What is atopic dermatitis (eczema)?
Atopic dermatitis (eczema) is a chronic rash that affects up to 20% of children in the U.S. and is caused by a genetic defect in the skin barrier that allows excessive water loss. As a result, the skin becomes scaly, red, dry, and itchy. Although eczema can occur at any age, most individuals will develop symptoms by 5 years of age. Many children will outgrow their eczema by late childhood or adolescence.
Where on the body does atopic dermatitis/eczema typically occur?
Infants tend to develop eczema on the elbows, scalp, and cheeks. Childhood eczema frequently occurs on the inside part of the arm at the elbow crease, behind the knees and on the wrists, ankles, and neck.
What can make atopic dermatitis/eczema worse?
Many triggers can make eczema worse, including:
- Scratchy, itchy clothes
- Harsh soaps, detergents, and cleaning solutions
- Personal care products with strong fragrances
- Excessive perspiration, dry environments (typically worse during winter)
- Stress or anxiety
- Heat or extremes of temperature
- Cigarette smoke
- Food allergies (see next question)
- Environmental allergens
- Dust mites, pet dander, molds, pollens
Can food allergies make atopic dermatitis / eczema worse?
Most children with mild or moderately severe eczema will not have a food allergy triggering the eczema. However, approximately 1/3 of children with more severe eczema may have a food allergy. Generally speaking, the more severe the eczema, the more likely a food allergy is involved. A good rule-of-thumb is that food allergies are not likely involved if the eczema can be well controlled by using a moisturizer or low potency steroid cream.
The majority of food triggers are accounted for by the following foods:
- Cow’s milk
- Tree nuts
Can my child outgrow his/her eczema?
Yes, many children do outgrow their eczema by late childhood or adolescence.
How can I treat my child’s eczema?
It is important for patients and families to know that eczema is a chronic condition that will fluctuate in severity over time. For most patients, there is no magic pill to take that can make the rash go away. But there are many things that you can do to help keep it under control. One of the most important things is keeping the skin well moisturized. Children and adults with eczema lose excessive moisture through the skin and must take measures to help prevent this water loss.
Atopic dermatitis/eczema skin care
- Frequent use of a moisturizer is one of the most helpful and important components of treating eczema. This point is usually not emphasized enough to patients. Moisturizers should be generously applied up to several times each day. The best time to moisturize is immediately after bathing when the skin is still damp. Choices of moisturizers will be discussed in a separate section.
- Moisturizers help lock in moisture and prevent water loss from the skin. Emollients have been used synonymously with moisturizers. Emollients are substances added to a moisturizer that help fill in the rough cracks and increase the skin smoothness.
- The best moisturizers are thick creams and ointments. Lotions are typically less protective that creams or ointments as the alcohol added can have a drying effect on the skin.
- Examples of effective over-the-counter moisturizers include:
- Creams: Cetaphil® and Eucerin®
- Ointments: Petroleoum jelly (Vaseline®) and Aquaphor®
- Ointments are the most effective moisturizers but are much greasier than creams or lotions
- Ointments are better tolerated in infants and toddlers
- If you have been prescribed a topical corticosteroid medication, apply the over-the-counter moisturizer approximately 30-45 minutes after applying the topical corticosteroid medication (or as directed by your physician).
- Choice of clothing and detergent: Abrasive/ itchy clothes (such as wool) should be avoided. Cotton clothing washed with hypoallergenic detergent without bleaches or fabric softeners may make the clothes more comfortable.
- Keep things cool in the house. Aim to keep the temperature 76 degrees or lower if possible. Keeping humidity levels between 35-40% can also be helpful.
- Bathing: Although once discouraged, daily bathing actually promotes better skin hydration when done with certain restrictions. Baths should be shorter in duration with lukewarm temperatures. Excessively long hot baths can dry the skin. A modest amount of bath oil can be added to the bath if desired. It is important to pat, not rub, the skin dry. Moisturizers should be applied very generously within several minutes of bathing, while the skin is still damp. This will help lock in the moisture. Avoid scrubbing the skin with a washcloth. During a severe flare up, it is best to avoid use of cleansers as well, as this can further irritate the skin.
- Soaps/ cleansers: It is important to use a replenishing non-soap cleanser that does not dry out the skin. Although many people enjoy the feeling of having a “clean” face after using various cleansing products and astringents, it is important to remember that wiping away too much of the skin surface will strip away the natural protective barriers of the skin. Cleansers with a neutral pH are preferred.
- Examples of non-soap cleansers include:
- AVEENO ® Active Naturals Skin Relief Body Wash
- Aquanil ® Cleanser
- Aquaphor ® Gentle Wash
- CereVe ® Hydrating Skin Bar
- CereVe ® Hydrating Cleanser
- Cetaphil ® Gentle Skin Cleanser
- Cetaphil ® Gentle Cleansing Bar
- Dove ® Sensitive Skin Unscented Beauty Bar
- Mustela ®Stelatopia Cream Cleanser
- Oilatum® Cleansing Bar
My doctor has prescribed a topical corticosteroid cream for my child’s eczema. Are these medications safe?
When frequent use of moisturizers is not adequate to control the eczema, prescription corticosteroid creams are often added. Topical corticosteroid creams range from very mild to very potent. The least potent topical steroid cream is hydrocortisone 1% cream and is available over-the-counter. Many people fear using topical corticosteroids because of possible side effects. However, under appropriate physician supervision, topical corticosteroid medications can be a safe and effective childhood eczema treatment. The skin of the eyelids, face, under-arms, and groin area is very thin and susceptible to side effects from topical corticosteroid medications. Even mild topical corticosteroid medications should be avoided on the eyelids, underarms, and groin area. Under appropriate physician supervision, a low potency corticosteroid medication can be used safely on the face (making sure to avoid the eyelids). While it is important to understand the potential side effects of these medications, avoiding them all together can prolong a child’s suffering unnecessarily.
Topical corticosteroids: These medications are safer than oral corticosteroids but side effects can still occur- particularly with the more potent prescription topical corticosteroids.
Side effects can include:
- Thinning of the skin (atrophy)
- Stretch marks of the skin caused by scarring
- Changes in skin pigmentation
- Contact allergy to the corticosteroid medication or one of the preservatives
- Rarely, the topical corticosteroid medications may be sufficiently absorbed into the system and affect the body’s ability to naturally produce corticosteroids during a time of stress (hypothalamic pituitary axis suppression).
Are there any other topical prescription medications that can be used for eczema that do not contain a corticosteroid?
Yes. Elidel® (pimecrolimus) and Protopic® (tacrolimus) are referred to as immunomodulators and are fairly new topical eczema treatment options. These medications do not contain corticosteroid medications and can be used safely on sensitive areas of the skin such as the eyelids, face, groin, and underarms. Although they have been used safely for many years, the FDA has issued a warning for these medications until longer-term safety studies have been completed. Much of this concern comes from animal studies that used exceptionally high doses of the oral formulation of the medications. These very large oral doses caused rare cases of cancer in some animals. Many dermatologists and allergists feel that the warning issued by the FDA has created unnecessary concern, preventing many children and adults from receiving adequate relief of their symptoms. In fact, The American Academy of Dermatology and The National Jewish Medical Center, both nationally recognized authorities on the eczema treatment, have each issued formal statements in which they disagree with the FDA warning. Each of these organizations feels that the medications are safe when used properly and while under appropriate physician supervision. Elidel® and Protopic® are best used on an intermittent basis and in children older than two years of age. The FDA recommends that topical corticosteroid creams should be used prior to initiating eczema treatment with these medications. Proper sunscreen should be used to protect the skin when using these medications.
Are anti-histamines helpful for eczema?
Anti-histmamines are frequently used to help treat eczema but their effectiveness has not been clearly shown.