ECZEMA!

What is it???

Eczema is a common very itchy skin condition in children that has a wide range in severity. It is also known as "Atopic Dermatitis" because it is often part of a triad with allergies and eczema. Note that while allergies are also commonly seen in patients with eczema, only rarely in severe disease do they seem to be a direct cause of flare ups. Eczema has a third name: "The Itch that Rashes". This is because often the itchiness is present first and then the rash appears! In most cases, eczema starts before age 5 [1], and about half can persist into adulthood [2]. It tends to run in families, and frequently there is a family member who also has it.

The main abnormality is a breakdown of the skin barrier function. The exact cause is still unknown and may be a combination of genetic and environmental factors. Changes in several genes and parts of the immune system likely play a role. Also, the "hygiene hypothesis" suggests that early exposure to daycare, dogs and farm animals may be protective against eczema [3].

What does it look like???

There are dry, red, scaly, very itchy patches scattered on the body. The child may have dry, rough skin in general. If not treated properly, the skin can thicken and sometimes scar. Also, after treatment there may be lighter spots remaining (post-inflammatory changes).

There are some differences in the presentation of eczema amongst various age groups:

Under age 2: Most patches are on the cheeks, scalp, and outer surfaces of the arms and legs. They can also be on the belly, back or chest. There can be some crusting and clear drainage.

Older children: Patches tend to form more on the backs of knees, inside the elbows, and on the neck, wrists and ankles. It can also appear on the eyelids and lips. There is a certain form called dyshidrotic eczema that appears more like blisters on the hands and feet.

These patches can be prone to infection, especially if the skin is broken open due to a significant flare up or from scratching. This can be due to bacteria or viruses. If there is a change in appearance to any patches - especially with increased redness, drainage, swelling - or if your child has a fever, you should see your pediatrician right away.

It is also imperative to follow with your pediatrician for treatment of routine flare ups. Eczema is usually diagnosed based on appearance without any additional testing. However, if it is difficult to control with typical treatments or if the diagnosis isn't certain, you may be referred to a dermatologist (skin specialist).

Treatments

I usually write out a comprehensive treatment plan for my patients with eczema that goes something like this:

1. Lots of moisturization!! Since the main issue is breakdown of the skin barrier, it is very important to try to create a new barrier with a product such Cerave, Eucerin, Aquaphor, Aveeno or even good ol' Vaseline. Your doctor may suggest a certain one that he or she prefers. Apply it all over, especially to the eczema patches. This part is easy for the little ones, but work hard to convince the teenage boys as well!

2. Infrequent bathing, if possible. Again, this works better for the little ones. Regardless of how often bathing happens, pat dry with a towel afterwards (don't rub) and lock in that moisture right away with your favorite product from #1.

3. No fun, yummy-smelling products😢. Since their skin is so so sensitive, it is best to stick with hypo-allergenic, fragrance- and dye-free lotions, soaps, laundry detergents, dryer sheets and anything else that may touch their skin.

4. Control the itching. Your doctor will recommend an over-the-counter or prescription medication, likely in the antihistamine family. Many parents tell me that they have found Aveeno oatmeal baths helpful as well.

5. Treat the flare ups. This will be with medications prescribed by your pediatrician and/or dermatologist. Usually, it involves a topical steroid cream, lotion or ointment. It is possible you will have a lower potency topical steroid for sensitive spots like the face and genitourinary areas and a stronger one for other parts of the body. Since this is a chronic disease, you may be using these intermittently for quite some time. You want to strictly follow the prescription given to you by your doctor. There can be side effects to long term use of topical steroids, so your doctor will most likely prescribe a routine that keeps you from using them for too long without a break (I aim for 14 days in a row max, but usually recommend applying on the weekdays and taking the weekends off, repeating as needed). If the eczema isn't responding well to increasing strengths of topical steroids, there are other treatment options approved for various age groups including non-steroid-containing topical medications (calcineurin inhibitors or Crisaborole), immune system suppressors, oral steroids or phototherapy.

6. Avoid triggers. Some patients have clear triggers such as low-humidity, stress, nickel (some costume jewelry or snaps on pants), or products like we talked about in #3. It tends to flare up in the winter. As mentioned above, food allergies are not usually investigated as a cause except in severe cases. We don't like taking food groups away from growing children unless it is totally necessary, but unfortunately sometimes it is. Whether or not other environmental allergens play a role is currently up for debate, but thought to be rare.

To sum it up, eczema is a chronic skin condition that can cause intermittent flares ups and is known for being very itchy. While it can be uncomfortable and possibly make your child more prone to skin infections, it is manageable with the steps above. Regular follow-up with your pediatrician is very important to keep your child's skin as healthy as possible for the long term!! 😊❤

1. Kang K, Polster AM, Nedorost St, et al. Atopic dermatitis. In: Dermatology, Bolognia JL, Jorizzo JL, Rapini RP, et al (Eds), Mosby, New York 2003. p.199.

2. Mortz CG, Andersen KE, Dellgren C, Barington T, Bindslev-Jensen C. Atopic dermatitis from adolescence to adulthood in the TOACS cohort: prevalence, persistence and comorbidities. Allergy. 2015 Jul;70(7):836-45. doi: 10.1111/all.12619. Epub 2015 Apr 16. PMID: 25832131.

3. Flohr C, Yeo L. Atopic dermatitis and the hygiene hypothesis revisited. Curr Probl Dermatol. 2011;41:1-34. doi: 10.1159/000323290. Epub 2011 May 12. PMID: 21576944.

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