What is eczema? Eczema (pronounced eck’zema) or atopic dermatitis (AD) is a frustrating disease of the skin that ranges in severity from mild dry patches on the face to total body skin thickening. The simplest synonym for eczema is sensitive, allergic or itchy skin.
How often does eczema occur? About 15-20% of children have some form of eczema with 2% having the most severe forms. Studies suggest an almost 3 fold rise in this diagnosis over the past 30 years. This may be because we are now better at diagnosis and treatment or that the condition is actually more common. Unfortunately, many children with eczema or allergic skin go on to have other allergic manifestations including asthma (allergic lungs) and allergic rhinitis (allergic nose). Remember that eczema is a condition not a disease. This means that although most children’s skin improves with time, children with eczema have a life-long predisposition to dry, sensitive skin.
What are the three stages of eczema?
- Infancy – Under two years of age, dry skin is the most common manifestation. In newborns, it often presents in the first few weeks of life as red, splotchy dry or moist areas on the cheeks and upper neck and can be confused with newborn acne. Newborn acne however, is never dry and tends to improve with time while eczema tends to get worse.
- Childhood – From two years to the onset of puberty, the eczematous areas are more oozing and weeping, with wet and dry patches on the arms and legs as well as in the joint creases. In addition, the skin begins to thicken (or lichenify). A common presentation for the school age child is keratosis pilaris (dry pillars of skin), a condition of very bumpy, and thickened skin on the upper arms, legs or face.
- Adolescence – After puberty, the face is once again involved with more intense involvement of previously affected areas.
What causes eczema? Most dermatologists agree that eczema is an allergic disease. Indeed, 80-85% of patients have elevated IgE, the immunoglobulin, or immune molecule most associated with classic allergies. Patients with eczema have chronically itchy skin and the more the skin itches, the more the child will scratch. Scratching worsens the reaction by causing the release of inflammatory chemicals (called cytokines) that cause the skin to itch more. And the vicious cycle begins again with more scratching.
How does food allergy impact on the course of eczema? In a recent study, 67% of children with positive skin test reactions to various foods did not break out when eating that food. That means that a child may appear to tolerate a particular food, but may still be very allergic to that food. The opposite is also true. A child may have very severe eczema but not have an identifiable allergy to any specific food. So what is a parent to do? When there is a real correlation between a particular food and the development of dry skin or a rash, the child should be evaluated for potential food allergy. In addition, children who are unresponsive to routine eczema therapy (see treatment section) or who respond but continue to require vigorous daily therapy for several months should be evaluated for potential food allergy. Finally, any child who has systemic reactions (blood in stools, respiratory or GI symptoms) merits further investigation. And what foods should one consider avoiding? In one study of children with eczema, 37% were allergic to one of the “Big 5”: egg, peanut, milk, wheat or soy. 20% reacted to four or more foods. When the implicated foods were eliminated from the diet, the eczema cleared significantly. When eczema is severe and persists past a year, we routinely find that the child is allergic to one or many foods. So when you think eczema, think food allergy.
What tests can be done? Under one year of age, it is generally impractical to test for food allergies because even children with severe allergies will often have negative tests. Over a year of age, an allergist can do a skin test or we can do a blood test called an ImmunocapTM test. It is obviously easier and less painful for us to do the blood test and you get results within a week. There are over 1000 Immunocap tests but we usually test for milk, egg, soy, wheat, and peanut. RAST tests are scored from class 0 (non allergic) to class 5 (severely allergic).
Can breastfed babies have food allergies? Absolutely! Breastfed babies can be very allergic to foods such as milk, soy, eggs, and wheat or peanut and then, even small amounts can cause severe eczema or blood in the stools. The reason is that many proteins eaten by a nursing mother appear almost unchanged in the breast milk of that woman.
What about the newborn sibling of a patient with eczema? Our experience is that when foods have been implicated in the development of eczema in a first child, it is worthwhile eliminating those same foods in all subsequent children. We usually suggest beginning that elimination diet in the third trimester of pregnancy and continuing it at least for the first 2 months of life. Please consult us before trying such an elimination diet so that we can insure that your child is getting the appropriate minerals and vitamins.
How often do patients with eczema and food allergies, outgrow both? 33% stop having clinical reactions in 1-3 years. Sensitivity to milk and eggs is most likely to be outgrown while sensitivity to peanuts, nuts, fish and shellfish are outgrown less rarely. The more you expose a child to a food to which he/she is potentially allergic, the more likely he is to develop a long-term allergy. Our recommendation is to do an Immunocap test at 1, 2 and 5 years. If still positive at 5 years, it is unlikely to resolve.
How do we approach treatment for eczema?
- Eczema is a complex disease. It has no obvious single cause and therefore, cannot have a simple, single form of therapy.
- Eczema is a chronic disease. It assumes many different forms at different ages and therapy will likely need to be modified as the disease changes.
- Eczema is rarely cured. It is either outgrown or it changes over time. Do not expect long-term miracles from the medications you receive.
- Although it is a chronic, relapsing disease, it is almost never disfiguring and fortunately, it almost always is markedly improved during adolescence when facial appearance becomes more important.
What are the recommended treatments for eczema?
- Lubricate extensively - Dry skin is best treated with extra moisture
- Moisturize often – We once had a child with horrible eczema except on Tuesday night. Upon further investigation, it was discovered that the grandmother babysat on Tuesday and lubricated every 30 minutes while her grandchild was in her charge. The point is not that you have to lubricate 15 times a day. But three or four times are better than one or two times. Place a pump of moisturizing cream by the changing table and you are likely to use it more and more often. Remember it is not usually what you use, but how often your use it. Beware the Madison Avenue hype and try out different products because there is always one cream or lotion that works best for your child’s skin. For truly hard to treat skin, Aveeno, Moisturelle, Eucerin and Cocoa Butter (many types) are some useful brands.
- Bathe and lubricate - We used to recommend minimal bathing. But in the past few years, the approach has changed 180 degrees. We now feel that in order to remove layers of dead skin and lock in moisture, your child should be bathed at least once or twice a day (or three times for an infant!). Use a capful of bath oil such as oilatum, Alpha Keri or Aveeno in the bath because these products allow the oil to go in solution and coat the skin. Routine baby oil is less useful because it tends to stay on top of the water and not mix with it. Babies should be left wet when taken out of the bath (be careful- wet babies are very slippery ones). Moisturizer should be applied within 3 minutes of removal from a bath, during that period when the fingers still look like prunes.
- Avoid drying soaps – Soaps such as Ivory and most deodorant soaps are very drying and irritating to the skin. Use mild cleansers such as Dove or Cetaphil in a child with moderate to severe eczema.
- Add a humidifier to the bedroom- Keeping a humidifier in the room and maintaining the humidity level at 50% winter (because heat is drying) and summer (because air conditioning is drying), is another helpful hint. Swimming is another useful source of humidity, although, in some children, chlorine can worsen eczema.
- Avoid irritant sources: Wear cotton clothing because wool and polyester can be real irritants. Children with eczema should wear only cotton underwear and socks and, during the winter, should wear layers of cotton and not wool. Irritating perfumes and deodorants should be avoided. In general, roll-on deodorants are better tolerated that sprays and unscented forms are preferred.
- Use mild laundry detergents – In general, most studies have found no significant advantage to any particular brand unless there is a strong clinical correlation between a skin outbreak and a laundry detergent. For most children Dreft is no better than any of the other detergents. Avoid bleach and fabric softeners and stay away from perfumed laundry products.
- Reduce sweating – Excessive sweating increases the itch sensation. Thus, during the hot summer months, a cool environment should be provided using fans and air conditioners as well as natural breezes and cross ventilation.
- Use steroid medications wisely – For mild eczema, moisturizing cream alone will probably suffice, provided you use it early and often. However, moderate to severe eczema will usually require treatment with some steroid cream or ointment. For mild eczema on the face, use over the counter products such as 1% hydrocortisone, twice a day for about a week. When using both a moisturizing cream and a topical steroid, rub in the steroid cream first so that it can penetrate the skin. For areas with very thickened skin, we will usually recommend a prescription steroid such as 0.1% triamcinolone or betamethasone, which should be used twice a day for 7-10 days. Avoid the advertised hype or the friend whose child was ‘miraculously’ cured after using a specific brand. There are many different steroid preparations and each can be characterized by its potency. There is almost always a generic product that is as good as the brand name. Use the steroid cream for as short a period as possible and immediately switch to plain moisturizing cream.
- Understand the difference between an ointment and a cream – Ointments are oil based and do not evaporate. They are useful on the body and in heavily thickened areas. They should not be used on the face or over open wounds to reduce the amount absorbed by the rest of the body. They should also not be used in hot weather because they will clog sweat pores and can cause rashes. Creams are alcohol based and can be used more readily in sensitive areas of the face and in hot weather.
- Treat any associated infection – Because of the itch scratch cycle, there are often areas where the skin is broken down, allowing the invasion of strep and staph, two germs that normally cover our skin. Infected skin itches more and is therefore associated with thicker, more irritated skin. A local infection is often implicated in hard to treat eczema and should be treated by a prescription product called mupiricin (or Bactroban). It is unusual for over the counter (OTC) antibiotic products to be useful in controlling outbreaks. In more severe cases, we will prescribe an oral antibiotic to wipe out the associated infection.
- Use anti itch medications – Benadryl (diphenhydramine-OTC) or Atarax (hydroxyzine-prescription only) appear to be helpful because they break the itch-scratch cycle. The newer, non-sedating antihistamines (Claritin and Zyrtec) are helpful for mild cases but often not as helpful in more severe cases
- Consider deeper penetrating creams – There is now a new category of creams (Mimyx and others) that penetrate the top or dead layer of skin and moisturize from the bottom up. Because of its cost, we will usually prescribe this category only when other moisturizing creams and topical steroids have not been helpful.
- Conclusion – Eczema can be at once both frustrating and gratifying. The exacerbations can be enormously disturbing especially when the offending foreign protein cannot be identified. But it can also be very exciting when you hit upon the combination of anti-itch, antibiotic and moisturizing care products. We are dedicated to walking alongside you as you discover that unique approach or combination of approaches.