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Eczema

Eczema; atopic; dermatitis; skin; itch; rashes; allergy; rash; itch;

Eczema (also called atopic dermatitis) is a skin rash which is common in babies and young children, but which tends to get better as they get older. The skin is very itchy and it can be quite distressing to the child. It can usually be controlled and the child helped to feel more comfortable.

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If a child's eczema suddenly gets worse, it may be due to an infection. See your doctor as extra treatment may be needed.

What does eczema look like?

  • Babies with eczema have a pinkish-red, scaly rash which is very itchy. This is often on their faces, scalp, behind the ears, over the body and on the arms and legs. The rash can get lumpy, weep and crust.
  • As children grow, the eczema tends to clear from the face and scalp, and be mostly in the elbows, behind the knees, on wrists and hands.
  • Eczema may get better as the child grows older and it may be gone by adolescence or adulthood. Some forms of eczema start in adult life.

What causes eczema? 

  • Children who are born into families where there are allergies are more likely to develop atopic (allergy-type) diseases such as asthma, hay fever and eczema.
  • The child's skin has less body oils that usually keep skin supple and intact.
  • The skin barrier is usually damaged, although you may not be able to clearly see this.
  • When the skin is damaged and the barrier is impaired, moisture evaporates from the skin, cells shrink and this causes cracks.
  • Allergens and other irritants can get in and lead to a reaction that causes the skin to feel itchy. The rash is made worse by rubbing and scratching.
  • Many things can trigger eczema such as teething, viral infections, food chemicals even forgetting to use moisturisers for a while. Immunisations are very important and need to be up-to-date to prevent many dangerous diseases we rarely see now days. Some people believe that immunisations ‘trigger’ eczema. If you have found/heard this in the past we suggest you increase the moisturizing regime for a few days before the immunizations are due. That way, the skin is prepared.
  • Often there is no obvious cause for a flare up of the rash at a particular time.
  • The rash tends to come and go no matter how well it is treated. There are days and weeks when the child has more rash than usual, then there will be times when it is better.

About 40% of babies who get eczema go on to get asthma and/or hay fever when they get older.

 

What has happened to the skin

Having eczema means your skin is lacking the particular body oils, lipids (fats) and moisturisers that usually keep skin supple and intact. Bonds between the skin and cells are also not as strong. This allows cells to lose moisture, shrink and cause cracks allowing moisture to evaporate from the skin. Allergens and irritants can then get in.

Sometimes this triggers an immune response to the allergens, causing sensitisation.

Sometimes the irritants trigger a red and itchy response. This makes your skin release chemicals that make the skin feel itchy and red. Scratching, despite providing some very temporary relief, actually causes more chemicals to be released and the skin feels itchier.

This ‘scratch and itch cycle’ is most distressing.

 

Bricks and mortar theory

Healthy skin is like a brick wall. Lamellar lipids and moisturising factors are part of the ‘mortar’ which helps to keep water in the cells. Normally, bonds between the cells are strong and break down slowly. Thus skin is shed slowly.

When your skin becomes dry with eczema, the ‘mortar’ shrinks, causing cracks and splits. Then the allergens, germs and irritants in the environment can get into your skin and cause a problem. We cannot change your genes but you can replace the moisturising factors and lipids with moisturiser/emollient therapy.

Emollient therapy is the term for non-soap based washes and the moisturisers applied to skin after washing/bathing. These preparations also put a barrier onto the skin to help stop allergens/irritants entering. They are important to replace as much moisture as possible to maintain a barrier on the skin.

What you need to do 

  • See your doctor to be sure the rash is due to eczema and to talk about ways to treat it.
  • There is information in this pamphlet 'Eczema - how to manage it' which has been published by the Women's and Children's Hospital, South Australia.
  • Children who get eczema need special care of their skin all of the time, plus extra treatments when the rash flares up.
  • By using your moisturiser/emollient ‘regime’ a minimum of twice daily you will usually find your skin gets red less often and the reddened areas may even be less severe, when they do occur. Intact skin usually gets less infection. It is like a car – if you maintain and service it, it will keep working, allowing you to drive without much trouble. Let servicing and maintenance slip and the car will falter. It is the same with your skin.
  • When you have dry skin/active eczema, adults and teenagers should use 500gm of moisturiser in a week, children 250gm and a baby 125gm to get enough moisture replaced.

Note: That you can never ‘over moisturise’ the skin – moisturiser is not a medication.

 

Bathing and showering

  • Bath/shower using non-soap based washes or oils as soap products dry out the skin – ‘bubbles is  trouble’. Non-soap based products that bubble are also drying.
  • It is often best to buy products from the chemist rather than the supermarket where Health professionals are available to advise.
  • Water must not be too hot: tepid is best.

Moisturising the skin after bathing/showering

 Step one

If the skin feels ‘good’ (soft and supple), use a runnier cream or lotion morning and night. This is called maintenance.

Step two

The thicker creams will contain white or soft paraffin (see ingredient list on product). Paraffin provides a longer lasting barrier and seals in moisture for longer. To work out if cream is thick enough turn the tub upside down for 30 seconds. The cream should stay in the tub if it is thick enough.

If you use ‘step two’ creams during the day, we suggest you use a greasy preparation from ‘step three’ at night after the bath.

Step three

For dry skin or where there are dry patches, apply a greasy preparation e.g. Dermeze, QV intensive, QV balm or 50/50. These seal in the most moisture best but many people find them too greasy during the day. Try to bear with your doctor’s recommendation, but if not possible apply this thickness at night and ‘step two’ during the day, with the greasy preparation on the driest patches.

Always apply any preparations to the skin, in a downward stroking motion, in the direction the hair follicles come out from the skin. This reduces the likelihood of blocked hair follicles (folliculitis).

Other things that may help 

  • Dress your child in soft clothes. Use cotton (or cotton and polyester mix) against the skin. Put cotton trousers on crawling babies so their legs don't rub on carpet.
  • Keep your child cool. Avoid hot baths, hot rooms and over dressing.
  • Avoid contact with wool, including lambskins. (Parents may also need to avoid wearing wool, so that their baby's skin does not become irritated when they cuddle). They also harbour house dust mites.
  • The skin of a child with eczema is very sensitive. If any moisturiser or oil you are using seems to make the skin worse, change to another one. Perfumed creams and creams which have plant extracts such as tea tree oil, pawpaw and aloevera can irritate the skin.
  • Giving the baby a massage with a natural vegetable oil or mineral oil can be great for dry skin if the child is not sensitive to the oil.
  • If swimming in chlorinated water, moisturise the child's skin before going into the water. After swimming rinse off and apply more moisturiser
  • Sea water seems OK, but again apply moisturiser to your child's skin before going into the sea as the salt water may sting sensitive skin.

 

Topical cortico-steroids

All parents and patients fear ‘steroids’. These preparations are prescribed to reduce the red and itchy areas, and allow the skin to heal.

Preparations come in different strengths – mild, moderately potent, potent and very potent. Only mild is available from the chemist without prescription. All must be used as prescribed. The doctor or nurse should show you how much to apply. Ask them to show you if they do not.

TCS do not replace the moisture to the rest of the skin, so it is important to continue to use emollients. Different doctors suggest different time gaps between application of steroid and moisturiser. One time gap is not better than another but remember if you use the greasy preparations (QV Intensive, Kids Balm, Dermeze or 50/50) the steroid cream must be put on first. The grease creates such a good barrier that the medication cannot get through!

How much steroid cream to use

Squeeze out the cream from the crease nearest the top of the index (first/pointer) finger to the fingertip. This is enough to cover the inside surface of two adult palms, with the fingers together. From that you can work out how much to apply to a smaller or larger area. Apply in a downward stroking motion until you can see a ‘shine’ on the skin. Apply too little and you just see a slight shimmer.

PDF documentEczema - how to manage it
         (brochure from the Women's and Children's Hospital, South Australia)

Further problems with eczema

  • If eczema is more severe and doesn't get better with the treatments that have been suggested, go back to your doctor.
  • There may be an infection which needs treatment.
  • Allergies may be making the eczema worse (see below).
  • Treatment in hospital is sometimes needed if the rash is severe and covers a large part of the baby's or child's body.
      Treatment does not 'cure' eczema. The aim is to keep the child as comfortable as possible.

Eczema with allergic triggers 

  • In most cases, removing things that irritate the skin and treating the skin (as above) is enough to control the eczema.
  • If this does not work it may help to find out if the child is allergic to something, which you can then avoid. These investigations should be undertaken by a trained allergy specialist as natural practitioners may undertake costly tests that have no scientific basis (ASCIA 2015).
    • House dust mites droppings or animal fur (cats or dogs) may cause problems. Control measures and suggestions can be found at the Australasian Society of Clinical Immunology and Allergy (ASCIA) website.
    • A few babies may be allergic to foods they eat or drink, or if breastfed, to foods their mothers eat.
      • Cows' milk, eggs and peanuts are the most common foods causing allergies but many others are possible triggers.
      • Some foods cause a rash around the mouth when eaten, but don't affect the rest of the body.
  • Skin prick tests can be done to help work out what the problem is if the problem seems to be due to an allergy. Your doctor can refer you to an allergy specialist with specialist training to help sort this out.
  • Don't change or restrict your child's diet without checking with a trained medical doctor or accredited practicing dietitian to be sure the diet is still healthy. Natural pratitioners who carry out unorthodox tests may suggest restricting hildren's diets which may cause harmful effects when foods are re-introduced. (ASCIA 2015)

Resources and references  

Australian Society of Clincial Immunology and Allergy Inc
http://www.allergy.org.au/  

Eczema Association of Australasia 
http://www.eczema.org.au  

Women's and Children's Hospital, SA Health
PDF documentEczema - how to manage it  (brochure)

Additional references

British Dermatological Nursing Group (2012b) 'Dermatology Nursing Competencies: Developing Dermatology Nurses from Novice to Expert. Retrieved from http://www.bdng.org.uk/ documents/EmollientBPG.pdf on 16 June 2015.

Danby SG, Al-Enezi T, Sultan A, Chittock J, Kennedy K, Cork MJ British. 2011 The effect of aqueous cream BP on the skin barrier in volunteers with a previous history of atopic dermatitis. British Journal Dermatology
165(2):329-34. doi: 10.1111/j.1365-2133.2011.10395.x. Epub 2011 Jul 11.

**Any products referred to in our health topics are usually well-known brands readily available in Australia. The brand names are given as examples only, and do not necessarily represent the best products, nor the full range of effective products on the market.

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The information on this site should not be used as an alternative to professional care. If you have a particular problem, see a doctor, or ring the Parent Helpline on 1300 364 100 (local call cost from anywhere in South Australia).

This topic may use 'he' and 'she' in turn - please change to suit your child's sex.

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