Eczema is an itchy dry red rash which comes and goes and appears in different areas. In young children the face is commonly affected, while in older children it is the elbow, wrist, knee and ankle creases. Up to one in five children in the UK are affected. It usually starts in the first year of life and often improves with time. Many will go on to suffer from asthma or hay fever. Immediate reactions to some foods, pollens and animal danders are more common. There may be a family history; specific genetic factors e.g. filaggrin gene involved in maintaining skin barrier is now known to be important in 2 in 5 patients with eczema.
The diagnosis is made on the history and examination rather than tests. Some conditions may mimic eczema, for example scabies.
Eczema is due to a defect of the skin barrier which allows water to escape from the skin leading to skin dryness. Many factors (house dust mites, pet dander, pollen and occasionally foods especially cow’s milk in young infants) can make the problem worse. Routine allergy tests are not usually helpful as they only test for immediate allergic reactions and not those delayed by many hours as occur in eczema.
Key is the regular use of emollients / moisturisers to help with the skin barrier. Steroid-containing ointments may be needed for flare ups or for more severe disease.
Emollients / Moisturisers:
The skin in children with eczema dries out due to a defect in the barrier function. Soaps, bubble bath and normal shampoos may make this worse. Moisturisers help restore the natural skin barrier and reduce itching and scratching, allowing healing. They are safe and should be applied regularly even when the skin looks clear. You cannot overuse emollients! Ideally apply at least four times a day. Ointments have less water than creams so act as a better barrier on the skin surface. Use the one your child is comfortable with. Emollients can be used instead of shampoo in infants.
Garments / wraps:
Sometimes your doctor may prescribe wraps or bandages to apply on top of emollients and to protect against damage from scratching. Although wet wraps may help to control severe eczema they can lead to skin infections. Some children may benefit from avoiding wool.
Topical steroids or calcineurin inhibitors [e.g. tacrolimus]:
These anti-inflammatory medications reduce redness and swelling and are very useful in treating flare-ups and more severe eczema. Apply steroid ointment to affected red / sore areas and then preferably leave of gap of 30 minutes before applying emollient.
Although strong steroids used for a long time will cause thinning of the skin, mild steroids such as 1% hydrocortisone ointment can be used regularly long-term. Children requiring stronger steroids should be reviewed by their doctor regularly.
Tacrolimus is an alternative medicine that reduces inflammation. It is not a steroid so won’t cause thinning of the skin. It is used by specialists if the response to mild strength steroids is inadequate.
A “finger-tip unit” of steroid or tacrolimus ointment is enough to cover an area of skin the size of two outstretched hands of the person applying the treatment.
Antihistamines [sedative type]:
- Antihistamines do not relieve the itch in eczema. Sedative antihistamines act to induce sleep.
- They should be avoided in children less than 6 months old and for long periods. They may adversely affect concentration at school as their effects may last around 24 hours.
Infection is the commonest reason for a flare up of eczema.
- as the normal protective skin barrier is damaged, there is a risk of secondary infections most commonly with staphylococcus bacteria. This causes the skin to become painful and weep and there may be yellow crusted blisters / pustules (impetigo).
- topical antiseptics or bath antiseptics may help reduce this tendency. A course of antibiotic such as flucloxacillin may be required for up to 2 weeks.
Less commonly, but importantly, eczema may sometimes be infected with the herpes cold sore virus. The classical appearance is a crop of small blisters [photo]. Later there may be “punched-out” lesions about 2mm in size. A doctor should be consulted as soon as possible, certainly the same day, as there is a risk the virus may cause more general serious illness.
Changes to the diet of growing children should not be taken lightly as they may reduce nutrition and lead to worsening of allergies. In children with more severe eczema where a specific food consistently causes eczema to flare, see your doctor for advice as to how dietary avoidance measures may be put in place. Support from dieticians is often required if foods such as dairy and wheat are avoided.
|National Eczema Society||www.eczema.org|