Eczema is common, frustrating, and often misunderstood.

In this episode, we break down what eczema actually looks like at different ages, how specialists determine severity, and why treatment should always start with strengthening the skin barrier.

We discuss:

• How to recognize eczema, including how it differs in infants vs older children
• How doctors determine mild, moderate, and severe eczema
• When allergy testing is appropriate — and when it is not
• Why blanket food panels can cause more harm than good
• The risk of false positives and unnecessary elimination diets
• How to build an eczema action plan
• First-line skincare strategies that actually work
• The role of moisturizers, emollients, and when prescription treatments are needed

Want more? Listen to the full, ⁠⁠original episode⁠⁠.

Our podcasts are also now on YouTube. If you prefer a video podcast with closed captioning, check us out there and⁠⁠ ⁠subscribe to PedsDocTalk⁠⁠⁠.

Get trusted pediatric advice, relatable parenting insights, and evidence-based tips delivered straight to your inbox—join thousands of parents who rely on the PDT newsletter to stay informed, supported, and confident.⁠⁠ ⁠⁠⁠⁠Join the newsletter⁠⁠⁠⁠⁠⁠!

And don’t forget to follow⁠⁠ ⁠⁠⁠⁠@pedsdoctalkpodcast⁠⁠⁠⁠⁠⁠ on Instagram—our new space just for parents looking for real talk and real support.

We love the sponsors that make this show possible! You can always find all the special deals and codes for all our current sponsors on the⁠⁠ ⁠PedsDocTalk Podcast Sponsorships⁠⁠⁠ page of the website. 

00;00;00;02 – 00;00;25;06

Dr. Mona

Hey, hey. Welcome back to the FollowUp. It’s Doctor Mona, your online pediatrician mom friend, and we revisit a favorite episode in less time than it takes your child to scratch the same eczema patch right after you moisturized it. With the weather shifting, eczema tends to flare. Temperature changes, dry air, seasonal allergies. All of it can trigger those red, itchy patches that leave families frustrated and exhaust it.

 

00;00;25;08 – 00;00;47;15

Dr. Mona

That’s why I’m repairing this conversation today. On this episode, I sat down with Doctor Shreya Patel, allergist, an immunologist, and we broke down eczema. We talked about what eczema looks like, which children may be more predisposed. Whether there are preventable measures. When it’s time to see an allergist, what a workup might entail, and the basic skincare strategies that truly make the difference.

 

00;00;47;17 – 00;01;20;20

Dr. Mona

I’ll be honest, eczema is probably one of the hardest skin conditions I manage. As a pediatrician, it requires consistent skin care, close monitoring of triggers which are so individualized, medication adjustments, and it carries a huge mental load for families. The itching, the sleep disruption, the constant cycle of flare treat. Come. Repeat. It is a lot. If this episode helps you, or if any of my eczema resources on YouTube have supported your family, please share it on social media and tag PedsDocTalk and the PedsDocTalkpodcast.

 

00;01;20;20 – 00;01;36;04

Dr. Mona

Some more families can discover it. Make sure you download the full episode of this conversation and subscribe to the show so you don’t miss a future follow up episode. Let’s get into it.

 

00;01;36;07 – 00;01;39;28

Dr. Mona

How would you describe how the eczema rash would look like?

 

00;01;40;00 – 00;02;04;24

Dr. Shreya Patel

Yeah, so eczema is usually characterized by like this itchy, red and scaly patches on the skin. If you were to touch it, it would feel really rough to the touch because it’s dry. You’d usually see a lot of overlapping scratch marks, or as we call them, excoriation. And if it’s been there longer, it’ll be, thicker. It’ll be discolored, like you might have some areas that are darker or some areas that are lighter.

 

00;02;04;26 – 00;02;23;18

Dr. Shreya Patel

And then where you’ll find it on the body, actually, interestingly enough, varies by age. So infants and younger children, you’ll usually see it on the scalp, the knees, the elbows, and then on the face. But on the face you’ll see it more on the cheeks. And you’ll characteristically have what the, the so called headlight sign, which means like that the nose is spared.

 

00;02;23;20 – 00;02;37;01

Dr. Shreya Patel

So it’s usually going to be on the cheeks, on the face. For older children and adults, you’re going to see it more in the creases of the wrist. The creases of the elbows, the knees. So that means behind the knees, also on the ankles, the face and the neck.

 

00;02;37;04 – 00;02;54;01

Dr. Mona

Okay. And then, you know, we, we always kind of look at okay. Is it mild moderate severe. I know that might just be based on how the person who’s looking at it is describing it. But how would you as an, you know, allergist immunologist, how would you describe or categorize mild moderate severe eczema?

 

00;02;54;04 – 00;03;14;23

Dr. Shreya Patel

So if I want to determine the severity of and eczema, there’s two major things that I look for. The first thing I look for is how much of the body is actually affected. And then the second thing I look for is the intensity of the eczema. So just generally looking at, you know, how do I calculate the body surface area affected as I look at the head, the trunk, the upper limbs and the lower limbs?

 

00;03;14;25 – 00;03;32;00

Dr. Shreya Patel

And then you look at it all kind of together and determine how much of the skin is actually involved. And then for the intensity, I look at four things as well. I look at the redness, the thickness of the skin, how much scratching there actually is or scratch marks. And then the like can ification. And that’s a term that usually you’re going to see that more in chronic eczema.

 

00;03;32;00 – 00;03;52;06

Dr. Shreya Patel

And that describes when you see lines in the skin furrowing. Sometimes if it’s really bad and in there long term and you actually see nodules on the skin. So usually you can kind of take those two big categories together and determine is it mild, moderate or severe? A lot of times allergists and dermatologists like to have a real score attached to it.

 

00;03;52;06 – 00;04;08;16

Dr. Shreya Patel

And so we’ll actually use standardized scoring tools to determine that. And so one example of that is like the eczema er area and severity index, the ESR, that’s a common one that we use. So it just gives people an idea of what your doctors will use to determine the severity.

 

00;04;08;18 – 00;04;15;09

Dr. Mona

And you described it earlier that it would be kind of like dry patches. Does it always have to be red or can it just be dry?

 

00;04;15;12 – 00;04;35;08

Dr. Shreya Patel

It can be just dry, especially if it’s not acutely inflamed. But usually you will have some sort of at least faint redness there. But I see a lot of kids who just come in. They have like even these circular areas which we call numb or eczema. And they’re almost just like the circle of dry skin, not necessarily red.

 

00;04;35;15 – 00;04;39;26

Dr. Shreya Patel

So, yeah, you could definitely just have these dry patches of skin and it could be eczema.

 

00;04;39;29 – 00;04;47;11

Dr. Mona

And if they do come to you obviously. What is it you mentioned? Briefly about the workup. What does that workup look like or entail?

 

00;04;47;14 – 00;05;10;02

Dr. Shreya Patel

Okay. So, if a patient comes to me and their history physical, everything is consistent with eczema. So the first thing I do is I usually assess the severity because really how severe the eczema guides, how I’m going to treat them and what kind of workup I’m going to do. So based on, again, the severity I make recommendations for like skin moisturizers, prescription topical medications.

 

00;05;10;04 – 00;05;33;24

Dr. Shreya Patel

I usually evaluate for whether there’s an infection. And then again, how to kind of we already mentioned whether there’s a possible inhalant environmental food allergy or something like that that could be triggering the eczema. To decide that I can actually skin test right in my office, and we can have results the same day to suspected triggers. But I also go to testing if I cannot get the eczema under control with a good skincare regimen.

 

00;05;33;24 – 00;05;52;18

Dr. Shreya Patel

So I usually try that first. Now, the exception to that is the patient that we just described where they’re coming in, telling me that it’s the egg or telling me that it’s the dog, and then I can consider testing, sooner rather than, you know, waiting to try the topical stuff first. But we can start it sooner. That way we can prevent the flares.

 

00;05;52;20 – 00;06;14;25

Dr. Shreya Patel

And I’m just going to stress this point because this is so, so important. I do not do blanket skin testing for all of my eczema patients. Okay. Food allergy has been implicated in about a third of patients with eczema. And testing usually consists of some sort of skin prick testing. It should really just be to a small panel of foods that I usually pick based on the current diet.

 

00;06;14;28 – 00;06;36;29

Dr. Shreya Patel

This is a team decision between myself and the family. I sit down with them. I talk about what is currently in the child’s diet. What are they eating regularly again? Is there something that, you know that’s triggering it, like the egg, right? Based on that conversation, we decide how to proceed the testing. And I always say, and this is something really good for pediatricians and primary care providers to, to tell their patients as well.

 

00;06;37;01 – 00;06;53;07

Dr. Shreya Patel

So it’s a good idea for families from the very beginning to come prepared with like a food diary or something that helps them zone in a potential trigger so that by the time they get to the specialist, they can open up that diary and say, look, these are the things that we’ve noticed over the last few weeks. These are the things we’re concerned about.

 

00;06;53;09 – 00;07;20;04

Dr. Shreya Patel

So I still get asked that question though. But why don’t you just test for everything, doctor Patel, please? Like just do the full panel of food allergies. The reason I don’t do this is because there really are a high rate of false positives. Okay? So our skin tests, unfortunately, they’re not perfect. Even though people think that this is going to be gospel when they get the results, they’re really not perfect and they lead to a lot of unnecessary large elimination diets that can result in nutritional deficiencies.

 

00;07;20;06 – 00;07;41;25

Dr. Shreya Patel

And actually, if you eliminate foods early on that a child’s not actually allergic to you can actually create sensitivity down the road because their body is not seeing it enough now and then later when they see it, it’s deemed foreign. The food is, you know, thought of as something foreign. And they might actually develop the allergy. So I don’t like to do these, you know, panel food testings.

 

00;07;41;28 – 00;08;05;08

Dr. Shreya Patel

Instead, I just like to have the conversation test based on certain, potential specific triggers. So I can also do skin testing to environmental triggers. So like we talked about dust pads, pollen that also is done on a very individualized basis. But it can be part of the workup when it’s appropriate. If, I find that a child’s skin is too inflamed for the skin test, we can always do a blood test.

 

00;08;05;10 – 00;08;25;24

Dr. Shreya Patel

But again, with that, I’m very careful about sending unnecessary testing in the blood. Same thing. We can have lots of false positive results here too, especially if you’re dealing with that really allergic kid. Probably has a lot of that general IgG floating around the body. IgG is an allergic antibody that anybody who’s an allergic person just has a lot of this floating around in their blood.

 

00;08;25;24 – 00;08;47;08

Dr. Shreya Patel

It’s just a general marker of that. So if they have a lot of the general IgG floating around, then they have a false elevated specific IgG to like milk, egg or peanut. And it’s not truly that they’re allergic to that food, but they just have a lot of IgG floating around. And so that’s why I don’t like to do a lot of, you know, a lot of blood testing either unnecessarily.

 

00;08;47;11 – 00;09;09;11

Dr. Shreya Patel

And then lastly, one of the things that can be part of my workup is if a parent is pediatrician is concerned about a potential contact allergy, and then we can discuss patch testing. So this will be to things like chemicals, fragrances, preservatives, things that you might find in the child’s laundry detergent, in the child’s products that they’re using, even dyes in their clothes.

 

00;09;09;12 – 00;09;12;13

Dr. Shreya Patel

So these are things that a patch test can can tell us.

 

00;09;12;17 – 00;09;21;00

Dr. Mona

And so you mentioned between the blood and skin testing is one more I know you said there’s false positives for both but is one more accurate than the other.

 

00;09;21;02 – 00;09;22;19

Dr. Shreya Patel

No it’s not that one is.

 

00;09;22;19 – 00;09;40;21

Dr. Shreya Patel

And no, it’s not one more accurate than the other. People usually choose skin tests because it’s a little bit easier of a test. They don’t need to go through a needle stick. They can have results the same day within 20 minutes versus like going getting your blood drawn, waiting a week to get the results. Skin tests are usually more sensitive.

 

00;09;40;21 – 00;09;50;10

Dr. Shreya Patel

Tests and blood testing are usually more specific. And so each one kind of has their strengths. But, skin test is generally what’s preferred.

 

00;09;50;13 – 00;10;16;28

Dr. Mona

Families will come in and they, you know, their child is sneezing or their child has one little spot and they want the whole, like you said, the whole panel of allergy testing. And I’m happy you brought it up because one, it’s very expensive too. It used like you said, it has a lot of false positives. And three if symptoms are mild and we’re able to manage it well with just say it’s eczema, we’re managing it well with, ointments and steroid creams or whatever may be.

 

00;10;17;05 – 00;10;46;11

Dr. Mona

You don’t need that because it’s being managed. It’s not going to change the management anyway. So I love that you brought that up because I really want the listeners to know that the testing, well, the clinical exam will always trump testing. You know, it’s more important to look at the at the kid. And I love skin testing because the skin testing can kind of get you an idea of, okay, well, obviously we need to avoid these certain foods that are flaring flaring up, but to just go in and many times even for food allergies, I want to just be tested for everything.

 

00;10;46;11 – 00;11;04;17

Dr. Mona

Even before I introduce food, I’m like, well, that’s not really how it goes. But not always all the time. But we should we can absolutely talk about testing and, you know, food allergies at a later time, because I do get that. Could that comment a lot? Do you, what are your basic like going into like management?

 

00;11;04;17 – 00;11;12;02

Dr. Mona

What are your basic skincare tips for a family who’s, you know, obviously taking care of a child with eczema.

 

00;11;12;05 – 00;11;32;22

Dr. Shreya Patel

Okay, so that’s another great question because in my opinion, the most important and first step in the treatment of eczema is creating an eczema action plan, which lists out what you should use, how you should use it, and when you should use it. So every single one of my eczema patients walks out of my office and they have an eczema action plan in their hands.

 

00;11;32;24 – 00;11;55;11

Dr. Shreya Patel

And treatment is really multi-pronged. So you have to think about skin hydration, topical anti-inflammatory medications when needed. Antiparasitic therapy because breaking the so called itch scratch cycle is also very important. Some patients might need antibacterial measures if they have like an overlying bacterial infection. And then of course, eliminating the exacerbating factors right in the diet in the environment.

 

00;11;55;11 – 00;12;27;14

Dr. Shreya Patel

So there’s a lot of things that go into it. So basic skin care tips though, in terms of what I recommend. So remember again and I sound like a broken record, but remember again that eczema is characterized by a reduced skin barrier function. So this leads to enhance water loss as well as dry skin. So I usually recommend hydration with warm soaking bat daily with an unscented hypoallergenic soap such as dove at least ten minutes daily, like I said, followed by application of a really good moisturizer.

 

00;12;27;16 – 00;12;48;09

Dr. Shreya Patel

Moisturizers, really are the first line therapy. I prefer the thicker emollients like Aquaphor. These contain less water, more oil than creams or lotions. They also burn less because people who have those like open eczema lesions, they always complain the children as soon as they put their cream on, you know, they were screaming that it was burning. So things like Aquaphor usually burn less.

 

00;12;48;16 – 00;13;07;21

Dr. Shreya Patel

They also act as both a barrier as well as a moisturizer. So Aquaphor is going to be something, you know, that’s clear versus like those white creams. That’s kind of the main difference between those other, moisturizers that sometimes I’ll recommend. Basic skin skincare tips would be like surveys that have flow of anti cream. Those are, good, always good products to use as well.

 

00;13;07;27 – 00;13;21;18

Dr. Shreya Patel

But again, I’m still a big fan of the hack before and then when eczema becomes more severe, that’s when you’re going to come in and start discussing the anti-inflammatory topical medications. With, I don’t think, a pediatrician for myself.

 

00;13;21;20 – 00;13;27;17

Dr. Mona

What about Vaseline? Is that in a motion that you like, or would you say Aquaphor vanney cream are a little better?

 

00;13;27;19 – 00;13;48;24

Dr. Shreya Patel

So I used to love Vaseline, and I still have found that most of my patients do pretty well with Vaseline, but from from my experience, from reading some, you know, different articles and stuff. One thing I’ve learned it the main difference between Aquaphor and Vaseline is that Vaseline is still more of a barrier, and Aquaphor acts as a barrier and a moisturizer.

 

00;13;48;24 – 00;14;09;23

Dr. Shreya Patel

So that’s why I like Aquaphor a little bit better. But I have seen a lot of patients who may not necessarily want to pay a lot of money for the offer, and so they go for the Vaseline, which is totally understandable and appropriate, and they do great with that. And so, you know, it just depends. It’s it’s definitely, okay to try it.

 

00;14;09;25 – 00;14;31;04

Dr. Mona

And that’s your follow up. Just a small dose of the real relatable and eye opening conversations we love to have here. If you smiled, nodded, or had an moment, go ahead and download, follow and share this episode with a friend. Let’s grow this village together for more everyday parenting wins and real talk. Hang out with us on Instagram at the Peds Doc Talk podcast.

 

00;14;31;12 – 00;14;46;24

Dr. Mona

Want more? Dive into the full episode and more at Peds Doc Talk. Com because parenting is better with support. And remember, consistency is key. Humor is medicine and follow ups are everything. I’m Doctor Mona. See you next time for your next dose.