Eczema: The Itch That Rashes

Eczema is a very common childhood skin condition. It can affect all ages, and it ranges in severity from mild (hardly noticeable and requiring no prescription medications) to very severe (requiring multiple prescription medications and very life-altering). The key to successful treatment is in understanding what eczema is all about.

What is Eczema?

Eczema is a skin condition that can cause the skin to look red, dry, or flaky. Sometimes there are small fluid filled bumps and oozing. In the chronic stage, eczema can make the skin look thick and scaly. It can affect skin anywhere on the body, but in children it is usually on the face, the bends of the elbows, and behind the knees. Eczema is sometimes called “the itch that rashes” because it is extremely itchy and bothersome (even before the rash appears). The other medical term for eczema is “atopic dermatitis.” When broken down, “atopic” simply means “allergic,” “derm” means skin, and “-itis” means inflammation. In medicine, we have a habit of making things sound more complicated than they are. Atopic dermatitis is simply then, allergic, inflamed skin.

The Science

When patients come into my office for the first time with eczema, I always give a two minute science lesson. The science often sheds light on the “why” of the diagnosis. There are factors in everyone’s blood called “immunoglobulins,” which are responsible for different parts of our immune system. The one which plays a role in eczema is “immunoglobulin E,” (abbreviated to IgE). IgE is the immunoglobulin largely responsible for allergic type conditions. IgE is also the immunoglobulin involved in allergies and asthma. Consequently, allergies, eczema, and asthma all go together. This is why you will see these three conditions run in families. Almost always, when a parent brings in a child for eczema and I ask about family history, the mom, dad, siblings, aunts, or uncles, etc. have eczema, allergies, or asthma (or all three). When a person has more than one of the conditions, it is often referred to as the “atopic march” (again, “atopic” or “atopy” just means allergic). So yes, having one puts you at higher risk of having another.

There is nothing to do medically to bring down a person’s IgE levels. They are what they are. If you tested all the IgE levels in an allergic family, they would all be higher than normal. Knowing that a person who has eczema has higher baseline IgE levels, helps in understanding why eczema is a chronic condition without a cure.

Treatment

As mentioned above, there is no cure, but there are lots of things to do to modify eczema and decrease the number of flare ups. Everything that touches the skin, like detergent, soap, or lotions, must be hypoallergenic and fragrance free.

Wash all clothes, sheets, towels, etc. in detergent that is free of dyes and fragrance. Many brands make a “free” version (“All Free and Clear,” “Tide Free and Clear,” “Kirkland brand Free and clear,” etc.).

• Soaps. All soaps need to be hypoallergenic and fragrance free. If you have a baby with eczema, the soap doesn’t necessarily have to be a baby product. What you want is a soap that is gentle on the skin. Soaps like Dove, Aveeno, Cetaphil, etc. are all good options, to name a few.
• Moisturizers. This is the key to eczema treatment and maintenance. Moisturizers should be used all of the time, even if your child is not experiencing a flare up (prevention is key in Pediatrics). Again, the products need to be hypoallergenic and fragrance free. The general rule of thumb is the product needs to be white or clear (color means dyes were used), have no smell, and the thicker the better. Products like Eucerin (cream and lotion), Cetaphil (cream and lotion), Aquaphor, Aveeno, etc. are all good choices (stay clear of the pink, highly fragrant stuff if your child has eczema). I tell all my patients that at minimum, they need to be putting on a thick lotion/cream twice a day. Twice a day is easy to remember if coordinated with getting dressed in the morning and at night before bed. Moisturizers need to be applied AFTER baths/showers. If the eczema is more severe, you may need to apply moisturizers multiple times a day (as often as every hour or two). You can never overdo moisturizers. Moisturizers will help restore the natural barrier to the skin that is lost with eczema.
• Prescription medications. These should be used as needed and as prescribed.
  • Steroid creams. The long-established and first-line prescription recommendation for eczema is steroid creams. There are dozens of different steroid creams (e.g., hydrocortisone, triamcinalone) on the market in all different strengthens. They should be used under careful guidance from your doctor because certain strengths are typically used (or not used) on different parts of the body. There are also potential side effects from continuous long-term use. Because eczema is a chronic condition, a long-term treatment plan should be discussed with your doctor.
  • Non-steroidal creams. When these drugs first came out, they were touted as the miracle drug. They treat eczema well without the side effects of steroids. However, shortly after coming out, a warning was issued on them. They are still available for people who don’t respond to steroid creams or cannot use steroid creams, but they should be used with caution and in consultation with your doctor.
  • Oral medications. Sometimes oral antihistamines are used in severe cases of eczema. They help with the itching that is associated with eczema. The big drawback is that they are sedating (make you feel sleepy).
  • Antibiotics. Occasionally antibiotics are necessary if the skin itself has become infected with bacteria. This usually happens in severe, complicated cases.

Complications

Anytime the skin is compromised, the protective barrier is lost and complications can arise. Talk to your pediatrician if:

• The rash is severe.
• The rash doesn’t respond to treatment.
• There are signs of fever or infection (e.g., blisters, increased redness, pain, yellow crusts, oozing).
• The rash is spreading.
• Another rash develops.

For more information, visit the National Eczema Association: www.nationaleczema.org/