Eczema (Atopic Dermatitis)

If your child has a rash that is dry and itchy and just won’t go away, then you need to consider that they may have eczema.

What happens in the body

Skin covers the entire body, helps hold water, and protects us from bacterial, viral, and fungal infections. People that have eczema don’t hold the water or moisture in the skin. This protective barrier breaks down and people are more exposed to infections and things that can irritate the skin. We know that eczema is both hereditary and triggered by things in the environment. One of the first things I ask my patients when I’m trying to figure out if they have eczema, is do you have any family members that have asthma, eczema, or allergies? Eczema is a sister to asthma and allergies. Some children may grow out of eczema, but others will not.

Prevention is key- moisturize!

Eczema is a chronic (meaning long-term), dry, bumpy or red rash that has times when it is worse and times when it is better. The goal of care is keep the flares (times when skin is red, irritated, itchy and inflamed) to a minimum. To do this, it’s important to give the body what is missing – moisture. Vaseline is an ointment that will hold moisture in. I like it because it is both affordable and available all over the world. Vaseline is one of the many ointments that dermatologists recommend as a first line prevention. (Avoid vaseline that has fragrance added to it.) Creams don’t hold moisture as well. Lotions often have scent added that can burn and dry out the skin.

Daily routine

1. Choose hypoallergenic, scent free soaps and detergents when able because they can be irritating to your child’s skin and may trigger a flare. Keep in mind that many products marketed to babies have added fragrance that kids with eczema should avoid. If you don’t have those options, then be sure to double rinse all of your baby’s clothes.
2. Apply vaseline all over your baby when he or she first wakes up in the morning.
3. For babies with widespread eczema, apply vaseline all over your baby with every diaper change. For older kids, keep vaseline in the bathroom and teach them to apply it regularly to affected areas.
4. In the evening, allow your baby to soak in lukewarm bath water for 10-15 minutes. Don’t put any soap or bubble bath in the water. Just before getting baby out of the bath clean under their arms and in soiled areas with a gentle, allergen free, fragrance free soap and rinse well. Pat them dry. While your baby is still moist, rub vaseline all over their body. Apply snug fitting pajamas to help keep the moisture in.

Treating eczema flares

You should always follow the daily routine prevention with eczema, but when areas in the skin are red and irritated, then it is time to step up the daily routine and treat the flare. Topical steroids are the first line of treatment for a flare. Some steroids are more powerful than others. The goal is use the least powerful steroid that helps. Also, steroids only need to be applied to the inflamed areas. And, they should not be used for more than two weeks in a month. As a general rule the ointment is preferred over creams.

Some examples of steroids in order of least to most potent

Hydrocortisone 1% ointment is the least powerful steroid. It is available all over the world and can be found over the counter in the United States. It is safe for a limited time on the face and diaper area. It is also the first choice for young babies on the body.

Hydrocortisone 2.5% ointment is a little more powerful and can be used on the body for babies 2-3 months and older. It can be used with caution on the face and diaper area.

Triamcinolone acetonide 0.025% ointment (prescription) is more powerful. It can be used on babies over six months on the body for mild to moderate inflammation.

Triamcinolone acetonide 0.1% ointment (prescription) is even more powerful and should be reserved for moderate to severe eczema and should not be used for anyone under 1 year and should not be used on the face or diaper area.

Mometasone 0.1% ointment (prescription) should not be used on children younger than 5 years and should be reserved for use on the body and only for moderate to severe eczema.

Betamethasone Dipropionate (prescription) is one of the highest potency steroids. I mention it here because I found it sold alongside hydrocortisone over the counter in Malawi. It was also one of the ingredients in many of the combination creams sold over the counter. Often parents think that because a medicine is a cream it is safe, but that is not true. We prescribe these medications to avoid them being used in the wrong way. This medicine should not be used in little children and should only be used under the supervision of a well informed healthcare provider for the most severe inflammations. (This is another reason why you should not use your family member’s prescription medication.)

How to treat a flare

1. Apply a thin layer of the prescribed steroid to the red inflamed areas as the first layer twice a day for a week.
2. Next, apply the vaseline.
3. When the areas are no longer red and inflamed then stop using the steroid, but continue with your daily prevention routine.
4. If there are certain areas that get inflamed frequently, then you can apply the steroid once or twice a week to that area to avoid a relapse.
5. You may use Benadryl (diphenhydramine) syrup by mouth at night to help relieve itching symptoms. This medication may also help your child sleep better. (It is Docoff pediatric in Malawi)
6. Don’t use steroids for more than 2 weeks in a month. If you are needing the steroid more often, then it could be a sign that the eczema is not well controlled and you should go back to your healthcare provider. (There are other medications such as topical calcineurin inhibitors and PDE-4 inhibitors that are now being used to treat eczema as well.)

When to go to the clinic:

1. If the flares are lasting longer than two weeks without improving
2. If there is any sign of infection. Infected areas may be red and crusty. If in doubt, take them in.
3. If there is are tiny red or fluid filled blisters on the skin. Kids with eczema are more likely to catch a virus called eczema herpeticum. This must be monitored closely because it can spread to other areas of the body.
4. If your child has a fever and worsening rash.

You Got This!

I feel like well informed parents become the experts on their own child’s eczema. Over time, you will tell when your children need more moisture, are having a flare, and when it’s time to bring them in. While there are constantly new products coming out, I love that Vaseline and hydrocortisone can prevent and care for most eczema flares and are readily available to the moms in the villages of Africa as well as the moms in suburbia USA. There’s something unifying about that!

Resources:

Pedsderm.net has many useful patient education resources, including videos under the patients and families tab.

healthychildren.org/eczemaCare provides a toolkit for parents to understand and treat eczema