Eczema: The Itch that Rashes
By: Michelle Place, CRNP-P
What is it?
Atopic dermatitis (AD), commonly referred to as eczema, is a chronic, extremely itchy, dry, red rash that improves and then worsens again over time. It primarily affects children, and appears before the ages of 1 and 5 years in 65% and 85% of affected children, respectively. A recent national study suggested that the prevalence of eczema in children is at least 10% in most of the United States. (PEDIATRICS Volume 134, Number 6, December 2014)
What does it look like?
Eczema occurs in a typical distribution that changes with age. In infancy, the cheeks, scalp, trunk, and extremities are most commonly affected. In early childhood, the flexural areas are characteristic, as in the folds of the elbows and behind the knees. In adolescents and adults, the hands and feet are typically involved.
How long will it last?
The good news is that most children outgrow the symptoms. At the very least the severity of the disease will improve over time. Until then, new data supports the theory that eczema results from abnormalities of the skin barrier, this means that taking care of the skin is the most important part of treating a child with eczema.
Food allergy does NOT cause eczema
It is important to stress that food allergies do not cause eczema. More than 90% of parents incorrectly believe that food allergy is the sole or main cause of their child’s skin disease. This focus on food allergy can result in elimination diets, potential nutritional concerns, and misdirection of treatment away from the skin, which leads to undertreatment.
The belief that food allergies play an important role in eczema results from the fact that food allergies occur more often in people with eczema. The prevalence of food allergy in all children in the first 5 years of life is about 5%. In children with eczema the prevalence of food allergy is more like 30% to 40%. In addition, children who have food allergy often have earlier-onset and more severe eczema, and those with early-onset eczema have a higher risk of developing food allergies than those with later-onset disease. The presence of food allergy predicts that severe and persistent eczema is more likely but does not cause the skin disease. As a result, if there is no proof through skin or blood testing of a food allergy, food avoidance will make no difference to a child’s eczema.
Evaluation for milk, egg, peanut, wheat and soy allergies is a good idea in a child under 5 who has severe eczema that persists despite optimal skin treatment or whose itching and rash noticeably worsen after eating a specific food. It is recommended that infants who develop severe eczema in the first few months of life have early exposure to allergenic foods, like peanuts, because early exposure has been shown to decrease the development of food allergies. This should be done only with the supervision of an allergist.
Eczema and development of other allergy disorders
The “atopic march” is the idea that eczema is the first stop in the progression to other allergic disorders, such as asthma and seasonal allergies. Early optimal and successful treatment of AD may prevent or lessen the development of other allergic conditions. Optimal treatment of the skin helps because the skin acts as a barrier, when this barrier is disrupted it allows for the entry of allergens. This highlights the importance of good skin care in the treatment of eczema.
The primary function of the skin barrier is to restrict water loss and to prevent entry of irritants, allergens, and bacteria or viruses that live on the skin. Skin-directed therapies should be the first approach to managing a child’s eczema. This approach has 4 main components, each focusing on a specific symptom of eczema:
(1) maintenance skin care;
(2) topical anti-inflammatory medications;
(3) itch control;
(4) managing infectious triggers
(1) Skin Care
Maintenance skin care is the foundation of AD management; its goal is to repair and maintain a functional skin barrier. It is important to develop good skin care habits and perform them daily, these good habits help to reduce both the frequency and severity of AD flares. The key factors in care include maintaining skin hydration and avoiding irritants and triggers.
- Bathing: The optimal frequency of bathing for children with eczema has not been well studied. Soaking baths allow the skin to absorb moisture, and a daily bath can be beneficial in children with AD as long as a moisturizer is applied afterward. The frequency of bathing should be individualized to each child and his or her response to bathing. The use of lukewarm water and limiting the amount of time in the bath can prevent skin dehydration. Cleansing also removes bacteria from the skin surface. A mild soap without fragrance can be used without making eczema worse.
- Moisturization: Frequent moisturization reduces discomfort associated with dry skin, helps to repair the skin barrier, and reduces the amount and strength of steroids needed. There are no studies comparing specific moisturizers and the sheer number of colorful bottles lining drugstore shelves can be overwhelming. The best moisturizers for children with eczema are fragrance-free and have the least amount of preservatives because these can be irritating.
To break it down, all moisturizers are mixtures of lipids (fats or oils) and water:
- Ointments have the highest proportion of lipids to water (for example, petroleum jelly AKA Vaseline is 100% lipid); as a result they have a greasy feel when applied to the skin but they have the greatest moisturizing effect.
- Creams are mixtures of water in lipid (oil > water) which contain preservatives to keep the ingredients from separating. They feel less greasy but the added ingredients sometimes burn or sting eczematous skin.
- Lotions have a higher proportion of water to lipids than creams. They are the least moisturizing so need to be reapplied frequently to maintain skin hydration.
There are some moisturizers that are available by prescription only. Sometimes parents feel that something they can get with a prescription works better than a product sold over the counter. These prescription moisturizers have no active pharmacologic ingredients. A small study compared these products with an over-the-counter ointment and showed that although the prescription products caused no harm there was no significant difference in effectiveness either. Since the prescription products are much more expensive than their over-the counter counterparts they are not worth the extra cost.
- Triggers: Multiple child-specific factors, commonly referred to as triggers, may worsen AD. Triggers may be unavoidable, but minimizing exposure to them can be helpful. Common triggers include environmental allergens, infections (especially viral illnesses), harsh soaps and detergents, fragrances, rough or non- breathable clothing fabrics, sweat, excess saliva, and psychosocial stress.
(2) Topical Steroids
The itchy, dry, red rash seen in eczema results from an inflammatory immune response in the skin. Flares of eczema are unlikely to respond to moisturization alone, and during these times, treatment should focus on decreasing the inflammatory response. Topical steroids are the first-line, most commonly used medications to treat active AD and have been used for the last 40 to 50 years. When used appropriately they are effective and safe, however, when used inappropriately there are potential risks. This can sometimes result in “steroid phobia” among parents and caregivers. This fear can lead to undertreatment of eczema and its flares.
Topical steroids should be applied to affected areas in a thin layer once or twice daily until the skin is smooth to touch and no longer red or itchy.
- How? When comparing the same active ingredient and concentration, ointments are more effective than creams or lotions because their occlusive effect results in a higher relative potency. Ointments are also less likely to burn or sting so are better tolerated by infants and younger children.
- How long? Topical steroids are stopped when eczema is quiet and restarted when flare-ups recur. Because of the improving then worsening nature of eczema, placing a limit on the length of time topical steroids should be used can be confusing and lead to unsatisfactory outcomes. If eczema has not improved after 1 to 2 weeks of steroid treatment, however, your doctor should be called to re- evaluate in order to consider other diagnoses or decide if a different treatment plan is needed.
**When these general guidelines are followed, the risk of adverse effects from the use of topical steroids is extremely low.
Eczema is commonly referred to as the itch that rashes; this is because the eczematous child can experience significant itching even in the absence of significant rash. Parents may be unaware of how much their child scratches because itching is generally worse at night.
- Oral antihistamines
-Anti-itch medicines do not have a direct effect on the rash, but can help reduce the sensation of itching which decreases scratching and the resulting trauma to the skin.
-Sedating antihistamines (such as diphenhydramine (Benadryl) or hydroxyzine(Atarax)) should be used carefully in infants, who may be more prone to the adverse effects of these medications. In addition, agitation instead of sedation may occur in some children.
-Non-sedating antihistamines (such as cetirizine (Zyrtec) and loratadine (Claritin)) are less effective for the itching but are helpful for children who have environmental allergic triggers.
-Topical antihistamines like creams or lotions are not effective in the treatment of AD- associated itching and contain potential irritants that may make the rash worse. They can also be absorbed through the skin so parents can accidentally overdose their child if the cream is used along with medicine by mouth.
- Wet Wrap Therapy: For acute flares and moderate to severe cases of eczema, wet wrap therapy (also called wet dressings) can be used along with topical steroids to decrease itching, and discourage scratching. After a soaking bath, topical steroid is applied to affected areas then a moisturizer is spread over the rest of the skin; next, moist gauze or cotton clothing that has been dampened with warm water is applied; the wet layer is covered with dry cotton clothing. Blankets and a warm room keep the child comfortable. The dressings can be left in place for 3 to 8 hours before being changed. Wet dressings can be used continuously for 24 to 72 hours or overnight for up to 1 week at a time.
(4) Infectious Triggers
Both bacterial and viral skin infections are associated with flares in children with eczema. Affected children, especially those whose eczema is poorly controlled, have a higher risk of developing skin infections.
Bleach Baths: Dilute bleach baths may have a useful role in the management of children with AD, particularly those prone to recurrent infection and AD flares. A recent study looked at the effects of 0.005% bleach baths plus the application of an antibacterial ointment (mupirocin, Bactroban) compared to no treatment in children with moderate to severe AD. Patients bathed for 5 to 10 minutes twice weekly. Those in the treatment group had significant improvement in their AD severity. Areas of the body that were not submerged in the bleach-containing water, specifically the head and the neck, did not show any change. The bleach baths were well tolerated, without any adverse effect, and without any increase in resistant strains of bacteria. A concentration of 0.005% bleach is made by adding 120 mL (1/2 cup) of 6% household bleach to a full bathtub (estimated to be 40 gallons) of water.
(information for this article taken from PEDIATRICS Volume 134, Number 6, December 2014)
Eczema can be a challenging and frustrating chronic disease for both affected children and their parents. Let us relieve some of that frustration, call us here at Potomac Pediatrics at 301-279-6750 to make an appointment so one of our providers can help you come up with a treatment plan that is right for you and your child
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