Eczema, or atopic dermatitis, is the most common rash presenting during infancy and childhood. It generally presents in the first few months of life as a red rash that is dry, scaly, and extremely itchy. It often presents with a characteristic distribution on the body. In infants, and it typically involves the cheeks, the back of the ears, the buttocks, the bends of the arms, and behind the knees. As children grow older, the rash can involve any place on the body that can be rubbed or scratched, but the classic distribution continues to be in the folds of the arms and behind the knees.
Many patients with eczema have a strong family history of allergies, and many go on to develop allergies themselves. When patients with eczema develop allergies, the eczema is also called atopic dermatitis. Recent research has suggested that, in certain individuals, the immune system may become sensitized to allergens because of exposure through the inflamed skin of eczema. Many children who have atopic dermatitis go on to develop nasal allergies and/or asthma, a progression described as the “atopic march”. Up to one-third of atopic dermatitis patients have a food allergy trigger, such as egg, milk, wheat, soy, or peanut. Contact with dust mites or other environmental allergens may also worsen the skin. An allergist may perform allergy testing to determine which, if any, may be contributing factors. Avoidance of those known allergens will be crucial to help the skin heal.
Because itching in the skin can precede the rash, eczema is sometimes known as “the itch that rashes”. The skin of eczema patients is very sensitive and can be easily irritated. Common irritant triggers for all eczema patients include the physical trauma of scratching, synthetic or wool fibers in clothing, perspiration, and skin infections, especially with Staphylococcal bacteria.
As a general rule, eczema improves during childhood and, in many cases, resolves by the time a child reaches school age. However, some individuals never outgrow their eczema and it may develop into a chronic condition. On rare occasions, atopic dermatitis can present for the first time as an adult.
For recurrent or chronic atopic dermatitis, skin testing may be helpful in discovering allergic triggers of the rash. In most cases, the allergist will look for highly allergenic foods such as milk, eggs, soy, wheat, peanuts or nuts, although many other foods and inhalant allergens may be involved. Patients can also be helpful in tracking down the cause by keeping a food diary. This detective work sometimes is very helpful in establishing an important cause and effect relationship.
In certain cases, blood testing (RAST or ImmunoCAP) may be helpful. This form of testing may be preferable if one’s skin rash is too inflamed to perform skin tests, or if the patient is unable to discontinue antihistamine usage five days prior to skin testing. In the case of food allergies, allergy testing may provide useful information about when the food might be safely reintroduced into the diet.
Break the Itch-Scratch Cycle
The first, and perhaps most vital step in treatment, involves careful daily skin care designed to keep the skin clean and well hydrated. Research shows that even the unaffected skin of atopic dermatitis patients cannot retain water like normal skin does, so it dries out very quickly, worsening the itchy sensation. To combat this, the eczema patient should follow the soak and sealî technique:
Examples of good moisturizers include:
Creams and ointments are better than lotions, which contain alcohol and can dry the skin. Ask your doctor which is a good choice for you. Sometimes diligent daily skin care is all that is needed to control mild eczema.
Identify and Eliminate Eczema Triggers
The second step in effective eczema treatment involves identifying and eliminating triggers which can irritate or inflame the skin. Loose-fitting and comfortable clothes, preferably made of cotton, should be worn. Carefully modifying the diet to remove food allergens is also very important.
Medications comprise the third step in controlling eczema. In some patients, anti-inflammatory medications, including topical steroids may be added to the soak and seal regimen. Steroid creams and/or ointments will reduce the skin inflammation quickly and effectively. These treatments are commonly prescribed, highly effective, and generally safe, but should be used sparingly and only as prescribed. A short course of antibiotics may be necessary to control infection from Staphylococcal bacteria or fungus on the skin.
Topical steroids are commonly prescribed to control and minimize the skin inflammation of eczema. Minimal strength steroid creams or ointments may be sufficient to maintain control of minor flare-ups, however more potent steroids are commonly required to treat difficult areas of inflammation, or when the inflammation is present on thick skin such as the hands. Oral steroids are also occasionally required for severe exacerbations of atopic dermatitis. You physician will likely prescribe the lowest strength topical or systemic steroid necessary to control symptoms, and for the shortest period of time necessary.
A newer class of topical anti-inflammatory medications is available for atopic dermatitis. These medications, including tacrolimus (Protopic) and pimecrolimus (Elidel), are non-steroidal creams which work by reducing the inflammation in your skin. However, they are currently recommended for children above the age of two, and only for short term due to concerns about possible side effects. Other medications often used for eczema are oral antihistamines which help to reduce the itching and help eczema patients sleep more comfortably.
The treatment of eczema can be very difficult and frustrating. Best results are likely to be obtained with a combination of close follow up with your or your child’s physician and a big dose of patience.