Two exhausted parents bring their infant in to my office. The child is covered in red, rough patches and scratch marks. He's clearly uncomfortable and his parents tell me he doesn't sleep well. They were given a prescription for hydrocortisone cream by their pediatrician, but are worried that it will harm their child and so have been reluctant to use it. No one in the house has slept well in months and everyone is on edge. This is a hypothetical scenario but ones just like it are all too common in my practice.
Atopic eczema, also known as atopic dermatitis, is a very common childhood rash in which children get red, scaly, itchy patches on their skin. About 15-20% of children will have this type of eczema at one point or another, most commonly in infancy and early childhood. Children with atopic eczema require special attention to their skin care routines, and proper care of their skin can go a long way towards controlling the uncomfortable itch associated with this rash.
What Causes Atopic Eczema?
There are several different types of eczema, of which atopic dermatitis is by far the most common in children. Causes of atopic eczema are complex, and include heredity (genetic factors), as well as environmental factors. Children are more likely to develop eczema if they have a parent or sibling with the condition, or if a close family member has asthma or seasonal allergies.
Normally, the top layer of our skin forms a barrier whose functions include keeping water in the skin and keep foreign particles out. In atopic eczema, genetic factors result in a "leaky" skin barrier that allows moisture to be lost from the skin, leading to dryness and flaking. This leaky barrier also allows irritating particles from the air into the skin, where they trigger inflammation. Part of the immune system in these children is often hypersensitive to triggers which do not bother individuals without atopic dermatitis. The combination of a "leaky" skin barrier with a hyper-excitable immune system leads to the itch, redness and flaking of eczema.
Why Should I Be Worried About My Child's Eczema?
If you're thinking..."why should I be worried about a skin rash", then you have obviously never had a child with moderate or severe eczema. The itch associated with atopic eczema can be unbearable. It can disrupt sleep and can leave children, and their parents, miserable. Itch is an extremely unpleasant sensation; one that we should absolutely treat in children in order to improve their quality of life. If your child is itchy and uncomfortable, please read on...
Why Is Proper Skin Care So Important For Children With Eczema?
The "leaky" skin barrier described above is thought to be one of the reasons why children develop eczema. Proper skin care can improve that leaky barrier, resulting in less water loss from the skin, and less activation of the immune system because fewer irritating particles can get through the skin barrier and trigger inflammation. In fact, the frequent use of moisturizers has been shown to improve symptoms of eczema, and to result in less frequent flares of this condition. Exciting recent research has also shown that early use of a moisturizer each day may actually prevent some children from developing eczema, and this practice should be considered in babies who have a family history of the condition.
How Should I Take Care of My Child's Skin?
The key to taking care of the skin of children with eczema is avoiding anything that dries out or irritates their skin, while also using measures that hydrate the skin and improve its protective barrier. The following steps can be helpful in managing atopic dermatitis:
- Bathe your child daily in lukewarm (not hot) water for about 10 minutes.
- Use a gentle, liquid, soap-free, fragrance-free cleanser as needed.
- After the bath, pat your child's skin dry with a towel (don't rub).
- If you are using prescription medications such as topical cortisone creams, pimecrolimus or tacrolimus, apply these to areas that have active eczema (where the skin is red and inflamed). Most topical medications should be used twice per day as needed; once immediately after the bath and a second time earlier/later in the day.
- Immediately after the bath, liberally apply a moisturizer to the entire skin surface in order to seal in the moisture from the bath.
- Use a moisturizer twice per day; once after the bath and a second time earlier/later in the day.
How Do I Choose Skin Care Products For My Child?
There are many excellent products available that can be used in children with sensitive skin. When choosing a cleanser, look for a liquid, soap-free, non-foaming, fragrance-free product. Avoid traditional bar soaps, scented bath gels and bubble baths. Choose moisturizers for your child that are fragrance-free and contain few additives. Heavier products such as greasy ointments or rich creams have more oil in them and are better at keeping moisture in the skin than are lotions (a lighter lotion can be used in the summer, if desired). Products that have added ceramides (fats that make up an important part of the outer layer of the skin) may also be helpful. The National Eczema Association maintains a list of products they recommend, many of which can be found in Canadian stores.
Are There Any Other Tips That Might Be Helpful?
- Keep your child's nails short.
- Stick to cotton clothing. Avoid synthetic fabrics, wool, and other rough fabrics
- Cigarette smoke, pet fur, pollen or dust mites may worsen eczema in some children. Avoid any irritants that you have identified trigger your child's symptoms.
- Avoid fragrances. Choose fragrance-free skin care products, laundry detergents and fabric softeners
- For young children who have eczema around the mouth, apply Vaseline®, or a similar greasy ointment, liberally to the face around the mouth and on the cheeks before meals. The wet food on the cheeks can aggravate eczema and the ointment serves as a barrier to protect the skin. The use of ointments can also help prevent skin irritation on cold, windy days.
What About Food Allergies?
This is actually controversial. Food allergies are more common in children with eczema than in children without eczema, but in most cases, foods do not play a role in worsening of the eczema, There are exceptions to this, and in some children certain foods will exacerbate symptoms of atopic dermatitis. If your child gets rashes when eating certain foods, or their eczema consistently worsens within 48 hours of eating a particular type of food, speak with your pediatrician about whether they should be evaluated by an allergist. Avoid making drastic changes to your child's diet without seeking medical attention.
I'm Worried About Using Cortisone Creams On My Child. I've Read That They Thin The Skin
Unfortunately, this concern is all too common among parents of children with eczema. Used properly, mild and medium-strength cortisones are very unlikely to cause skin thinning. I have written an entire post on this very question. In the vast majority of cases, the small risk of side effects that comes with using these creams is far outweighed by the improvement in quality of life that children achieve once their eczema has been properly treated.
Will My Child "Grow Out" Of Their Eczema?
Unfortunately, no one can know for certain whether your child will "outgrow" their eczema. About 60% of children with atopic dermatitis will go in to remission by the time they are 12, and only 5-10% of adults have atopic dermatitis, which tells us that eczema remits in the majority of children.
When Should I Take My Child To See A Doctor?
If your child is itchy and uncomfortable, please see your family doctor or pediatrician, or visit a dermatologist. There are many causes of rashes in children, and an expert can determine whether the above suggestions apply to your child. Although there is no "cure" for atopic dermatitis, it can always be managed, and children's symptoms can improve dramatically. If your child has eczema that was previously well controlled and has suddenly worsened, or your child has fever or pain associated with their rash, please seek medical attention immediately.