Eczema (Atopic Dermatitis)

Eczema is a chronic condition that often begins during the first year of life, tends to get a little worse during the first year, and then often improves. Many patients with eczema  have a genetic component that causes a susceptibility to dryness and inflammation of the skin.

In some children certain foods (milk, egg, wheat) or environmental conditions (heat, sweating, dryness of the air during heating season) may aggravate the symptoms, although in most children the condition is neither caused nor contributed to by specific allergies.
The treatment of eczema aims to control dryness, inflammation, and itchiness. Treating eczema can be quite frustrating for parents and patients alike, as it cannot be cured, only suppressed and controlled.

General Guidelines:

  1. Avoid skin contact with wool or synthetic materials; use only 100% cotton if possible.
  2. Avoid regular, harsher laundry detergents, consider Liquid Ivory Snow® or Zero® and be careful with “organic” products that can often be quite irritating to the skin (despite the promise of being organic).
  3. Do not use any fabric softeners in the dryer.
  4. If you notice worsening of the eczema in response to certain foods you may proceed with trials before assuming that the food is making the eczema worse:
    • avoid the foods and observe how the skin rash responds
    • after observing significant improvement, reintroduce the food some time later
    • look for reactions
    • adjust the diet accordingly
  5. Avoid bubble baths and use only very mild soaps (Dove® or Neutragena®); alternatively you may use Cetaphil® Gentle Skin Cleanser.

Treatment of Dryness:

  1. Use a humidifier in the child’s bedroom (water only, no additives) when the air in the house is dry.
  2. Baths
    • Once (or even twice) a day is beneficial and hydrates the skin (the earlier idea that frequent bathing dries out the skin has been shown to be incorrect).
  3. Colloidal oatmeal baths soothe the irritated skin and decrease itchiness (pruritus);
    • You may use Aveeno® products
    • Or buy oatmeal in bulk, fill an old nylon stocking, tie it off and place it in the bathwater to allow the oatmeal to slowly seep out (this works very well and is much cheaper)
  4. After the bath, pat the child gently dry and massage olive oil or coconut oil into the child’s skin, particularly the dry areas. We used to recommend the application of Vaseline®, Lubriderm®, Glaxal Base® or Lipikar Baume® to keep the skin well moisturized but have recently found that massaging the child’s skin with olive oil or coconut oil often is more effective.

Treatment of Inflammation:

  1. Once the dry (xerotic) skin becomes inflamed, irritated and itchy, prescription medications can make a big difference in the child’s symptoms; it has to be remembered that eczema cannot be cured, but that the goal of treatment is the control of the symptoms to make the child more comfortable;
  2. For eczema in the face, over the counter 0.5% Cortate® can be applied – this medication does not require a prescription. We usually will prescribe 1% Hydrocortisone Ointment for lesions in the face, and this can be applied two to three times daily. Once there is improvement, the number of applications can be slowly reduced. Avoid suddenly stopping the ointment, but decrease very slowly while observing the skin for any worsening of the inflammation.
  3. For lesions on the trunk and extremities, we usually prescribe Betnovate ointment, either half strength (0.05%) or full strength (0.1%). Because the skin is dry, we use ointment (clear appearance, like Vaseline®) rather than cream (white appearance). Again, this treatment is applied two to three times daily and, when improvement has occurred, the number of applications is slowly reduced. Please note that the steroid ointments prescribed, when used as directed, do not cause problematic side-effects and do not cause thinning of the skin. The usual problem is the opposite: parents are so concerned about steroid ointment side-effects, that they under-treat the condition and the child suffers more than necessary.
  4. As the number of applications of prescription medication is reduced, the number of applications of moisturizer is correspondingly increased.
  5. For moderate to severe eczema, children 2-15 years of age who have not responded well to other treatment, may be prescribed Protopic® ointment, 0.03%, for short periods of time.
  6. Very rarely children do not respond to the above treatments and require a referral to a paediatric dermatologist or allergist.

Treatment of Itchiness (Pruritus):

  1. The above treatments are all targeting dryness and inflammation and, when effective, decrease itchiness as well.
  2. If the itchiness is severe, we may suggest antihistamines such as diphenhydramine (Benadryl®) (5 mg/kg/day in four divided doses, by mouth, available over the counter) or hydroxizine (Atarax®) (2 mg/kg/day by mouth, available by prescription) – particularly at bedtime, when the itching may be most severe and the additional sedative effect of the antihistamine helps the child fall asleep;
  3. Keep fingernails cut short to avoid damage to the skin when scratching.