Atopic Dermatitis/Eczema in Children
Quick links
Symptoms
Eczema, also known as dermatitis, is a skin condition causing inflammation and intense irritation. Eczema symptoms tend to be caused by dry skin. The skin becomes hot, itchy and inflamed; it may also be red and appear irritated.
In young children, patches of dry, scaly skin, or (less commonly) wet, weepy skin, can appear anywhere on the body. In older children, the eczema usually appears on wrists, ankles, elbows, knees and face, including the eyelids.
Skin that is affected by eczema gets sore and broken when it is scratched, and can look wet and may bleed. This scratching is hard to avoid since the main distressing symptom of eczema is unbearable itching but, once the skin gets broken and cracked, infections can set in causing even more discomfort.
Disease
This skin condition can affect any age range, and it is thought to be caused by a defect in the skin barrier that makes it more susceptible to inflammation and allows allergens to enter the body.
If individuals are atopic they are more prone to atopic eczema (also known as atopic dermatitis), that is, eczema caused by allergies.
Eczema can affect a child’s quality of life and may affect sleep patterns; this can make children irritable and frustrated, but good management can help alleviate these problems. This skin condition is well understood and dermatologists (skin doctors) have developed effective skin treatment regimes to control and manage the symptoms. It can, though, take some time to find the most suitable regime for each child, and many children do struggle with the embarrassment and daily frustration of the symptoms in the meantime.
Diagnosis
Generally, GPs can diagnose eczema and differentiate whether you have atopic dermatitis or contact dermatitis.
Some people have triggers for their eczema such as allergies, e.g. house dust mite, pets, cows' milk or certain foods. Seasons of the year (for example, in winter), or even emotional responses (such as stress), may cause eczema to worsen. However, a large number of atopic eczema sufferers are not able to link a cause to their symptoms. It is essential that any known triggers are avoided, and sometimes keeping a ‘trigger symptom’ diary at home may help you to realise just what might be causing the condition. Things to consider could include bubble baths, shampoos, make-up products, face paints, etc.
If further investigation is needed, or the skin’s condition is not improving with treatment, your GP may make a referral to see a specialist dermatologist to pinpoint the exact cause of the condition. Allergy tests may help indicate which allergen is causing the flare up, but in some circumstances (e.g. where skin is badly damaged) blood tests are used instead.
Can Food Allergies Cause Eczema?
No. Children are born with the tendency to have eczema and many things can make their eczema worse. These are known as “triggers” for the eczema. Foods can be triggers for eczema in some cases but DO NOT CAUSE eczema.
Further information on this topic is available here.
Treatment of Eczema
Emollients
Emollient lotions and creams are prescribed for eczema and dry skin, and are, in their simplest form, mixtures of oil and water. Some emollients may also contain slight amounts of antibacterial chemicals (to avoid infection in broken skin), or steroids (to reduce inflammation).
Emollient products range from being runny lotions to thick creams, and while they can be a very cooling and soothing treatment for eczema, the stickiness of the thicker products can sometimes make them a source of annoyance for children. It is important to find a product that is suitable for your child to tolerate.
Dry skin is more susceptible to eczema, and once the skin barrier is broken it is open to infection and further irritation from allergens. Scratching also causes the body to release histamine which further aggravates the symptoms. Emollients work to reduce eczema symptoms by creating a protective barrier on the top layer of the skin, moisturising it and reducing water loss. The oil also provides lubrication so that the dry skin, which is often itchy and rough, will not be as easily irritated.
Although emollients do not stop the underlying cause of eczema, they can calm and soothe the skin, and give it time to repair itself. For emollients to work effectively, they need to be used as part of a regular treatment regime. This means that they should be applied at set times of day, and should be used whether they appear to be needed or not.
Eczema can flare up at any time, in some instances due to infection, stress or allergens, but also for no obvious reason. Even when emollients are used, there may be times when eczema seems to get worse. However, regular treatment can help to minimise the number and severity of flare ups.
Emollients should be continued for as long as possible, even when all traces of eczema have vanished. By keeping the skin moisturised, it will be better hydrated, and with less chance of the skin barrier being broken, the risk of allergens and other irritants causing eczema is reduced.
Emollients are available as lotions, creams, ointments, shower and bath products, and soap substitutes. These products should be used every day as emollients support the skin’s barrier function by helping it to retain water and form a protective layer against allergens or bacteria. They can also help to relieve the ‘itchy’ symptoms typical of eczema.
Water can have a drying effect on skin, and so emollients are also available as bath products, which help to hydrate and protect the skin while soaking in the water. In addition, soap can also make eczema worse because it dries the skin further. Soap substitute emollients can also be prescribed, which can be rubbed on and rinsed off skin
just like liquid soap.
You may find that your child has several creams if their eczema symptoms vary, and some children have different creams for different times. For example, a child going to nursery may use a less oily cream in the morning and during the day, and use a thicker treatment at night.
How to use
- You need to understand how and when to apply your child’s treatments so ask your healthcare professional for advice or a demonstration
- Make sure your hands are clean, as well as your child’s if they are going to help because skin with eczema is vulnerable to infection. Many emollient creams come in dispensers with a pump top, but if not, use a spoon or similar utensil to dispense the emollient on to your hand. DON’T PUT YOUR HAND in the tub, as you will then transfer bacteria from your hand and the child's into emollient container!
- Dab the lotion over the affected area, and then smooth the cream in one direction only so that hair follicles are not aggravated by rubbing
- After treatment make sure that all bowls and other equipment is washed in hot, soapy water and kept only for use with the eczema treatment
Topical Steroid Creams
It is sometimes necessary to apply topical corticosteroids (e.g. hydrocortisone), as these reduce inflammation in the skin.
Many people worry when steroids are mentioned as a treatment option because of stories they may have heard in the media, particularly related to anabolic steroid abuse in sports. These, however, are not the same steroids that are used as medical treatments and, when used as directed by a physician, steroids have an important role to play in treating a range of ailments, including allergies.
Topical steroids are safe to use but always follow the prescribed instructions making sure you understand which areas you apply the cream to. If you have any questions, then ask your treating doctor or nurse for further advice and information.
Steroid creams only need to be applied to the areas of skin which are flaring up. One finger tip of cream (where the cream is squeezed along the finger tip as far as the first joint) is usually enough to cover an area of skin twice the size of an adult’s hand.
Sometimes emollients and other creams (i.e. steroids and antibiotics) are needed in combination. It is important to leave an adequate gap between applying the different creams to allow one cream to be absorbed before applying another. If creams are applied too soon after each other they may be diluted, and healing and control of the symptoms can take longer. In general, you want to apply medication creams (including steroids) first, and the emollients last. Your doctor can advise you on this, or you can ask your pharmacist what is a suitable time gap between applying the creams.
Steroid creams, when used for a long time at a high dose, can cause skin to be damaged. However, uncontrolled eczema will damage the skin more than steroid creams. So it is better to use low dose steroid creams as soon as the skin appears to become inflamed, rather than waiting for things to become worse, as this may then need stronger creams in order to control symptoms. In this way, less steroid is needed than if a patient had waited for treatment until the condition worsened.
Wet Wraps
Sometimes, you may need to use bandages (known as wet wraps) for your child. These are used if a child has not responded to the usual topical application of emollients or steroids. Wet wraps can also be useful if the child suffers from itch at night and cannot sleep; the wraps allow them to have a better quality of sleep during times when the eczema is particularly bad. There are various ways of applying these bandages and your nurse or doctor will be able to demonstrate the best way of application.
It important to follow the advice of your treating practitioner for the length of time of wet wrap treatment, and it is a good idea to have your child’s skin re-assessed when the treatment comes to an end.
Calcineurin Inhibitors
Calcineurin inhibitors are a new treatment, currently available as two creams - Tacrolimus and Pimecrolimus (also known as Protopic and Elidel) - for use on children over the age of two. They work by reducing the sensitivity of the immune system when the skin comes into contact with an allergen. In this way they reduce inflammation, primarily in the case of atopic eczema, and can lessen itching and relieve rashes associated with allergic skin conditions.
These creams are suitable for use on almost every part of the body and are often used when steroids have proved unsuccessful, or are not suitable, for example, on sensitive skin around the eyes. Emollients should continue to be used as well as these creams, but should not be applied within two hours of applying the cream.
Vaccinations should be avoided for a period before and during the course of this treatment. A common side effect of these creams is a burning sensation on application, which generally settles down after a few days. These drugs are thought to be safe and extremely effective in the short-term, but their safety for long term use has yet to be proven.
Good Practice
- Despite our best efforts, as children get older the chore of a twice daily skin cream regime can become annoying for everyone, especially if their symptoms have improved. Remember that the symptoms have improved because the eczema is under control, so you and your child should feel pleased. Without the cream, it may flare up again. You now want to keep up the routine so that your hard work at keeping your child’s skin healthy and hydrated is not ruined. It is important, therefore, to continue praising your child and raising their self-esteem regarding how well they have taken part in their treatment as this may help to keep up their motivation
- Current medical guidance advises the best way to manage atopic eczema and improve the quality of life for sufferers is to identify and avoid allergy triggers while using the most suitable emollients, even when the skin is in good condition. Having a stepwise approach in place, where patients can use other treatments when necessary, provides a good support system to try to keep eczema under control
- Sometimes people react to the other ingredients in the emollient so any changes or worsening of skin condition needs to be reported to your doctor
- Frequency of application of emollient varies but it could be two to four times a day. It can be useful to have extra emollients available should your child need them when they are away from home. For example, keep spares at school, at relatives' homes, or in the car
- Don’t be concerned about requesting emollient prescriptions through your GP; the skin can take a large amount of hydration, and it is not uncommon to use up to 250g of emollient per week. It is good to be able to use an emollient instead of other stronger medications to control your child’s eczema. However, there are times when other medications are needed if the eczema has flared up
- Ready-made wet wrap products are sometimes available instead of bandages, and these should be discussed with your GP or practice nurse if you think they may be beneficial to your child to see if it is applicable
- Sometimes other alternative treatments may be offered such as phototherapy or dietetic advice – these are all specialist areas which you will need to discuss in depth with your treating health care practitioner
- It is important to be aware of, and look for, the signs of bacterial infections since the skin of children with eczema is more prone to infection due to the cracks and constant itchy symptoms that eczema can produce
- Severe eczema can sometimes lead to a hospital stay to try to prevent infection and help the child respond to treatment. Specialist bandages, light therapy and sometimes specialist medications, such as immunosuppressive agents, may be used to try to control the eczema
Tips
- Baths and emollients should be undertaken before application of wet wraps, and the skin should be patted dry, rather than rubbed, to avoid friction which could start irritation and scratching
- Ointments can be messy, so prepare by covering up your clothes and the area in which the treatment will take place. For example, wear an apron or old shirt over your clothes, and place towels on the bed if this is where you are going to administer the treatment
- If your child is very young and does not like the treatment it can be very helpful to encourage them to help in putting on any lotions. This is also good for helping them to understand their condition as they get older
- If your child does not cooperate easily with the treatment, try to keep talking to them, tell them a story, sing a song, or listen to a DVD – anything to keep their mind occupied. Try to remain calm yourself and don’t get flustered if your child does not want to cooperate. Aim for a small improvement in applying the treatment each day and over time your child will get more used to it as a regular activity. The important thing is to make it as pleasant as possible
- Some parents decorate the tubs and pots of emollients with stickers to make them look more fun and less clinical. It can help to personalise the jars so that the child feels that it is special and that they have some participation in their treatment
- Check the ingredients of any other skin products your child uses, and if they want to have bubble baths, etc. with their favourite characters on, try cutting out the characters and sticking them onto their prescribed skincare bottles. Alternatively, for older children emollients can be dispensed into more fashionable bathroom containers
- Younger children can be helped by showing how dolls (made from hard plastic so they can be cleaned) can have the treatment applied. They can even put cream on the doll while you are applying the treatments to them. This increases their understanding and allows them to feel involved
- Many manufacturers give away activities, star charts and rewards for wet wrap patients so it may be worth contacting them. Your practice nurse or doctor may be able to help you with this
- Remember to involve siblings so that they are included during treatment time
Self Help
- Bacterial infections cannot always be avoided, since it is important that children with eczema take part in as many activities as their friends. However, there may be times when covering the affected area will help reduce infection, such as when playing in a sand pit, or playing sport. If necessary, discuss with teachers at school to find out if your child can do sport in tracksuit bottoms or long-sleeved tops
- When outside take care not to allow skin to become sunburnt. There are specially formulated sunscreens available for eczema sufferers that do not contain some of the ingredients which may make the skin become more irritated; for further information contact the Allergy UK helpline. You should still keep up your child’s skin care regime of emollients and check with your doctor about suitability of sunscreens
- There are now specialist clothing ranges available for eczema sufferers. For example, many children now wear UV sun suits (for further details contact Allergy UK). Cool cotton or natural fibre clothes are ideal for eczema as these allow the skin to remain cool and less irritated
- Your child may prefer to wear trousers rather than skirts or shorts if they are concerned about the look of the eczema on their legs
- Some specific brands of clothing are available on prescription; however, this would need further discussion with your prescribing doctor
- When taking part in sports and showering afterwards, make sure emollients are used. This is particularly important when swimming as the emollient acts as a barrier when chlorine may adversely affect the skin and cause irritation
- Keep nails short and clean and try to keep your child distracted from scratching Keep your home cool, as a hot environment increases the itching
- Make sure you are aware if your child is worrying about something, as eczema can be exacerbated by anxiety. Make sure you keep the school informed about your child’s treatment, and that teachers are aware of any extra care needs for your child. Talk to the SENCO or school nurse for extra advice and help
Last updated: March 2012