An Overview of Eczema (Atopic Dermatitis) in Children

Recognizing and Treating Atopic Dermatitis in Babies and Kids

Child with eczema

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Eczema, also known as atopic dermatitis, is a common childhood skin condition. Around 10% of kids in the United States have the disease, according to the National Institutes of Health.

In infants, the characteristic itchy, red, scaly rash appears most often on the cheeks, chin, and forehead. In children, the rash commonly develops on the insides of the elbows and behind the knees.

Treatments are available that can alleviate symptoms and even lead to sustained remission. Although it is possible to get your child's eczema under control, it is likely to come back periodically in what is called an eczema flare.

Symptoms

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

A rash caused by eczema usually looks like:

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

Children, in particular, are prone to scratching eczema rash. Unfortunately, this only makes the condition worse.

Affected Areas

The location of an eczema rash can vary by age. 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, elbows, knees, and legs. Eczema does not generally appear in the diaper area.

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.

It is important to note that eczema can develop anywhere on the body, although these are considered the "classic" locations.

When to Call a Doctor

Eczema makes skin more vulnerable to infection. Call your child's pediatrician if you notice signs of infection, including:

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

Eczema vs. Cradle Cap

Cradle cap is another type of dermatitis, called seborrheic dermatitis. It is an incredibly common childhood rash and can occur alongside eczema, particularly in infants. It looks very similar to eczema and can appear in some of the same areas.

Cradle cap causes yellowish flakes or crust on the scalp, eyebrows, or on and around the ears. Eczema can also cause flaking in these areas, but eczema rashes cause the skin to be red and inflamed, as well as dry and scaly. Eczema scales are not likely to be yellow.

The scales of cradle cap can be softened with the application of mineral oil and gently brushed away. By contrast, eczema flakes are tenacious and cannot be removed in this way. Cradle cap generally goes away on its own by the time the child is one year old.

Causes

Eczema is not contagious. Your child did not catch the condition from somebody else, nor can they pass it along to another person.

There isn't one factor alone that has been specifically implicated in causing eczema. Instead, it 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 the protein filaggrin. Filaggrin helps shape individual cells and plays an important role in the skin's barrier function by blocking the entry of microbes and allergens into the outer layer of skin cells (called the epidermis).

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

The lack of filaggrin not only undermines the barrier function of the skin but reduces its ability to remain hydrated, leading to dryness and scaling. It also allows allergens to enter skin cells, triggering an immune response and localized inflammation.

Environment

It is also believed that certain environmental factors can trigger changes in the gene pool that predispose a child to eczema. Many such factors have been implicated (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 the microbes and allergens it encounters.

The combination of an immune deficiency and filaggrin deficiency could go a long way toward explaining why some children develop eczema and other related skin disorders.

Risk Factors

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

  • Parents who have (or have had) eczema: There seems to be a clear genetic component as eczema does run in families.
  • A history of asthma or allergies (including food allergies): Eczema is linked to these conditions, which is why asthma, allergies, and eczema are sometimes referred to as "the triad."
  • Urban living: Some studies have suggested that air pollution and other environmental factors may raise the risk of eczema in children.

Diagnosis

Diagnosing your child's eczema is usually fairly straightforward. The pediatrician can typically diagnose eczema based on the appearance of the rash and your child's medical history.

If there is any doubt, or if there is a concern of allergies, the physician may recommend:

These tests do not diagnose eczema itself, as there is no specific diagnostic test that can do so. Instead, these help rule out other skin conditions that may be causing your child's rash.

Thankfully, for most kids, eczema eases up or even disappears entirely as they get older. In the meantime, there are plenty of treatment options as well as strategies for preventing rashes from flaring up.

Treatment

How you deal with your child's eczema will depend in part on how old your child is. For very young infants, pediatricians often take the watch-and-wait approach. Besides keeping the skin well-moisturized and avoiding triggers, infants may not need any treatment at all as eczema can go away over time.

If your child does need treatment, your pediatrician will steer you toward the best medications and therapies.

Trigger Avoidance

Triggers don't cause eczema, but they do make existing cases worse. Avoiding trigger factors as much as possible is a key component of treatment. Every child has there own unique triggers, but there are several that are more common than others.

Common Eczema Triggers

  • 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

Creams and ointments are the cornerstone treatment for eczema. Keeping the skin well-moisturized protects the skin from future flare-ups and helps existing rashes heal.

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

Wet Wraps

Wet wrap therapy is a complementary treatment that can help ease eczema flares and relieve itching. This is especially helpful at bedtime if itching is keeping your child up at night.

Wet wipe therapy 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 do so if wet wraps are recommended.

Topical Steroids

If simple moisturizing treatments just aren't enough, topical steroids are the next step. They range from over-the-counter hydrocortisone creams to stronger mid- and super-potent ones that require a prescription.

If used for too long, though, these can cause thinning of the skin and stretch marks. Prescription topical steroids should never be applied to the face or be covered by a bandage or diaper.

Topical steroids are grouped by potency into classes, ranging from Class 1 (most potent) to Class 7 (least potent). Those in Classes 6 and 7 are usually most appropriate for children.

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.

Dermatology guidelines state that intermittent, short-term use of sedating antihistamines may help insomnia secondary to an eczema itch but should not be used as a substitute for topical therapies.

Immunomodulators

Immunomodulators, also called topical calcineurin inhibitors, are non-steroid medications. These are also applied directly to the skin twice daily and can be used anywhere on a child's body, including the face. The most common of these steroid-free medications are Elidel (pimecrolimus cream) and Protopic (tacrolimus ointment).

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

Unlike topical steroids, Elidel and Protopic are not absorbed into the body to any significant degree and do not cause skin thinning, pigment changes, stretch marks, or the loss of response with prolonged use.

However, they can cause side effects (including mild itching or burning sensations) and carry a black box warning from the U.S. Food and Drug Administration suggesting an increased risk of cancer and lymphomas (although there remains considerable debate on how significant that risk really is).

Bleach Baths

If a case is not responding well to traditional treatment, your physician may recommend giving your child a dilute bleach bath consisting of a half cup of bleach diluted in a 40-gallon tub of water. This can help reduce the number of bacteria on the skin, allowing the skin to heal.

Bleach baths should be drawn carefully and should only be given under a doctor's instructions.

Treatments for Recalcitrant Eczema

For stubborn eczema that doesn't respond to any of the standard treatments, there are more aggressive options, including oral steroids, ultraviolet light therapy, and immunosuppressive drugs like cyclosporine. In cases of secondary skin infections associated with stubborn eczema, a child may also need 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.

Coping

Eczema flares are especially 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 doing what you can to help your child avoid triggers, it's imperative that you make an effort to keep your child's skin moist and supple. Here are some tips that can help:

  • Give your child a daily bath. Use lukewarm water and a mild moisturizing soap or a soap substitute. Avoid hot water and harsh soaps that can exacerbate skin dryness. Short, daily baths (around 10 minutes) are not only beneficial but safe so long as a moisturizer is used afterward to restore moisture loss.
  • Apply moisturizer. Blot the skin with a towel so the child isn't dripping wet, but don't rub their skin completely dry. Apply moisturizer while the skin is still damp. If you're also using a topical medication, apply that first.
  • Continue to moisturize regularly. Keep creams handy and re-apply at least once or twice more during the day.
  • Avoid scratchy clothing. Opt for soft, breathable fabrics (like rayon and cotton) over heavier wools and textured fabrics. Loose-fitting clothes and the avoidance of tight belts, headbands, and waistbands also helps.
  • Try a humidifier. While there is no scientific evidence that humidifiers help improve eczema, some people claim that they help with dryness and improve sleep at night.

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 to grab and use them.

Never use a cream or ointment prescribed for someone else on your child.

A Word From Verywell

Eczema can be exasperating because it tends to recur, often without rhyme or reason. It is rather like a boomerang: while you may be able to clear the rash, it's likely to come back suddenly and without warning. Sustained remission often requires persistence and plenty of trial-and-error to find the approach that works best for your child as an individual.

Fortunately, with a little patience and guidance from a specialist dermatologist, most cases of childhood eczema can be successfully managed.

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Article Sources

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