An Overview of Eczema (Atopic Dermatitis) in Children

Child with eczema

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Eczema (atopic dermatitis) is a skin condition that affects adults, but is also common in childhood. Around 10% of kids in the United States have it, according to the National Institutes of Health (NIH). In infants, the itchy, red, scaly rash appears most often on the cheeks, chin, and forehead. In older children, the rash is more likely to develop on the insides of the elbows and behind the knees.

Eczema can usually be diagnosed based on its appearance. Although it is possible to get your child's eczema under control with the proper treatment, it may reappear periodically in episodic flares.

Eczema tends to improve as a child gets older and may even disappear completely by adulthood. Some, however, may experience a temporary easing of symptoms, only to see them re-emerge in their 20s.

Pediatric Eczema Symptoms

The tell-tale symptom of pediatric eczema is an intensely itchy rash that typically appears in early infancy but can first show up in kids as old as 5. It is sometimes mistaken for other rashes, such as contact dermatitis, heat rash, and psoriasis, but has many of its own distinct characteristics.

Symptoms of eczema include:

  • Patches of rough, red, itchy skin
  • Small bumps
  • Scaly, dry patches
  • Small, fluid-filled blisters (vesicles)

Children, in particular, are prone to scratching, which only makes the condition worse.

Common Locations

Eczema can develop on any part of the body, although the location of the rash tends to vary by age.

Where Eczema Rash Most Commonly Occurs
Age Group Location
1 to 6 months Cheeks, chin, forehead, scalp
6 months to 2 years Outer arms and legs, skin covering joints
2 years+ Creases of elbows, behind knees, ankles, wrists, hands
Adolescents/teens

Face, neck, hands, feet, and areas of skin on a joint fold

In infants between the ages of 1 and 6 months, it most often starts on the cheeks and can progress to the chin, forehead, and sometimes the scalp.

Babies older than 6 months may also develop the rash on their outer arms and legs as well as extensor surfaces (areas of skin on a joint, such as the elbow or knee). Eczema does not usually appear in the diaper area, though it can.

In children 2 years of age and older, the rash is less common on the face and will instead develop in the creases of the elbows, behind the knees, or on the ankles and wrists. In school-age children, eczema is also common on the hands.

In adolescents and teens, the rash is commonly seen on the face, neck, hands, feet, and flexor surfaces (areas of skin on a joint fold like the crook of the elbow or back of the knee). The eczema patches are also more likely to lichenified (hardened and thick) as the condition persists.

When to Call a Doctor

Those with eczema are more susceptible to viral, bacterial, and fungal infections including warts, herpes simplex, impetigo, molluscum contagiosum, otitis media, pneumonia, and strep throat.

While eczema alone warrants a doctor's evaluation, call your child's pediatrician if you notice signs of infection, including, but not limited to:

  • Increasing redness, swelling, or pain
  • Pus or pus-filled blisters
  • Yellow or honey-colored crusting
  • Fever or flu-like symptoms

Causes

Eczema is not contagious. Your child did not catch it from somebody else and cannot pass it on to others. In fact, there isn't one factor that causes eczema on its own. Instead, eczema is believed to be the result of a combination of genetics and environmental factors.

Genetics

Eczema is known to be associated with the mutations of genes responsible for the synthesis of filaggrin. This protein maintains the structure of cells and plays an important role in the skin's barrier function by blocking microbes and allergens from entering the outer layer (epidermis).

A lack of filaggrin not only undermines the skin's barrier function but also reduces its ability to remain hydrated, leading to dryness and scaling. Breaks in the skin also allow allergens to enter, triggering inflammation and redness.

Any gene mutations that impair the synthesis of filaggrin can contribute to the development of eczema.

Environment

It is also believed that certain environmental factors can trigger genetic mutations that predispose a child to eczema. An array of triggers have been suggested (including dust mites, irritants, allergens, infections, breastfeeding, and the use of antibiotics), but none have pinned down as a consistent cause.

One theory, called the hygiene hypothesis, suggests that children raised in a "too-clean" environment lack the immune stimulation needed to build a robust immune system. This can lead to reduced adaptive immunity wherein the body is less able to launch a targeted response to common microbes and allergens.

The combination of an immune deficiency and filaggrin deficiency could go a long way toward explaining why some children develop eczema and others don't.

Risk Factors

There are several factors that appear to influence a child's risk of developing eczema. They include:

  • Parents who have (or have had) eczema: Research has long shown that eczema tends to run in families.
  • A history of asthma or allergies (including food allergies*): Asthma, allergies, and eczema are sometimes referred to as "the immunologic triad."
  • Urban living: Some studies have suggested that air pollution and other environmental factors may increase the risk of eczema in children.

*The role of food allergies and eczema remains controversial. Some scientists believe that a food allergy doesn't necessarily "cause" eczema but instead triggers symptoms, like rash and itching, that can instigate a flare or make symptoms worse.

Diagnosis

Although there are no tests to definitively diagnose eczema, a pediatrician can usually make the call based on the appearance of the rash and your child's medical history. If there is any doubt, the doctor may order tests to exclude other causes. These may include:

For certain tests, a pediatric dermatologist or an allergist may be needed.

Eczema vs. Cradle Cap

Cradle cap, an incredibly common childhood rash, is another type of dermatitis called seborrheic dermatitis. It causes yellowish flakes and crusting on the scalp, eyebrows, or on and around the ears. Given this, it looks similar to eczema. It can also appear in some of the same areas.

A doctor may consider this as an alternative diagnosis in a child, although cradle cap can also occur alongside eczema—particularly in infants.

Treatment

The treatment of childhood eczema can vary by a child's age. For newborns and very young infants, pediatricians will often take the watch-and-wait approach.

Besides keeping the skin well-moisturized and avoiding triggers, infants may not need any treatment as the symptoms are likely to go away on their own.

If your child needs treatment, your pediatrician will steer you toward the best medications and therapies and offer you guidelines on how to avoid flare.

Trigger Avoidance

Triggers don't cause eczema, but they can instigate flares if you don't avoid them. Avoiding triggers is a key component of eczema treatment. Every child has their own unique triggers, but there are several that are considered common.

Common eczema triggers include:

  • Environmental allergens, such as pollen, dust, and dander
  • Harsh or highly-fragranced soaps or skincare products
  • Certain foods, especially eggs, dairy, and nuts
  • Laundry detergents
  • Cold, dry weather
  • Stress
  • Sweat
  • Rough fabrics
  • Skin dryness

Moisturizing Creams

Moisturizing creams, lotions, and ointments are the cornerstone treatment for eczema. Keeping the skin well-moisturized protects the skin from flares and helps existing rashes heal.

Choose a mild, fragrance-free product like Eucerin, Aquaphor, or Aveeno. Apply it after every diaper change, immediately after a bath, or several times a day for older children. If you need help choosing a product, ask your pediatrician for recommendations.

Wet Wraps

Wet wrap therapy is a complementary treatment that can help ease eczema flares and relieve itching. It involves wrapping cool, damp cloths around the affected area and covering them with dry strips of cloth. Your pediatrician will give you precise instructions on how to apply the strips if wet wrap therapy is recommended.

This is especially helpful at bedtime if itching is keeping your child up at night.

Topical Steroids

If moisturizing treatments aren't enough to ease your child's symptoms, topical corticosteroids (also known as topical steroids) are the next logical step. These range from over-the-counter hydrocortisone creams to stronger topical steroids that require a prescription.

Topical steroids help temper localized inflammation and are intended for short-term use. If overused, the drugs can cause irreversible thinning of the skin and stretch marks. Some prescription steroids can be applied to the face, but speak to your doctor beforehand to ensure you do so correctly and for the right amount of time.

Antihistamines

If itching is keeping your child awake at night, a sedating antihistamine such as Benadryl (diphenhydramine) may ease discomfort and help them sleep. Antihistamines work by blocking a chemical called histamine that is central to an allergic response. Doing so helps reduce systemic inflammation and much of the itch associated with eczema.

The intermittent, short-term use of antihistamines may help relieve an eczema itch and improve sleep but should not be used as a substitute for topical therapies.

Topical Calcineurin Inhibitors

Topical calcineurin inhibitors (TCIs) are non-steroid drugs classified as immunomodulators. TCIs are applied directly to the skin twice daily and can be used anywhere on a child's body, including the face. The two approved by the U.S. Food and Drug Administration (FDA) are called Elidel (pimecrolimus cream) and Protopic (tacrolimus ointment).

Elidel and Protopic are approved for the second-line treatment of eczema in children after topical steroids and other conservative measures have failed to provide relief.

Unlike topical steroids, Elidel and Protopic do not cause skin thinning or lose their potency with ongoing use. Side effects including mild itching and burning sensations. However, TCIs do carry a black box warning from the FDA advising consumers of an increased risk of certain cancers.

Bleach Baths

If your child's eczema is not responding well to traditional treatments, your pediatrician may recommend a bleach bath consisting of a half cup of bleach diluted in 40 gallons of water This may reduce the number of bacteria on the child's skin, allowing the skin to heal.

Bleach baths should be measured carefully and should only be used under a doctor's instructions. Do not use a bleach bath if your child has broken skin.

Options for Recalcitrant Eczema

If your child's eczema doesn't respond to any of the above-listed treatments, your doctor may recommend more aggressive therapies, including oral steroids, ultraviolet light therapy, and immunosuppressive drugs like cyclosporine. To prevent secondary infections, your child may also be provided an oral or topical antibiotic.

Dupixent (dupilumab) is an injectable biologic drug used to treat moderate to severe eczema in adults and children over 12. Due to its immunosuppressant effects, it is not used in younger children whose immune systems are still developing.

Never use an eczema treatment prescribed for an adult or teen on a child or baby.

Coping

Eczema flares are more likely to happen in winter when the air is dry, and in summer if a child spends a lot of time swimming or gets overheated. Aside from avoiding these and other triggers, it is imperative that you keep your child's skin moist and supple.

Here are some tips that can help:

  • Give your child a daily bath: Use lukewarm water with a mild moisturizing soap or a soap substitute. Avoid hot water or harsh soaps that can cause skin dryness. Limit bathing time to no more than 10 minutes.
  • Apply moisturizer: After bathing, blot the skin with a towel rather than rubbing it vigorously. Apply moisturizer while the skin is still damp. If you're also using any topical medications, apply them first. Re-moisturize as needed, at least once or twice a day.
  • Avoid scratchy clothing: Opt for soft, breathable fabrics like rayon and cotton over heavier wools and textured fabrics. Dress your child in loose-fitting clothes. Soft, cotton diapers should be used if there is eczema on the legs or diaper area.
  • Try a humidifier: While there is no evidence that humidifiers help improve eczema symptoms, some people claim that they can help reduce dryness and improve a child's sleep.

It is important to keep your child's skin products just for them. Store the creams and ointments in a place where others in the family aren't likely use them.

A Word From Verywell

Eczema can be exasperating because it tends to recur, often without rhyme or reason. The sustained control of eczema ultimately requires patience and plenty of trial and error to find the right combination of treatments for your child.

With persistence and guidance from a qualified dermatologist, most cases of childhood eczema can be successfully managed. Up to 60% of cases may even resolve once a child reaches adulthood.

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