ECZEMA IN KIDS.
Uncontrolled eczema needs an aggressive treatment plan.
How is Eczema diagnosed in Children?
The following are pointers to Eczema – the child need not have all of these features except for itching:
- The rash is almost always itchy.
- Over 18 months of age the rash usually affects the front of the elbows or backs of the knees, back of the neck and other “flexural” areas – but not always
- Generally Dry Skin
- A child over 4 years has a history of Hayfever or Asthma
- A child under 4 years of age: There is a significant family history of Hayfever, Asthma, or Eczema
- The younger the age of onset, the more likely it is Eczema
Your GP will be able to make a diagnosis of Eczema in the majority of cases.
What Causes Eczema?
Eczema that starts in childhood is usually caused by a genetic susceptibility to environmental allergens – in otherwords, atopic dermatitis / Eczema. Other atopic conditions are asthma & hayfever.
A genetic defect in One of several genes that code for the Protein Filaggrin
Abnormal structure and function of the upper layer of skin (Epidermis)
Defective Skin Barrier Function
Skin becomes sensitised by allergens & inflamed in response to irritants, bacteria, dehydration etc
How is Eczema diagnosed in babies?
The rash tends to look different in babies & young toddlers compared to older children:
- The rash may look more “Acute” with red spots and/or blisters, and weeping.
- The rash often starts on the face & scalp, & may affect the neck and backs of elbows/knees (the extensor areas).
Similar Rashes include seborrhoeic dermatitis. Afro-Caribbean, Asian or African children’s Eczema is often different: Thickened or darker or nodular or discoid or tiny bumps (“Follicular”).
What Moisturisers are used to treat Eczema?
Moisturisers (Emollients) are very important. Depending on the severity of eczema, they are best applied at least once per day (up to four in primary care). Typical Brands are QV, Cetaphil and Dermeze. Get to know the range of your chosen manufacturer. The heavier the product, the more effective it is as a moisturiser but most people prefer the feel of lighter products. Vaseline may be messy but a very effective moisturiser. Emollients are ranked in this order: Ointments, Heavy Cream, Cream & Lotion. Avoid soap which is irritating to Eczema skin and use instead a “soap substitute.”
|Medium Moisturiser (eg. out and about)||QV Cream||Cetaphil Moisturising Cream|
|Heavy Moisturiser (eg. overnight or flare ups)||QV Flare Up Cream||Cetaphil Intensive Moisturising Cream|
|Light Moisturiser (Lotion)||QV Skin Lotion||Cetaphil Moisturising Lotion|
|Soap Substitute – For Bathing||QV Gentle Wash (Intensive wash has more moisturiser)||Cetaphil Gentle Skin Cleanser|
|Antibacterial Bathing Products||QV Flare Up Bath Oil||Cetaphil Gentle Cleansing Antibacterial Bar|
Dr Richard Beatty has no affiliation with any of the emollient cream retailers or manufacturers (or any other products) & gives no particular judgment or recommendation about these products.
In 2015, A consensus statement about the safety of steroid creams in kids was put out by 20 Australian Paediatric Dermatologists. They are worth listening to – I’ve heard a Paediatric Dermatologist say that around half of their workload is Paediatric Eczema, and they see lots of very severe cases including those admitted to hospital.
The statement goes along these lines “The advice given by dermatologists to parents of children with Eczema regarding the use of topical steroids is unfortunately frequently undermined by other health care professionals … Recommendation to ‘use sparingly’ is nonsensical and has no value”
The problem is that fears over the side effects of topical steroids are based on evidence from the 1960s and there’s a lot of data to support their safety when used according to guidelines. Indeed, the risk of not using it appropriately is really what has prompted this statement.
The statement indicates that the following side effects do not occur when the treatment is prescribed in accordance to guidelines: Thinning of the skin, loss of pigment, excessive hair, bruising, prominent blood vessels, stretch marks.
The experts above are really saying this: Look at the risks poorly controlled Eczema (they see a lot of that) and put the the much over-done risks of topical steroid treatment into perspective. We’re really all on the same page: The objective is well controlled Eczema with minimal side effects.
We all think of Eczema as being an allergic condition. In truth, only a small proportion of eczema is ‘explained’ by allergy to anything external.
There are three main types of allergies in Eczema. Contact allergic dermatitis is more common on adults and is confirmed with Patch testing. This test is usually performed in a dermatology or allergy clinic.
Airborn Allergy can contribute to eczema. Think of animal dander, grasses and house dust mite. The eyelids are normally involved.
Food allergy can also trigger eczema. This type of allergy starts in early childhood, most commonly after ingestion of eggs, wheat, cow’s milk, soy or peanuts. Look for an immediate flare of eczema after starting the new food. Food Allergy Testing with skin or blood testing is most useful in kids with moderate to severe eczema who do not improve on standard treatment. However, it is important to understand that the test may or may not help improve control of eczema. Around 1 in 5 infants with eczema have a trigger with some type of food.
Food intolerance is is rather different than food allergy because there is no known mechanism for the food to trigger an eczema flare up. In more practical terms, food intolerance can be suspected in kids with dermatitis around the mouth, even if food is eaten without contact on the skin. Foods that are implicated include strawberries, tomatoes, citrus, and artificial sweeteners.
Baby wipes are increasingly recognised as a cause of contact allergic dermatitis. Look for the ingredient Methylisothiazolinone which is found in a wide variety of products – not just baby wipes.
What is Discoid Eczema?
Discoid Eczema is a type of Eczema also known as Nummular Eczema or Nummular Dermatitis. It can occur at almost any age but is most common in adolescents/young adults (when it tends to be linked to atopic eczema) and in the 50’s and 60’s. The key condition to compare it with is ringworm (fungal skin infection).
What are the Symptoms of Discoid Eczema?
- The affected areas of skin are round (hence the name “discoid”) – usually at least the size of a coin and often larger.
- The affected skin is very itchy
- The affected skin looks like eczema but the appearance will vary depending on whether the eczema has started or is longstanding
What does it look like?
The lesions are reasonably well defined (but not as well defined as ringworm) and usually between 1 and 5cm in diameter. They usually occur on both sides of the body in a roughly symmetrical way eg. both arms or both calves. The lesions can occur almost anywhere but the most common distribution is to involve the calves and/or upper arms followed by the upper chest, sides of the torso and upper legs. Remember that they are itchy (ringworm is not usually itchy).
During the acute stage (eg. a flare-up), the lesions are pink or red and may be wet; there can be tiny blisters which may be intact or more likely have burst, and yellow crust can occur on its own or as a result of secondary infection. The condition can also go into a more chronic stage in which case the lesions will be red or purple, dry, scaley and sometimes thickened. The lesions may (in adults) leave behind darker skin (post inflammatory hyperpigmentation).
What is the Treatment for Discoid Eczema?
Discoid Eczema is treated in a similar way as other forms of eczema. Moisturisers should be used frequently. Steroid cream is normally needed. Avoid fragrant creams. The condition may be quite persistent in some people and other treatments and/or patch testing may be required in severe cases.