Christine Pham-Cutaran’s infant son Drew developed a rash just two weeks after he was born. No biggie, she thought. “We were sure it was baby acne or a reaction to hormones or nursing,” she said.
But shortly before his 2-month checkup, Drew rubbed his cheeks raw in his sleep. In the morning, Pham-Cutaran saw blood on his sheets. That’s when she realized his rash was much more serious than baby acne, and she was right. At 6 months, baby Drew was diagnosed with atopic dermatitis (AD).
Pham-Cuteran and her husband Joseph were up every night, holding their baby’s arms down so he wouldn’t scratch. Following their pediatrician’s advice, they applied an anti-fungal cream to his oozy, red cheeks, but “his eczema just got worse,” she said.
Dr. Robert Sidbury, a pediatric dermatologist at Seattle Children’s Hospital, knows the Cuterans’ struggle all too well. Based on recent research, he endorses early, consistent moisturizing of the skin of infants born into eczema-prone families. Eczema runs in Joseph Cuteran’s family, so his son fits that profile to a tee.
An ounce of prevention
Sidbury cited a 2014 study published in the Journal of Clinical Immunology that explored the benefits of moisturizing the skin of high-risk infants as early as two days after birth.
First author Dr. Eric Simpson, a professor of dermatology at Oregon Health & Science University in Portland, found that daily moisturizing with a petroleum- or plant-based emollient reduced AD risk by 50 percent by the time the babies reached 6 months old.
“That’s a significant finding,” said Sidbury. “The only caveat is that it’s still early in the research process. We’re not sure if early moisturizing will prevent AD from developing later on, and we don’t know whether it will prevent comorbidities like asthma and allergies.”
Still, he said, parents have every reason to embrace this potentially preventive strategy—one that’s also comforting for parent and baby alike.
Trigger avoidance vs. tolerance
For now, there is no sure-fire way to prevent eczema and its comorbidities from happening, but managing flares is well within parents’ reach, especially if their children have less severe forms of the condition.
Some parents try to keep their eczema kids away from every known trigger, while others adopt a more “laissez faire” attitude. Brittney Decker-Roche falls somewhere in the middle.
“Our son Payton is allergic to grass, dust mites, cats and dogs,” she said, “and he’s severely allergic to peanuts and fish. But you can only eliminate so much. It hasn’t been easy, but we’ve learned to pick our battles.”
Asked whether parents should aim to eliminate all potential irritants and allergens or help their children learn to tolerate them over time, Dr. Elaine Siegfried, a professor of pediatrics and dermatology at Saint Louis University School of Medicine, seconded Decker-Roche’s view, urging parents to choose their battles wisely.
“The biggest eczema triggers are germs, products and changes in ambient humidity,” she said. “Germs are everywhere, so there’s no point in trying to eliminate them. The same goes for environmental allergens, such as dust and pollen. And if you live in a part of the country that has four seasons, dry air can be challenging during winter.”
It can take time and extra effort—using a humidifier, for instance—to adapt to that season’s characteristic low humidity, she said.
“Of course, parents should keep their kids away from clear-cut triggers,” Siegfried said. “If a child has contact dermatitis in reaction to a specific substance, avoiding that substance is paramount. However, we don’t want kids to live in a bubble, nor is that a realistic goal.”
Siegfried went on to name another under-recognized source of eczema triggers: baby products, which are part of a larger phenomenon that she calls the “cosmeceutical industrial complex.”
“With the best of intentions, parents can be misled by a product’s advertising claims,” she said. Hypoallergenic, gentle, 100 percent pure—these are meaningless terms, and they conceal more than they reveal.”
Her best advice? Read not just the front but the back of every label. Figure out what’s really in those products. Avoid complex topicals that contain dozens of ingredients. You might save a bundle by resisting the temptation to buy into the “cosmeceutical industrial complex.”
Parents of children with eczema already have a powerful alternative resource at their fingertips that will help them make smarter, safer choices for their children. NEA’s Seal of Acceptance™ product directory allows you to filter your search by product type, age group or brand. You can even plug in an unwanted ingredient to filter out products that contain it.
When it comes to allergies and environmental triggers, such as trees, grasses, pollen and dust, the avoidance vs. tolerance question gets more complicated, said Dr. Jonathan Spergel, chief of the allergy program at Children’s Hospital of Philadelphia.
“In the Northeast, pollen season is [the spring can be intense]. If you go outside, you can’t avoid being exposed to it. I advise my young patients to wash it off once they’re indoors, take their medication and come in for regular allergy shots,” he said.
In other words, Spergel said children should do their best to live with the allergens that surround them rather than try to avoid them altogether. But if a child is allergic to cats and dogs, avoidance is the best strategy, he added.
“Food allergies are perhaps the hardest of all to manage, especially given their complex relationship with AD,” Spergel explained.
Most foods don’t actually trigger AD, he said. Recent studies indicate that it’s the other way around: an AD flare can aggravate a child’s food allergies.
But in a small percentage of patients, food allergies can trigger an AD flare—especially IgE-mediated allergies, said Spergel.
Associated with an antibody called immunoglobulin E (IgE) that’s found in the bloodstream, these can cause a range of allergic symptoms from mild to serious, including anaphylaxis, a dangerous whole-body allergic reaction.
The most common IgE-mediated food allergens include:
- Tree nuts
“Most children outgrow a milk allergy,” Spergel said, “but many kids with eczema remain allergic to one or more of the foods on the list. If your child reacts violently to peanuts, you have no choice but to eliminate them.”
In most cases, though, parents can opt to gradually introduce tiny amounts of wheat, eggs, fish or other problematic foods to their child with particular food sensitivities or allergies. And if the child tolerates the food in question, it’s safe to increase it little by little over time, said Spergel.
‘This is us!’
A few years ago, when she was nursing Drew, Pham-Cutaran tried to eliminate every food on the problem list.
Committed to breastfeeding, she eliminated “gluten, dairy and a whole slew of other foods from my diet. The only result was that I lost a tremendous amount of weight, while Drew’s AD continued to make him look like a burn victim.
“I got a lot of judgmental feedback from people,” she continued. “It was ‘mom guilt’ times 20.”
Pham-Cutaran then decided to adopt a more aggressive approach to treating Drew’s AD that included bleach baths, topical steroids and oral antibiotics, but nothing worked—at least not for long.
Finally, about a year ago, she stumbled across the Facebook page of Dr. Richard Aron, a pediatric dermatologist based in Cape Town, South Africa, who would change everything.
Pham-Cutaran watched a couple of Facebook videos showing families coping with their children’s AD, along with before and after pics following treatment with Aron’s unique formula: a personalized topical that he compounds using three ingredients: a corticosteroid, an antibiotic and a moisturizer.
She recognized her own family’s story in theirs. “Something clicked when I saw these images. All I could say was, ‘This is us!’
“Cape Town is a long way from our home in Fort Worth, Texas,” she added, “but Dr. Aron’s approach struck us as simple and low-risk. It’s all about compounding and tapering how much and how often you apply his formula. The bottom line is that it worked [for us].”
Today, 4-year-old Drew is doing well on the Aron regimen as maintenance therapy. “He’s living his best life now,” Pham-Cutaran said. “Eczema no longer defines him. And it’s so good to see him smile.”
Adherence: The path to healing for children at every age
Whatever the severity of your child’s eczema, always start with topicals as they are the cornerstone for treating the disease in infants, school-aged kids and teenagers alike, said Siegfried.
But there’s a big problem: non-adherence. “Studies show that 75 percent of families are afraid of topicals—especially steroids,” Sidbury said. “But if they don’t use topicals as prescribed, their children probably won’t get better.
“If used appropriately, topical steroids can be safe and highly effective for use in children,” Sidbury explained. “Parents are right to use caution where prescription medications are concerned. They’re understandably alarmed at the prospect of side effects, and they don’t want a bell that they can’t un-ring. But even side effects like skin thinning are avoidable and even reversible.”
As a general guideline, he said, use a fingertip’s worth of steroid cream or ointment per day for a maximum of two weeks per month. Then, ratchet down the dose to twice a week, and take a complete steroid break once your child’s skin clears up.
En route to adulthood
At some point, usually when they reach their double digits, children start to develop their own ideas and preferences, Siegfried said. They also tend to fall under the sway of peer pressure, and parents can feel sidelined in the process. That’s precisely the time to rethink the best ways to care for your child in transition to adulthood.
Parenting styles can range widely, she explained. “There are ‘helicopter parents’ who try to organize everything in their child’s life, and then there are those who turn everything over to their kid, often prematurely. Whatever a parent’s philosophy, I encourage them to ask themselves the following question: What’s the best way to prepare my child for independent living?”
It’s all in the timing, she said. And the best time to start transitioning care is during early adolescence, when a child is 12 or 13. To avoid a crisis later on, teach your child to practice regular skincare, read a prescription label and adhere to treatment under the care of a trusted specialist. That way, an older child will be prepared to deal with eczema—and with life—en route to adulthood.
Caring for the Caregiver
Eczema in children, especially when it’s severe, can wreak havoc on the lives of everyone in the family. If you’re a parent or caregiver of an infant or child with AD, you already know all the “should-do’s” like get plenty of rest, take time for yourself and live your own life to the full, right? Easier said than done.
According to Sidbury, studies show that eczema families average a loss of about two hours of sleep per night, and that goes for both parents and children. Good sleep hygiene can help. Here are five sleep hygiene basics from the Centers for Disease Control and Prevention that can help the whole family get their zzzs:
- Aim for the same bedtime every night and get up at the same time every morning, even on weekends.
- Keep everyone’s bedroom dark and comfortably cool.
- Turn off all TVs, computers and smart phones. Turn your bedrooms into phone- and screen-free zones from bedtime to rise-and-shine.
- A small snack is fine, but try to avoid eating a large meal before bed. Caffeine and alcohol are no-nos as well.
- Get plenty of exercise during the day and encourage your kids to do the same.
In an effort to help a child get past their itchy skin long enough to fall asleep, some parents turn to antihistamines for help. Sidbury thinks it’s reasonable to try them, but he warned against regular use.
Siegfried agreed, saying, “Antihistamines are sold over-the-counter, making them easy to overuse. And overuse can lead to unwanted side effects—especially agitation and even attention deficit/hyperactivity disorder (ADHD).” However, intermittent use is fine, she noted, especially on those nights when nothing else seems to do the trick.
Sidbury also suggested parents form a partnership during their child’s eczema flare, each taking a four-hour shift. That’s not always an option if you’re a single parent, he admitted.
Still, “there are different kinds of partnerships, and NEA can become your long-distance partner”—bringing you the information and support you need, even in the middle of the night.