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What is Eczema

Eczema is a dry, scaly condition of the skin. It is very common in infants and children. Eczema usually gets better as the child gets older. Eczema is related to other conditions that doctors refer to as “atopic” (ay-top-pick), such as asthma and allergies. Children who have one of these conditions often have others, and when one flares up, so do the others. The cause of eczema is an over-reaction of the skin to minor irritants. Dead and dry skin cells can be irritants to the skin, and when they collect on the skin, it can become inflamed, red, itchy, and painful. Eczema may look different in different parts of the body. Babies often have eczema most obviously on their cheeks, where it can be red, bumpy, and even shiny or oily-looking. Eczema on the backs of the hands, on the knees and tops of the feet can be pink and scaly or flaky. The skin may crack and have a red, raw appearance underneath. Children with eczema often scratch so much that they break the skin. Often this leads to infections. Many things can cause a flare-up of eczema, including colds, dry, dusty, or dirty air, soaps, pollen, pets, dust mites, and stress. Certain foods and proteins, especially those found in milk and soy, can also cause flare-ups in some children.

What is the biggest concern?

Eczema makes children and parents miserable. It itches and is often painful, and it hurts more when the child moves the affected area. Our main concern in eczema is to control the pain and itching and to prevent the damaged skin from becoming infected. Scars are unusual from eczema, but infected skin areas can leave scars.

How  to treat Eczema

We can treat mild eczema with moisture and protection. It is best to avoid “pure” soaps and all adult deodorant soaps. These can be drying to delicate skin. In fact, since small babies really don’t get very dirty, many doctors recommend avoiding all soaps entirely until the rash is better. Give your baby a warm bath once or twice a day just in water, and pat him or her dry without rubbing. Within a few minutes of getting out of the bath, you can then gently apply some moisturizing cream or lotion such as Vaseline Intensive Care®, Jergens®, or Eucerin®. Some of these and other brands also make liquid soaps – please be sure you are not using one of those by mistake! All moisturizing creams and lotions work best when used right after a bath. Try to keep your baby’s skin moist and protected as much as possible. If you go outside, especially if it is windy, cold, or very dry, be sure to apply more moisturizer when you come back inside. It may help to run a humidifier or vaporizer in your child’s room. Please remember to clean the water every day to prevent growth of mold and fungus.

You can give your child diphenhydramine (dye-fen-hi-drah-meen; Benadryl® and many others) to relieve itching. The main side effect of diphenhydramine is drowsiness, which is actually often helpful to a child whose itching is making him or her frantic.

In more severe cases of eczema, your doctor may recommend using a mild steroid ointment such as hydrocortisone 0.5% or 1%, or sometimes a prescription cream or ointment. Please try to use this medication on the smallest area possible – just where the rash is the worst, and for the smallest amount of time possible. Steroid creams and ointments can cause changes in skin color and texture with long-term use.

Children with very severe eczema require very intensive skin care. They may need to have several warm baths each day followed by application of hydrocortisone cream and then a moisturizer. They may need to be on antihistamine medications for a long period. In the very worst cases, some children require hospitalization to get as much treatment as they need.

In recent years doctors have started to use several new treatments for severe eczema, or eczema that does not get better with steroids. Creams containing the drugs tacrolimus (Protopic®) or pimecrolimus (Elidel®) may be helpful. They may produce a small increased risk of skin cancer, however. Some doctors also use certain other medicines designed for other immune system problems, such as asthma or allergy. You may want to discuss all of these medications with your doctor. The use of some of these medicines for eczema is considered “off-label,” meaning that the US Food and Drug Administration has not approved the drugs for use in eczema. You and your doctor should talk through all of these issues carefully as you decide on which medicines will work best for your child.

When should I be worried?

Eczema is frustrating for everyone, but with careful attention most flare-ups clear up after a week or so. Here are some things to look out for that might tell you the eczema is worse than usual, or that some other condition might be present:

  • Eczema that does not clear up or at least improve a lot within 10 days
  • Eczema that seems to be getting worse with treatment
  • Fever with no other obvious cause
  • Eczema with a rash that looks like tiny blisters
  • Severe pain
  • Signs of infection such as dark red color, oozing, heat, or tenderness
  • A rash with joint pain
  • Sores or ulcers in the mouth or eyes
  • Blistering or peeling of large areas of skin
  • A rash that looks like large raised red bumps, circles, targets or wavy lines
  • Wheezing or trouble breathing

If any of these occur, please be sure to call your doctor’s office right away.

Other points of concern

Eczema, asthma and allergies are all on the increase around the world. There are probably many causes for this, including increased overall cleanliness and reduced exposure to certain kind of germs. These changes improve health overall, but may make children more susceptible to these so-called “atopic” conditions. We know that certain specific exposures like cigarette smoke and dust mites increase children’s likelihood of developing one of these conditions. If there are smokers in the house, they may want to read our Stop Smoking instructions.

Like asthma, eczema often has triggers that parents can learn to recognize. Parents can help their children to identify and avoid these triggers. If your child has more than just mild eczema, it might be a good idea to note down things that the child has eaten or been exposed to in the days just before an outbreak. This is called keeping a “food and exposure diary.” Over time, you may see patterns will give you some ideas about possible triggers. Your doctor may want to test your child for specific allergies.

Other Conditions that Might Be Present with Eczema

If a child scratches an eczema rash the rash can become infected. You can treat minor local infections with an antibiotic ointment like polysporin or neomycin, or your doctor may prescribe mupirocin (Bactroban® ointment). A larger infection may require antibiotics by mouth.

Some children develop viral rashes as part of their eczema. When this happens with one of the herpes viruses, like chickenpox, herpes simplex, or CMV, a blistering, painful and tender rash can develop. This is called “eczema herpeticum” and it can cause fever and generalized illness. It is more common in children with weakened immune systems. Children with this condition usually must take anti-viral medicine.

Any rash that is present along with joint pain or swelling should get your doctor’s immediate attention. These could be signs of serious conditions such as systemic lupus erythematosum (SLE, or “Lupus”) or other so-called “connective tissue disorders.” Some viral and bacterial infections as well as some other unusual skin conditions can cause this combination of symptoms.