Eczema-Dry Rash that Won’t Go Away

Soap is by far the most popular baby gift in Africa.  Many of the post-delivery customs include detailed expectations of who is supposed to bathe the baby, how often, and when.  Understanding that frequent bathing (as much as several times a day) is a part of the Malawian custom has helped me understand why I frequently see eczema-like rashes.  Whether or not these dry patches are truly eczema, I have found that treating them like eczema has significantly improved them.  

How the body works:  

The skin is the largest organ in the body.  It protects the body from infections.  Also, the skin has oil glands that help it stay moist and flexible.  Bathing with soap is the most effective way to remove dirt and bacteria that quickly build up on the skin. However, the soap also removes some of the natural oils that provide moisture.  

This sweet baby’s eczema cleared up with step 1.

Eczema (atopic dermatitis) is a dry, itchy, bumpy rash that presents typically on the face in babies and on the elbows and knees as babies get older.  But it can show up anywhere.  It can range from mild irritation covering little areas to wide-spread dry, irritated, inflamed and even leaky, infected areas.  It is now understood that there is a link between eczema, seasonal allergies, and asthma.  Therefore, having family members with any of these allergy type syndromes can point toward the diagnosis of eczema. Unlike skin infections or ringworm which go away completely when treated, eczema is a long-term condition that may change or improve as your child ages.

Eczema follows a step up/ step down treatment plan. The goal is to stay on the lowest step as needed. Step up when symptoms worsen. Step down when they improve.

Step 1 – Preventive measures- for mild symptoms such as dry irritated patches:

  1. Try to reduce bathing to every other day.  If in your culture it is very important to at least bathe the baby daily, then try to limit the bathing to just once a day. 
  2. Use mild soaps for the groin and under arms, otherwise just use warm water.
  3. After the bath, pat the baby or child dry and apply Vaseline while she is still a little moist especially to the dry area.
    • Vaseline is preferred over lotion because lotions are watery and have alcohol based scents added which dry out the skin. (There are some lotions that are designed specifically for sensitive skin such as Cetaphil, Eucerin, or Lubriderm, but these are often quite expensive in Africa and Vaseline works well.)
    • Vaseline may be too thick and occlusive for some areas, such as the face.  One of my co-workers advises mixing one part Vaseline with one part liquid paraffin (the kind you buy from the pharmacy) instead of straight Vaseline. Her patients have had a lot of success with this.
  4. Dress baby and child in light cotton clothes. Avoid materials that are very heavy.  Don’t over-bundle baby.

Step 2- Treatment for mild flare-up:

  1. Do everything in step 1.
  2. Hydrocortisone cream is a topical steroid that can be purchased over the counter. For mild flare-ups it can be applied twice a day to the affected area. You’ll usually see improvement within a week and can step back down to step 1. 
  3. Only if the area is very itchy and keeping your child from sleeping, you may give her Docoff Pediatric. Marketed as a cough syrup, the active ingredient is diphenhydramine which is a first generation antihistamine that will reduce the symptoms of itching.  It will usually make your child sleepy, but some children get hyper with the medicine.  Watch your child closely while on the medicine and best not to give to children under the age of 2 yr.  Follow the directions on the bottle for dosing.  Ceterizine is a non-sedating antihistamine and is a better choice (though not as readily available in Africa).
  4. If the condition worsens or you don’t see an improvement, see your health care provider.

Step 3 – For flaky, oozing, infected or not improving eczema:

  1. See your health care provider.
  2. Betamethasone is a stronger topical steroid that can be purchased over the counter in most African pharmacies.  It’s important that you use it only under the care of a health care provider for several reasons: 
    • First, if your condition is severe enough to need the stronger steroid, then there may be other treatments your provider will prescribe. 
    • Also, there are other skin conditions that look similar to eczema, but are treated differently. Your child should have an evaluation before starting on a stronger steroid.
    • Sometimes severe eczema can get infected and needs to be treated by your health care provider.
    • Betamethasone can thin the skin and may result in scarring. It should not be used on the face, groin or under the arms unless advised by your health care provider.

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