COPING WITH ECZEMA

by Dr John Harper MD, MB BS MRCP, Consultant in Paediatric Dermatology, The Hospital for Sick Children, Great Ormond Street

Definition

The word eczema comes from the ancient Greek meaning "to boil over". It is used to describe an inflammation of the skin, which causes redness and intense itching. The most common type of eczema in children is atopic eczema, which may be associated with asthma or hayfever. The terms "atopic eczema" and "atopic dermatitis" mean the same thing and should not be confused.

Causes

Atopic eczema is essentially an inherited disorder. Often there is someone else in the family with eczema, asthma or hayfever, but this is not always the case. There are many external factors which may influence eczema on a day-to-day basis. These are discussed in more detail later on.

Relief

For the majority of sufferers, eczema gradually improves as the child gets older. The age at which eczema ceases to be a problem varies, but many show a significant improvement by the age of 5 years, and most will be clear by the time they are teenagers. Only a few continue to have troublesome eczema in adult life.

Allergic reaction

Eczema is not caused by one specific allergy. Children with eczema have a hyper-sensitive skin, which reacts to many different environmental allergens, such as grass pollen, house dust mite, dandruff from cats and dogs, and feathers. Young children may react to certain foods, in particular eggs, cow's milk, and peanuts. The pattern of allergic reactions from one child to another is not consistent and may alter as the child gets older

Children with eczema usually demonstrate multiple positive reactions on skin tests, which are of little guide to treatment. Blood allergy tests are similarly unhelpful.

Guidelines to treatment

There is no single medication which will cure eczema. However, for most children, it is possible to treat eczema effectively and keep it in check, using a simple regime of treatment, as outlined below.

Emollients

These are products which moisturise and soften the skin. They restore the elasticity and suppleness of the skin and help to reduce the itching and scratching.

Emollients are safe and should be used frequently, as first-line treatment. These should include:

• a bath oil emollient, with regular once or twice daily baths
• a soap substitute, such as aqueous cream
• a moisturiser applied liberally to all areas of dry skin, at least twice daily and if possible more frequently

Topical steroids (cream or ointment)

The use of an appropriate topical steroid is safe and an essential part of treatment. This should be applied once or twice daily specifically to the areas of inflammation, that is the red areas, immediately after a bath, and not at the same time as the moisturiser. The use of a mild topical steroid such as 1% hydrocortisone, is usually sufficient for most children. Occasionally, a slightly stronger steroid cream may be required for the treatment of more severe eczema.

Parents are often anxious about the use of topical steroids, but these worries stem from the misuse of the very strong steroids, which may cause problems, such as thinning of the skin, and should not be used routinely to treat children. The long-term use of a mild topical steroid, e.g. 1 % hydrocortisone ointment, applied once or twice daily to the areas of eczema, is safe. On the face of the very young, it is better to use this for short periods only, as necessary.

Antihistamine medicine

Given just before going to bed, this will help the child settle and have a more comfortable night's sleep.

Antihistamines medicines are not addictive and there is no evidence to suggest that long-term use is dangerous. Antihistamines reduce the itching and act as a sedative. They are therefore useful at night to help sleeping. The bedtime dose should be given at least half an hour before the child goes to bed.

Non-sedative antihistamines are sometimes prescribed during the day. These may help, and are especially useful for those children who suffer with hayfever during the summer months. Antihistamine creams should not be used on eczema as they may cause an allergic reaction.

Other treatments

The following may be used for difficult eczema, which has not responded to the more simple measures:

• wet or paste-medicated bandages
• evening primrose oil capsules (taken as a 3-month trial of treatment initially)
• dietary manipulation under the supervision of a doctor or preferably a dietician

Infection

Children with eczema are susceptible to skin infections, because of scratching and splitting of the skin. An acute flare-up of eczema is often associated with secondary bacterial infection and usually requires treatment with an antibiotic medicine. For localised areas of infection an antibiotic cream may be sufficient.

Children with eczema are especially susceptible to cold sores (caused by herpes simplex virus). Contact with the virus may result in a widespread infection, which may make the child feel very unwell. If this is suspected, you must contact your doctor as soon as possible. It is important to keep children with eczema away from anyone with an active cold sore.

Children with eczema are also susceptible to warts and mollusca contagiosa (water warts). These are often numerous and persistent, but eventually do disappear - with or without treatment!

Bathing

Bathing keeps the skin clean and free from crusts and scales, which helps to prevent infection. Frequent baths are the rule, at least once a day, twice daily if possible. It is essential to add a suitable bath oil emollient to the bath water, to prevent the skin from drying out.

Soaking in the water for at least 10 minutes, preferably 20 minutes, helps the skin considerably. Avoid ordinary over-the-counter soaps, which are irritant, alkaline and often perfumed. It is best to use aqueous cream to cleanse the skin. This is well tolerated by children and easy to use.

The temperature of the bath water should be cool and the bathroom warm. Avoid any sudden changes in temperature which may make the skin itch. Afterwards dry the skin by patting gently with a soft towel.

Bathing is better than showering, but if only a shower is possible, then use an appropriate emollient shower gel and rinse well before drying.

Dieting

It is the generally accepted view that children with eczema should not automatically be put on a diet. Many parents are concerned that eczema is caused by something the child is eating. However routine exclusion diets are usually unhelpful.

Diets should be reserved for the very young with severe eczema non-responsive to the standard treatment regime, and for those who have a clear history of specific food intolerance (e.g. eggs, cows' milk, cheese, fish, peanuts, marmite, and honey). The diets employed are usually avoidance of dairy products (substituting a soya or casein hydrolysate preparation for cows' milk) and sometimes avoidance of foods containing artificial additives. This should be for a trial period of two months and supervised by a dietician to ensure that the child is not at risk of nutritional deficiency.

Swimming

Swimming in the sea is excellent for eczema. In a pool, the chlorine may irritate the skin. In an attempt to prevent this, apply a thick moisturiser, such as vaseline (50-50 mixture of white soft paraffin and liquid paraffin) beforehand, and afterwards soak in a bath with an oily bath additive.

Taking babies with severe eczema into a swimming pool is not a good idea. Children over 4 years old should be actively encouraged to learn to swim and participate in all sporting activities.

Sunshine

Eczema usually improves in the sun, especially on holiday. It is important that children with eczema keep cool in the hot weather and wear loose cotton clothes. It is advisable to protect the skin from burning, using a suitable sun-screen product.

Vaccinations

Your baby should receive all the routine vaccinations, like any other baby. There is no cause for concern. Occasionally any of the vaccinations may aggravate eczema for a few days afterwards, but this is not usually a problem.

Other practical advice

In order to prevent the eczema from getting worse, dress children in cotton clothes and use non-biological washing powders. Foods such as citrus fruits and tomatoes can cause eczema around the mouth. This is often made worse by lip-licking and dribbling.
In an enclosed room, fumes will irritate the skin. It is best to ban smoking within the home.

Virtually all furry pets will produce an allergic reaction in a child with eczema. Cats and dogs leave their dandruff everywhere and so the child is always at risk, even if the animal itself is not around.

House dust mites are microscopic creatures that are found in large numbers in old mattresses and within the dust on the carpets and other surfaces. When scratched into the skin they will worsen eczema and, if inhaled, will provoke asthma. Simple measures to reduce the risk of house dust mite allergy should include: a new, or fairly new, mattress; regular use of an appropriate vacuum cleaner; damp-wipe surfaces; and keep furnishings simple to avoid dust traps. Wooden or lino flooring is preferable to carpeting. Another source is old soft furry toys, which should be kept in a cupboard and washed regularly.

In addition to the above, keep finger and toe nails short and avoid excessive heat. Use cotton bed linen; pillows and duvets should be feather-free and covered in cotton. Good general ventilation in the house is important. Dampness encourages the growth of fungi and moulds, which may cause allergic reactions. Hard water may irritate the skin and the use of a water softener may help.

School can present problems and it is important to liaise closely with the teacher. It is best if the child is seated in the centre of the class, away from the door, windows and radiators. They must avoid contact with any guinea pigs, hamsters, or rabbits in the school. They should take their own special soap and moisturising cream. Most children will apply their own creams at break and lunchtime, but this must be supervised. If properly informed, most schools will co-operate and help in this situation. It is important that children do not miss school because of their eczema.

Daily skin care

The following regime is recommended:

• bath or wash containing an oily bath additive
• application of treatment cream early in the morning (usually a topical steroid)
• application of moisturiser mid-morning, mid-day, and mid-afternoon
• application of treatment cream in the evening (usually a topical steroid)
• antihistamine medicine 30 minutes before going to bed

Asthma

Reliable statistics are not available but, in practice, the likelihood of a child developing troublesome asthma in addition to eczema is small.