Atopic Dermatitis, also known as eczema, causes the skin to itch, scale, swell, and blister. Atopic dermatitis is a skin defect in the skin barrier, allowing moisture out and germs in. This is typically hereditary and is associated with allergies, asthma, and stress.
Eczema is a chronic skin condition that affects 10-20% of children and 1-3% of adults. Approximately 50% of affected individuals will have symptoms during the first year of life. It almost always presents within the first 5 years of life an often improves dramatically during the grade school years. As eczema becomes less problematic over time, other allergic conditions may become evident. Children with eczema have a 30-50% chance of developing asthma and/or allergies as they get older.
Eczema damages the skin barrier, leading to water loss and cracking. The result is skin that is extremely dry and very itchy. The urge to scratch can be almost uncontrollable at times. Affected skin is no longer able to protect the body as it should, making it more susceptible to allergens, irritants, and organisms that it may encounter.
Keeping the skin barrier healthy requires that a strict skin care regimen be put into place. This plan includes daily skin hydration, frequent use of moisturizers, avoidance of irritants and allergens, and occasional use of medications. It is important to make proper skin care part of your daily routine. When the eczema is better, it is easy to let the routine slip. If this happens, the itching and the rash will start all over again. DO NOT be tempted to take days off when your skin improves. Daily bathing, moisturizer, and medication are a must for keeping eczema under control.
DAILY SKIN HYDRATION (“SOAK”)
BATHING- Daily bathing in warm water is recommended. Baths should be 10-15 minutes long. Oatmeal bath treatments (Aveeno) can be added to the bathwater to help sooth irritated, cracked dry skin. Bubble baths and fragranced oils should NOT be used. Patting dry is optimal. Make sure the areas involved are submerged in the water!
Additional hydration of certain “hot spots” can occur by wrapping a wet towel or ace bandage around the affected area and then sealing the water in with at thick moisturizer cream. This therapy can be used multiple times per day. For facial involvement, cut eye-holes out of a washcloth, wet it, and place it over the face. The cheeks are often involved in infants- dampen a washcloth and use it to “press” off food after meals, and then apply a good moisturizer-Aquaphor ointment works particularly well in this case.
Wet-wrap therapy can be very effective during times when the eczema is extensive. As the name implies, wet-wrap therapy involves wrapping wet bandages around the affected skin. This is generally done before bedtime. This treatment is messy and time consuming. It should not be used when the skin is infected. The basic technique is as follows:
1. After the individual soaks in a bath, pat the skin partially dry with a towel. Do not rub the skin as rubbing can irritate the skin.
2. Apply moisturizer and medication. This should be applied to the patient’s skin as directed by your physician.
3. Moisten the bandages and wrap. The bandages are generally moistened by soaking them in the bathwater. NOTE: When treating an infant or toddler, moistened pajamas may be used instead of wet wraps. Special care must be taken to prevent these children from becoming chilled.
4. Wrap the bandages on the area to be treated. Wet bandages can be used on any area of the body that the patient will tolerate, including the face.
5. Lock in moisture by applying dry bandages (or pajamas) over the wet ones.
SOAPS-The use of soaps should be minimized. Cetaphil or Vanicream liquid cleansers do not contain soap and are preferred. If needed, use a creamy, gentle soap (Vanicream, Dove-unscented, Oil of Olay, Basis, Oilatum, and Aveeno-bar) at the end of bath time, just on the places where it is needed. Don’t lather all over or rub with a washcloth; too much soap will make the dryness worse, and rubbing with a washcloth can irritate the skin. Be sure to rinse thoroughly to get all the soap off. Mild shampoos, such as baby shampoos (Aveeno baby wash and shampoo) are recommended.
MOISTURIZER USE (“SEAL”)
Moisturizers should be used as frequently as possible and are particularly effective when applied immediately after hydrating the skin. Ointments (Aquaphor) are most effective but can be greasy. Creams are less greasy than ointments and more effective than lotions because the latter products contain mainly water which quickly evaporates from the skin. Recommended moisturizer creams include Vanicream, Eucerin, Aveeno, Cetaphil, and Nivea. Lotions are easier to apply to hairy skin. Vegetable shortening (Crisco) can be used as an inexpensive moisturizing agent but is messy. Buy the largest available size once you find a moisturizer that works. Vanicream is an effective and well-tolerated product because it dose not contain most common chemical irritants found in other topical products. Keep in mind that certain moisturizers (Cetaphil lotion) may contain tree nut oils-these should absolutely be avoided if one is allergic to one or more of theses allergens.
Petroleum jelly (Vasoline) is NOT a moisturizer but can be used to seal in water left on the skin after a bath.
AVOIDANCE OF TRIGGERS
Because your child has sensitive skin, there are a number of things that can cause the rash to flare up. Some of these things are easy to fix. Eczema flare-ups can be caused by a combination of factors, and these factors may be hard to pinpoint. Here are some general steps you can take to manage those things that seem to trigger the itch.
Clothing/Laundry-Loose-fitting, soft cotton clothing is preferred. Other fabrics such as polyester, nylon, or wool can be irritating to the skin. A dye-free and perfume-free laundry detergent (All-free, Tide-free, Cheer-free) is recommended. Dreft is actually quite abrasive to the skin. Double rinsing can help remove residual detergent. Drier sheets should NOT be used. Washing new articles of clothing helps to remove certain irritating chemicals.
Time of Year-Eczema frequently flares during the winter months when indoor humidity is low. The dry air causes moisture on skin to evaporate, making the itching worse. Excessive sweating can cause problems with itching in the summer. Air conditioning is recommended to keep indoor temperatures comfortable. Sandals allow feet to breathe and prevent moisture build-up on feet. Crocs are a good option for someone who may develop localized itching from sandal straps. Swimming in a chlorinated pool can irritate the skin- shower and apply moisturizer immediately after coming out of the pool. Vanicream and Neutrogena both make sunscreens which are well tolerated by individuals with sensitive skin.
Allergens – Animal dander and house dust mites are common allergens which can trigger eczema to flare if one has an allergy to them. Carpeting can be irritating to the skin if made of wool or synthetic fibers and can also harbor dust mites. Food allergies, particularly in young children, can worsen eczema. Complete avoidance of allergens is critical.
Skin infections – There are bacteria on everyone’s skin. Healthy skin is a good barrier to theses unwanted organisms. The skin of a child with eczema is especially sensitive to these bacteria. Often when a child scratches the skin raw, bacteria will get into the open sores and can cause an infection. The child’s skin will be red and oozing in the infected area. Call a physician if this is noticed. Cutting fingernails as short as possible can help prevent an infection from developing. Diluting ¼ cup of bleach into a full tub of water a few times per week can keep the skin from getting infected- this technique should be used for red, warm, or swollen skin. Be sure to rinse the skin with regular bathwater after the bleach bath.
With a consistent skin care routine in place, eczema medications will be needed infrequently. They are typically used to gain control during a flare-up and are usually needed only for short periods of time. Once the skin recovers, the daily regimen will be enough to keep the skin barrier healthy.
Topical Corticosteroids – These medications help control itching and will reduce skin irritation and inflammation. They are considered “rescue medications”. They should be started immediately when the skin becomes itchy. Starting with a stronger steroid is recommended to get the itch under control more quickly. Switching to a weaker steroid can occur when control is achieved. These medications can then be completely stopped after the itch (and rash) have resolved. With a consistent skin care routine in place, these medications will be needed infrequently. The strength (potency) of the topical steroid prescribed and used is dependent upon the severity of the eczema flare-up. When prescribed, they should be used twice daily in a thin film. They should NOT be used on the face, groin, armpits, or other sensitive areas. Side effects (thinning of the skin and other skin changes) can occur with prolonged use.
Topical Immunomodulators – This class of “rescue” medication is also quite affective in alleviating the itch of eczema. The most common side effect is burning in the area where the medicine is applied. Examples included Elidel 1% cream and Protopic 0.03% and 0.1% ointment. They should also be used twice daily. They can be used on the face and on other sensitive areas. A “black box” warning has been placed on these products due to concern about the potential risk of cancer with their use at high concentrations. An expert panel concluded that there was no clear-cut link between treatment with these medications and cancer. There products are currently recommended for short-term or intermittent long-term use as needed.
Antihistamines – There is controversy as to whether or not these medications help to control the itch of eczema. Some cause drowsiness and allow for more restful sleep if taken before bed.
Oral Corticosteroids- These medications are rarely needed. They are reserved for severe eczema flare-ups when other management techniques have failed.
Antibiotics – This groups of drugs is used to treat skin infections that are common in people with eczema. Topical antibiotics may be sued early to help keep an infection from progressing. Oral antibiotics are commonly needed to help gain control of the skin.