Eczema is a chronic itchy skin condition. Eczema usually starts within the first five years of life, most often in the first six months. It typically lasts into childhood and adolescence. In some cases it may last into adulthood. Eczema tends to wax and wane. There are periods of time where the skin appears mildly affected or even normal, alternating with periods of moderate to severe involvement. Some children have very mild eczema and others have severe eczema (also known as atopic dermatitis).
Eczema tends to be more common in families that have a history of eczema, hay fever, and asthma. These disorders are all a part of what is called the “atopic triad.” A first or second degree relative with a history of one of these atopic conditions can often be identified in the family of a child with eczema. Children with eczema may be more likely to develop allergies or asthma but one does not cause the other.
The location and appearance of eczema changes as children grow. In young babies, eczema is most prominent on the cheeks, forehead, and scalp. It may affect most of the body but usually spares the diaper area. At 6 to 12 months of age, it is often worst on the crawling surfaces, the elbows and knees. Around the age of two the distribution changes and tends to involve the creases of the elbows and knees, the wrists, ankles, and hands. It may affect the skin around the mouth and the eyelids. Older children and adolescents may have eczema only involving the hands.
In young babies eczema tends to be more red and weepy. In toddlers and older children it often appears more dry, and the skin may be thickened with prominent skin lines (a skin change called lichenification).
Eczema flares occur when the skin is very dry, it comes in contact with irritating substances or allergic triggers, or when the skin is infected. Eczema tends to be worse in the winter when the air is dry and tends to improve in the summer when it is more humid. In babies, saliva from drooling may cause additional irritation, particularly to the cheeks, chin and neck. In such cases, applying an ointment like Aquaphor or Vaseline can prevent direct contact with saliva and decrease skin irritation. Specific triggers can vary based on the child and can include pets, carpet, dust mites, fabrics (such as wool), cigarette smoke, and scented products (such as perfume, laundry detergent and air freshener). When the skin is infected your pediatrician or dermatologist may have to prescribe an oral antibiotic to improve the eczema.
Unfortunately, there are no cures for eczema. Fortunately, in most children eczema becomes less severe with time. The good news is eczema can be controlled.
Treating eczema requires treating both skin dryness and skin inflammation. A good bathing routine is necessary to treat skin dryness. Anti-inflammatory medications, like topical steroids or topical calcineurin inhibitors (TCIs), are used to treat inflammation. Occasionally, oral anti-inflammatory agents are needed to treat the most severe cases.
Daily bathing is recommended for infants and children with eczema. Baths are generally preferred over showers. Baths should be warm, not hot, and they should be short in duration, lasting about 10 minutes. The use of soap should be limited. Bubble bath, epson salts, and some other bath additives should be avoided because they can be irritating to the skin and worsen eczema. Also avoid the use of scrubbers, loofahs, and rough washcloths. Immediately after bathing, a moisturizer should be applied to the skin.
Cetaphil® RESTORADERM® Eczema Calming Body Wash, Stelatopia Cream Cleanser, Cetaphil© Gentle Skin Cleanser, and CeraVe© Hydrating Cleanser are examples of cleansers often recommended by dermatologists to treat eczema. Cleansers should only be used to wash the diaper area and areas that appear dirty. They do not need to be used on a daily basis. See the Seal of Acceptance™ Product Directory for suggested cleansers.
Bleach baths may be recommended by your dermatologist if your child has moderate to severe eczema and/or a history of infection. Bleach baths help prevent infections and maintain better eczema control. Staphylococcal aureus is a bacteria that lives on the skin of many children with eczema and can occasionally grow to cause infection and eczema flares. Bleach baths can help control the amount of bacteria on the skin and lead to fewer skin infections. Bleach baths are safe and are similar to bathing in a chlorinated swimming pool. Bleach baths are made by pouring ¼ cup of bleach into a half-filled bathtub. For babies with eczema, 1 to 2 teaspoons of bleach per gallon of water may be added to a baby tub. Always be careful to dilute the bleach before contact, avoid getting bleach water in the eyes, and moisturize immediately after the bath. Bleach baths are usually recommended a few times per week.
Moisturizers should be applied at least twice daily—in a thick layer. Generally two types of moisturizers are recommended for treating eczema: ointments and creams. Lotions are mostly water and are not recommended. It is most important to moisturize the skin immediately after bathing (within 3 minutes) to prevent evaporation of moisture from the skin. Ointments and creams seal moisture from the bath into the skin, much like plastic wraps seal moisture into a cake. See the Seal of Acceptance™ Product Directory for suggested moisturizers.
Moisturizers are classified based on their oil and water content. The more oil a moisturizer has the more effective it is in treating dry skin. Ointments have the greatest oil content, followed by creams, and then lotions. Creams and lotions also often have added preservatives that may burn when applied to scratched open skin. Ointments usually do not burn when applied. Ointment-based emollients and medications are generally preferred over creams for these reasons. Lotions are not generally recommended. During the summer a cream may be preferable to an ointment to prevent miliaria (prickly heat), which can occur after application of an ointment in the summer heat and humidity.
To prevent skin irritation, seek out moisturizers that are fragrance- and dye-free.
Switching from a cream to an ointment will help. Ointments usually do not cause burning, even when applied to scratched open skin. One cup of table salt may be added to warm bathwater to prevent burning.
Most gentle baby shampoos can be used. Fragrance- and dye-free shampoos are preferred. The fewer the ingredients, the better. One example is Exederm™ Baby Eczema Shampoo. See the Seal of Acceptance™ Product Directory for suggested moisturizers.
Very mild eczema may be controlled with a good bathing and moisturizing routine alone. Mild eczema may require the occasional use of a low-potency topical steroid. But the majority of children with moderate to severe eczema (or atopic dermatitis) will need to use low- to medium-potency topical steroids on a more regular basis to control eczema.
Steroid ointments are safe when used appropriately. Some tips for safe application include:
Consider using topical calcineurin inhibitors (Protopic© ointment and Elidel© cream). These nonsteroidal anti-inflammatory medications are approved for children older than two years, but they are sometimes used “off-label,” especially in rotation with topical steroids, for infants.
Topical steroids should be applied no more than twice daily. One application should occur immediately after bathing as part of the bathing routine. A moisturizer should always be applied over the topical steroid. Topical steroids should be applied to red itchy skin until the skin is less inflamed and more comfortable. Be aware that the skin may look lighter in color after the redness clears. This is normal and improves with time.
Enough steroid ointment should be applied so that the skin feels tacky immediately after application. Within a few minutes it is will be absorbed by the skin. Topical steroids should be applied only to red itchy areas of skin.
Gentle skin care and the use of moisturizers, and topical steroids are the most important treatments for eczema. Tar preparations can also be helpful. It is important to prevent bacterial infection of the skin through the use of bleach baths as part of any ongoing skin maintenance routine. When infection is present, it should be treated with topical or oral antibiotics.
Oral antihistamines are very helpful for some children with eczema. They may reduce itch, but perhaps more importantly, they cause drowsiness, which helps children sleep. Some eczema does not respond as expected to the usual treatments. Such children may be candidates for oral or injected treatments that calm inflammation in the body. Your child’s dermatologist will help you decide if this kind of treatment is necessary.
While many parents assume that a particular food is the cause of their child’s eczema, the answer is rarely that simple. Most eczema is unrelated to diet. In fact, parents who remove food from their child’s diet in an effort to clear up the skin can be causing more harm than good. If your child’s eczema greatly improves with gentle skin care and topical medications as described above, it is unlikely that there is a “hidden” food allergy in play.
Some children with eczema have food allergies, but that does not mean that the food allergies actually cause the eczema. If your child gets hives (red, itchy swollen skin bumps that look different from eczema) within one hour of eating a specific food, this is a sign of a food allergy and this food should be avoided until you talk to your child’s doctor.
Most infant eczema is unrelated to diet, whether breast milk or formula. Many babies with eczema are incorrectly labeled as “milk allergic.” Do not stop breastfeeding or giving cow’s milk formula without first talking to your child’s doctor. In most cases the skin will improve by using the gentle skin care techniques and topical medications described above.
Because most eczema is not related to diet, and because current allergy tests do not accurately predict eczema triggers, allergy testing is not routinely recommended. However, if your child’s eczema has not responded to standard treatments or your child gets a rash after eating a specific food, allergy testing might be considered.
Children with eczema are encouraged to get all of the usual immunizations. If your child is taking an oral or injectable anti-inflammatory medication, your child’s doctor may recommend avoiding live vaccines.
Your child should be allowed to participate in normal childhood activities and this includes swimming. However, your child may not tolerate long periods in the water, particularly in pools with chemicals since these can dry the skin. You should rinse your child and apply moisturizer before and after swimming in a chlorinated pool.
The cells in your child’s skin that make the normal color (or “pigment”) don’t work properly when the skin is inflamed from eczema. The good news is that these cells will recover and the light spots eventually will return to the normal skin color.
Encourage your child to participate in their skin care routine (for example helping to apply cream). Establish a reward system if necessary.
There is no known way to prevent eczema, but good skin care with a daily bath and use of a moisturizer twice daily can help strengthen the skin against all kinds of irritants. Get to know your child’s triggers and avoid them as much as possible. Finally, treat patches of eczema with medications as soon as they appear, since this can prevent more severe rashes.
Request free information from the National Eczema Association.