Eczema: The Rash that Itches
Almost all babies have sensitive skin. We all know to avoid harsh detergents, strong perfumes, and rough fabrics during this period, but what is normal dry skin versus eczema? What can you do to avoid dry skin? And what medicines are safe and effective? Read on for a primer on this common, annoying and in certain cases dangerous condition.
The Early Years
After 9 months inside a protective moist environment, it’s no surprise that a baby’s skin will seem to “dry out” in the first week. This is normal, and not predictive of later eczema. You can actually wait it out, as the baby’s natural oils will be produced soon, and the dry flaky skin will go away on its own. It is safe however to use a baby friendly moisturizer during this period, to hasten the resolution. This natural drying out period is not painful or dangerous to the baby, but it sure can look impressive.
As your child grows, there may be a dry patch here and there, and this is often a contact dermatitis. Especially during the cooler months, red wind-blown cheeks will come and go and this usually responds to a good moisturizer. Every child is different, and some are more sensitive than others. Indeed, family history plays a role here, so the atopic parents - those with asthma, allergy and eczema - have a higher chance of having a child with true eczema.
Contact dermatitis is a reaction to a particular insult/allergen – such as nickel on a belt buckle, or a fragrance or chemical in a product or clothing. You’ll see a sudden onset of a reddish dry irritated patch and it will usually spare the covered areas such as under the diaper or beneath clothes. These rashes are often transient, and can be resolved with over the counter moisturizers, as long as the inciting agent is removed.
What Does Eczema Look Like?
Children with true eczema will have dry red patches that come all over, seemingly without cause. These children will have more than the occasional contact dermatitis that others have. They seem to react to anything and everything. Just like asthmatics, they are very sensitive to environmental triggers and yet sometimes they have unpredictable flares of dry skin. The most common areas are the “flexor areas”, in the elbow and behind the knees, but eczema can affect any part of the body.
For most children the eczema is not a dangerous condition, and more of a nuisance. But very thorough, well-done scientific studies have shown eczema can affect sleep quality and overall quality of life if the skin is too dry and itchy. Here lies the crux of eczema treatment: dry skin itches. If you see your baby or child itching it is up to you and me to help them stop the itching. This is crucial, as itching can lead to the one serious complication of eczema – infection.
Infections Can Happen
Kids are always playing in dirt and germs love to live under the nails. If your child itches and breaks the skin an infection can result. This can start as a small pustule, and progress to a large abscess or cellulitis. The normal skin flora can include bacterial species of strep, staph, and yes – the resistant type of staph called MRSA which can be more difficult to treat. It is crucial therefore to kept the nails short and observe for any itch.
Hydrating the skin is the most important part of eczema/dry skin care. You may hear some concerns about using petroleum products, but they really work well and I think they are safe. Most dermatologists agree that the frequent use of emollients, such as Aquaphor by Eucerine, are both effective and can reduce the need for other stronger creams. Lotions are creams mixed with powder – so they feel nice on our skin, but they just aren’t that effective.
Creams, such as Cetaphil, Aveeno, and Mustella are indeed effective, and on a hot humid day they are usually the better option, as the ointment will feel too greasy. You need to apply these ointments or creams 4-6 times every day with very dry skin. With mild dry skin these over the counter remedies may be all you need.
If you do see the skin start to get red or pus, and you are worried about infection, see your doctor immediately. It is never harmful to start an over the counter antibiotic, such as Neosporin or Bacitracin, but these infections can progress quickly and you may need oral or even IV antibiotics. A fever with a skin infection is a very dangerous sign, and could warrant an ER visit even in the middle of the night.
Prescription Medicines When Needed
When the skin is extremely dry and not responding to your moisturizer, you’ll need something stronger. These stronger creams are almost always steroid based creams or ointments. None of us like the idea of a steroid medicine, but you must remember that the harmful effects of steroids come only with systemic absorption, such as drinking the medicine. Using low strength creams, only when needed, will not lead to any significant absorption.
We have separated the strengths of the creams into 7 different categories, with the over the counter hydrocortisone 1% being the weakest. It is best to determine the weakest cream that will work based on the physical exam of the skin – how thick or lichenified each patch is. You should use these creams twice a day until you see full or almost full resolution - usually 7-14 days is enough. If after 14 days the dry skin patch is still there, we need to give you a stronger cream.
Ointments are better absorbed, and therefore will work better than creams – but they stain clothing and bedding. There are also newer foams and gels that can be helpful. Until the skin improves you may use an anti-itch oral medicine especially for a few nights such as Benadryl or Atarax.
Years ago we tried two new creams – Elidel and Protopic. Unfortunately these creams were also found to have potential side effects and they onestly don’t work as well as some of the steroid creams. I think the best thing about steroids is how well they work, and how well we know their potential side effects. You will sometimes see local effects such as thinning of the skin, but you really won’t see any adrenal suppression, bone loss, growth suppression or other scary well known potential side effects of steroids unless you use a class 1 or 2 (super potent) steroid all over the body for a month straight. Our goal is of course to use the lowest strength cream that works – as we need to avoid the itch so as to avoid the infection.
Baths, Bleach and When To See A Specialist
Despite what you may have heard, baths are not a bad idea for children with dry skin. Most newborns are only bathed 2-3 times a week, but as kids grow they often need daily baths. You should use water that is warm, not too hot, and avoid using any strong soap. Baby soap must be fragrance free and even then applied only at the end of the bath. For older kids, Dove soap has built in moisturizer, but there are also many natural hypoallergenic options. Since the pores are opened during the bath, you need to apply moisturizer immediately after, and this can also be a good time to apply the prescription strength cream strategically to those dry areas. The prescription strength cream goes first on all dry spots, and the moisturizer can go all over the body – even on the normal skin, to prevent the next flare up.
Bleach baths are actually a good thing for severe eczema. You can add a quarter cup of bleach to the entire bath and rinse after the bath. It will decrease infection and actually help eczema severity if done once a week.
Interestingly, in most cases of eczema food allergy does not play a role. That said, in children with severe persistent eczema, an allergy referral to search for a food related cause is a good idea. Dermatologists are specialists in eczema, yet most pediatricians can handle the majority of cases quite well. We all have access to the same creams and treatments, but I’ll refer some of the severe cases for second opinions.
The most frustrating thing about eczema is the fact that it always seems to come back! Luckily, most childhood eczema will resolve as the child grows, so hang in there…and moisturize!