Have you heard of “the itch that rashes”? What does that even mean? Does your infant seem to have dry cheeks that you can’t seem to get rid of? Is your child constantly itching their skin? These may be signs of eczema, a common skin condition in childhood and beyond.
What is eczema?
Eczema, also known as atopic dermatitis, is a chronic inflammatory skin condition characterized by dry, itchy, and inflamed skin. It’s called the “itch that rashes” because the condition can lead to a vicious itch-scratch cycle where itching leads to scratching, which results in the release of inflammatory mediators, leading to the development of eczema and more dry skin and subsequently more itching and scratching.
Eczema is very common – approximately 15-20% of children have eczema. Symptoms usually begin before 5 years of age. Fortunately, most children will outgrow eczema by adolescence; however, sometimes, it will persist into adolescence and adulthood. Predicting who will outgrow their eczema is difficult, but family history may play a role.
What causes eczema?
A combination of genetic and environmental factors causes eczema. Skin barrier dysfunction, environmental triggers, genetic predisposition, and immune dysfunction are all possible reasons.
One of the biggest risk factors is having a strong family history of atopic conditions. Atopic conditions include eczema, allergies, and asthma. These conditions commonly occur together due to the immune system overreacting to certain triggers or substances.
The most common environmental triggers of eczema include heat and sweating, harsh skin care products (soaps, lotions, detergents, or fragrances), wool or certain synthetic materials, emotional stress, illnesses (common cold), dry skin, weather changes, irritants, and harsh soaps. The reality is that the environmental triggers vary from person to person. This is why part of management is watching what causes a flare in your child and removing or reducing exposure to that trigger.
Symptoms of eczema
The diagnosis is clinical, which means how it presents on the skin, and there’s no test to make the diagnosis. Those with eczema tend to have dry, erythematous (or red) skin and scaly plaques or patches. Dry skin with intense itchiness is the cardinal symptom of eczema.
Eczema rashes ITCH! In infants and toddlers, it typically presents with red, scaly, itchy lesions on the cheeks, scalp, wrists, and ankles. In severe cases, it can result in oozing skin with crusting. In older children and teens, eczema is more likely to appear on the inside of skin folds, specifically inside the elbow and behind the knee, as well as around wrists and ankles. For those who experience long-lasting symptoms, it can cause pale or dark patches of skin. With repetitive scratching with those with chronic eczema, the skin can become very thick —something called lichenification.
How to manage eczema
The main components of eczema care include:
- Maintaining basic skin care and moisturization
- Noticing and eliminating triggers
- Topical ointments, wraps, and medication
- Managing and monitoring infections triggers and secondary infections
Maintaining basic skin care and moisturization
The maintenance phase includes daily, consistent use of a moisturizer to hydrate the skin. It’s so, so important to continue this even when symptoms are well controlled. Think of this as a preventative phase. Hydrating the skin consistently helps prevent dryness and reduces the likelihood of needing prescription medications. Ointments are ideal which are thick and come in a tub. Thick creams are a good alternative. Typically creams advertised as hypoallergenic, fragrance-free, and anti-itch are good options.
Noticing and eliminating triggers
A big part of treating eczema is also to notice triggers for your child. Avoiding triggers, such as harsh soaps, allergens, and extreme temperatures, is important. For some kids, you can identify a certain trigger based on history. For example, you put them in non-cotton pajamas, and they’re scratching all night. Or you apply a scented lotion, and they flare up. If you think you have identified a trigger, try to avoid it in the future.
Topical ointments, wraps, and medication
Ointments are ideal which are thick and come in a tub, this includes options such as Aquaphor or Vaseline. These work by locking moisture in the skin, but some parents or children complain about its greasiness. Thick creams are a good alternative, such as Cerave moisturizing cream, Cetaphil moisturizing cream, or Vanicream. Sometimes it’s helpful to mix a cream with an ointment. You can mix in your hands and lather this on whenever you notice the dry skin. For any ointment or lotion, patch-test the new ointment on your child’s skin before using it all over. If you notice a reaction or discomfort after applying it to a small area, it’s best to avoid using this product for your child in the future. Unfortunately, there is no one-size-fits-all “best” option out there – what works great for one child may not work well for another. You will likely have to try a few before you find the one that works best for your child.
Wet wraps can be used for more severe cases. To make a wet wrap, you first apply a moisturizer ideally an ointment like Vaseline or Aquaphor healing ointment, then apply a dampened cotton wrap to the affected skin and then cover it with a dry wrap and then pajamas on top. The wet layer should not be allowed to dry out and can be replaced if needed. This helps reduce itchiness and limits access to the skin to scratch it.
Medication for eczema management often includes topical steroids. The flare management phase is needed when dry, itchy patches develop. If you see the slightest redness and/or they are itching, continue your moisturizers and ointments but add on the prescription steroid. There are a few other prescription medications that are non-steroidal and approved for the treatment of eczema. It’s important to note that if you’re reaching a point where you are using steroid ointments for more than 2 weeks per month, it is likely time to see a dermatologist to discuss all treatment options.
Managing and monitoring infections triggers and secondary infections
Patients with eczema are at higher risk for skin infections due to the disruption in their skin barrier and scratching. These skin infections can be mild, such as impetigo, which presents with itchy, fluid-filled blisters and crusting. Rarely, these skin infections are more serious, such as eczema herpeticum, which is the spread of herpes simplex virus to the skin.
When should you see a clinician for eczema?
- You’re unsure of the diagnosis and need an action plan
- The eczema action plan is not working
- You’ve tried moisturizers as mentioned and removing triggers and it’s still difficult to manage
- You’re using topical steroids for more than 2 weeks/month (you may need a different medication or to see a specialist like a dermatologist)
- You have closely monitored food exposures and feel there is a connection between certain foods (you may need to see an allergist)
- If your child is feeling ill with a unique rash, it’s important to make sure it’s not a super-infection
Do you still have more questions about eczema?
For example, what about food allergies and eczema? What to do if you think a food is triggering your child’s eczema? What about gut health and eczema?