Eczema is one of those illnesses where great claims are made by alternative practitioners, drug companies and so called experts. An analysis of all treatments has found that Western medicine is by far the most successful at treating eczema. There are no magic oils or creams that eliminate or cure eczema. If they existed then these would be used by doctors instead of conventional therapy. As eczema improves with age and often improves quite suddenly many parents will mistakenly believe they have found a cure or identified some dietary trigger that has resulted in the cure.
There is a general trend in society that tends to be highly suspicious of doctors medication. This has resulted in the current steroid phobia that currently exists amongst parents, shop assistants; alternative practitioners, baby health nurses and even pharmacists. The myths surrounding steroids are quite alarming and generally have no basis of truth. See below for more discussion.
Where does it occur?
This depends on age and severity. Infants will often have dermatitis on the face and trunk. Later this moves to more traditional sites involving the elbows, ankles and knees. The milder forms will have eczema affecting the elbows and behind the knees.
What are the common triggers?
These include anything that dries and irritates the skin. Including wools, nylons, soaps, bubble baths, chlorine, house dust, pollens, and grasses. Changes in heat, humidity, and also colds can trigger eczema. Overheating and sweating is one of the most common triggers. All this is compounded by scratching which breaks the skin surface and increases the inflammation.
What about food?
It is true that food in about 15% is a trigger. However this is often overstated. The common foods include cows and soy milk protein, eggs, shellfish, wheat and foods containing salicylates such as fresh fruit and tomatoes. Peanuts are also a trigger. In those where food is identified as a trigger, it will be only a part of the picture.
It is important to realise there is no cure. Eczema can be controlled but this requires dedication and compliance. Easier said than done especially in a feisty 2 year old who is sick of the ointments and creams. Problems occur when therapy is stopped as soon as the dermatitis clears in the belief a 'cure' has been achieved. When the inevitable relapse occurs parents may abandon further therapy.
• Firstly avoid irritants. Use hypoallergenic or sensitive bath oils & washes and no soaps. Dress your child in loose cotton and be careful of overheating. If you suspect irritants such as dust mite, foods then these can be tested for. But this is not always straight forward. In the more moderate or severe cases it would be reasonable to assess for specific triggers that can be controlled such as diet. Skin prick testing or blood tests can sometimes help to differentiate some of these triggers but this is a complicated area.
• Secondly diminishing the inflammation requires the use of emollients and ointments. Hydrating the skin with a moisturising emollient cannot be overstated. Two to five times per day is sometimes necessary with an appropriate moisturiser. Ideally applied after a warm bath containing bath oil.
Moisturisers should contain paraffin and glycerine. They can be applied over the other ointments as often and as thickly as you like. Tub and jar moisturizers are preferred to pump packs because they contain less water. Some moisturisers such as sorbolene will sting when applied and cause a brief increase in redness. Tea tree, vitamin E, Paw Paw and aloe-vera can cause irritation and redness contributing to eczema. These latter creams sometimes contain propylene glycol which can irritate.
• Thirdly an appropriate steroid cream is needed for flare ups. Steroids are very successful and very safe if used as directed. Parents should use cortisone creams as soon as they see a patch of dermatitis. Waiting until the dermatitis gets really bad before using only results in having to use more. The earlier you start the better you will be able to control the situation. Steroid creams should be applied over the moisturising emollient.
• For the face, Examples are: Hydrocortisone and Logoderm. These should be applied twice per day during flare ups and as the eczema improves slowly weaned.
• For the body, Examples are: Celestone M, advantan ointment, Diprosone, Betnovate, Egocort, elocon. The advantan is a weak steroid that converts to a stronger steroid when in contact with inflamed skin. These should also be applied once or twice daily and under wet dressings - see below.
This medication is for those infants and children with mild to moderate eczema. This is a medication that suppresses the aggressive immune responses that occur in the skin. It is used to at the first sign of flare ups or sometimes on a preventative basis. This is not a steroid and has been available in the USA for the last 8 years with good success. Because it suppresses immune function at the skin level it should be used with sunscreen on areas exposed to the sun. It needs to be applied twice per day in a thin layer.
Damaged skin makes it prone to bacterial and viral infections. Staphylococcus aureus is a common bacteria that complicates eczema. It actually prevents topical steroids from working, by changing the steroid receptor on the skin. Sometimes oral and topical antibiotics are required in resistant eczema. Bathing in QV flare up oil helps eradicate these bacteria. Oilatum plus is another that helps prevent staphylococcus infection.
The herpes virus that causes cold sores can also result in a nasty skin eruption. These look like little blisters and if extensive require treatment in hospital.
Other day to day advice
1. Bath time - Bath your child once a day in cool water using a bath oil rather than a soap which can be irritating and drying to the skin. Bath 2 hours before bed time and make it a pleasurable experience. Do not spend too long in the bath as water is drying to the skin. Bath oil or moisturising wash should be added to the bath water and the skin moisturised thoroughly afterwards. Use a hypoallergenic or sensitive shampoo if the scalp is dry.
2. Swimming - Apply Sorbolene or Vaseline as a barrier prior to entering the salt or chlorine pool to aid in protecting the skin. A shower & using moisturiser and/or bath oil to the skin afterwards to remove chlorine or salt.
3. Clothing - Can be irritating to the skin especially if it has a "prickly" feeling to it or there are tags and labels. Avoid wool particularly against the skin, soft cotton or cotton/polyester is best in direct contact with the skin. When your child is hot from activity, environment or clothing the clothing will be more irritating to the skin than normal. Take a layer of clothing off prior to exercise. Beware furry toys, bunny rugs, car seat covers, and clothes the parent wears when carrying the child. Low irritant & 100% cotton clothing is available from many suppliers.
4. Bedding - Soft cotton and satin are the least irritating. Again avoid overheating at night and use cool cotton one piece pyjamas. Mittens or splints are occasionally needed if scratching a problem.
5. Dummies - Usually aggravate eczema around the mouth. Eczema sometimes gets worse during teething possibly due to a change in the immune system reacting to the gums.
6. Detergents - Certainly aggravates eczema. Try to use LUX or Velvet and a good rinse. Bandages may be washed in the machine using a good rinse cycle. The presence of vinegar, 15mls in the wash will bring clothes to a pH that is close to the skin.
7. Diet - Some (