Eczema (Atopic Dermatitis)
Also: Atopic Dermatitis
This is a common skin condition which can come and go. Typically skin becomes red, dry and itchy, and the resultant scratching can cause swelling, cracking, “weeping” of fluid, and scaling of skin.
Between 10 and 20% of people worldwide develop atopic dermatitis, which is the most common form of eczema. Many develop the condition in the first year of life, and most by age 5. Eczema is not contagious. Eczema can be genetic, caused by a lack of Filaggrin, a protein that helps keep the top skin barrier in place. Eczema is more common in children with food allergies and/or asthma, or with a family history of allergic diseases. The rash can be triggered by foods and topical agents (saliva, sweat, lotions) but often there is no obvious cause.
Infantile eczema is usually worst on the scalp and face, as well as in the creases of the neck/behind the ears but can also be found on flexor surfaces (elbows, knees), in the groin folds due to rubbing of skin on skin, and in patches elsewhere.
Seborrheic eczema may cause yellow, oily flakes on the scalp and face. Infants typically improve over time, often resolving by age 2. Sometimes yeast that lives in the oily parts of the skin can overgrow, causing an acute worsening of eczema- this may be treated with an antifungal medication.
Toddlers, older children and teens with eczema commonly have elbow and knee involvement, as well as patches on the hands/feet/wrists/face/neck/eyelids and upper chest. Thumb suckers, pacifier use, and lip lickers often get areas of irritation around the mouth due to salivary enzymes that cause skin breakdown.
Nummular eczema can cause round patches of affected areas that are sometimes mistaken for ringworm. Long standing eczema can cause either pale or darkened patches of skin, or scaly/thickened skin due to chronic inflammation (especially on elbows and knees). Sun exposure can exaggerate skin color differences.
Chronic dryness and irritation of the skin can lead to fungal and bacterial infections, typified by increased redness, itch, crusting and discharge.
Many everyday exposures can cause flares of atopic dermatitis. Wool and other rough fabrics, juices from meats and fruits, jewelry (particularly cheaper, nickel-containing metals), latex in band-aids or tapes, and even some lotions. Metal snaps on jeans often cause a chronic rash around the belly-button (place duct-tape over the inside of the snap.) Wear gloves when using cleaning agents or cooking.
Dyshidrotic eczema is an irritation of the palms and/or soles that causes itch, blisters and peeling or cracking. Often mistaken for athlete’s foot (which is uncommon in prepubertal children, and typically between the toes.)
TREATMENT
- SOAK AND SEAL
- Lukewarm bath for 5-10 minutes. Avoid any oil-removing soaps. Cetaphil, CeraVe, Mustela, Oilatum or Aveeno non-soap cleansers can be used sparingly in particularly dirty areas. Otherwise just use water.
- After bathing, immediately PAT dry (NO rubbing)
- Apply any prescription topical medication to affected areas of skin.
- Within 3 minutes apply a thick layer of moisturizer. Vaseline, Vanicream Ointment or Aquaphor (CVS equivalent is fine) work best. For particularly tough areas, try a thick diaper ointment like Triple Paste under cotton pajamas. Wait a few minutes for the moisturizer to absorb before dressing.
- Reapply ointments or creams (lotions are lighter but not effective due to low oil content) frequently during the day, particularly to prevent exposure to irritants (i.e. to face before eating, before going outside.) We recommend Vaseline, Vanicream Ointment or Cream, Aquaphor, CeraVe Cream , Aveeno Cream or Eucerin Cream.
- Avoid laundry products with perfumes or dyes– particularly dryer sheets that can leave a residue on clothing.
- AVOID ITCH– this is the “itch” that “rashes.” Treating the itch will help avoid resultant irritation and infection. Keep your child’s nails well trimmed. Try COLD lotions or compresses/ice packs, antihistamines such as Cetirizine (Zyrtec), covering bad areas with moisturizer and and wet wraps (see below for instructions.)
- TOPICAL STEROIDS -For mild eczema you can start with over-the-counter 1% hydrocortisone cream applied twice a day. If skin is open, crusty or weeping, or persistently irritated and itchy see your physician; topical anti-bacterials or prescription steroids may be necessary. As steroids can thin the skin and cause color-change over time, they should be used in “bursts”- every day at the prescribed frequency for up to 2 weeks, then at least a 2 week break. DO NOT use on eyelids/around eyes. If eczema is uncontrollable off topical steroids, revisit the physician.
- CALCINEURIN INHIBITORS– otherwise known as Pimecrolimus (Elidel )or Tacrolimus (Protopic), these prescription medications interfere with the inflammatory process that causes eczema. These can be used long term without adverse consequences for moderate to severe eczema. These are particularly useful around the eye, where topical steroid is not recommended. Use a prescribed steroid along with the medication for the first few days if they sting when applied.
- ANTIBIOTICS– when there is skin breakdown, bacteria such as staph and strep, which normal lives on the skin surface, can cause increased redness/scabbing/discharge and itch. We will use topical antibiotics (Mupirocin/Bactroban) for small areas, or oral (Cephalexin/Keflex or Amoxicillin) for larger areas of infection.
- BLEACH BATHS– eczema flares are often caused or accompanied by superinfection with skin bacteria such as staph. Bathing 3 x week in a weak bleach bath (the equivalent of a swimming pool) can help. Use standard, unconcentrated bleach (5.25-6%). Add 1.2 cup to a full standard bathtub (20 gallons), or 1 tablespoon to a baby bathtub (about 4 gallons). Soak for 10 minutes, then gently dry and moisturize. An alternative is to use Cln Wash (available on Amazon and in drugstores) which is a bleach based soap for bath or showering.
- Wet Wraps:
- Using gauze or cotton gloves, moisten in warm water until damp.
- Wrap around are of affected skin
- Gently wrap dry layer around wet layer
- Leave on several hours or overnight under pajamas.
- CRADLE CAP/DANDRUFF– simple treatment consists of moisturizing wet hair with olive or mineral oil, and combing out the flakes. For more persistent cases, Selsun shampoo can be used 2-3 times a week (shield eyes to avoid burning) and/or OTC 1% hydrocortisone cream 2 times a day for several days.
- DYSHIDROTIC ECZEMA– use moisture wicking socks, and change frequently to avoid sweat-soaked feet. Flip flops and Crocs in the summer may worsen symptoms due to feet sitting in sweat/moisture. Moisturize frequently, use prescribed steroids as needed for itch/irritation/cracking and peeling.
