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COPING WITH ECZEMA: COMMON QUESTIONS
by Doctor John Harper MD FRCP, Consultant in Paediatric Dermatology Great Ormond Street Hospital for Children, NHS Trust, London WC1 3JH

PREFACE
The purpose of this information is to answer those questions which are most commonly asked by parents of children with eczema. I hope that this information is useful and that these suggestions will benefit your child. Regular daily skin care is essential. It is important to remember that the long-term outlook is usually excellent.

WHAT IS ECZEMA?
The word eczema comes from the ancient Greek meaning "to boil over". It is used to describe an inflammation of the skin, which causes redness and intense itching. The most common type of eczema in children is atopic eczema, which may be associated with asthma or hayfever. The terms 'atopic eczema' and 'atopic dermatitis' mean the same thing and should not be confused.

WHY DOES MY CHILD HAVE ECZEMA?
Atopic eczema is essentially a genetic disorder. Often there is someone else in the family with eczema, asthma or hayfever, but this not always the case. There are many external factors which may influence eczema on a day to day basis. These are discussed in more detail later on.

WILL MY CHILD GROW OUT OF ECZEMA?

Yes, for the majority of sufferers.

Eczema will gradually improve as the child gets older. The age at which eczema ceases to be a problem varies, but many show a significant improvement by the age of five years old and most will be clear by the time they are teenagers. Only a few continue to have troublesome eczema in adult life.

IS ECZEMA DUE TO AN ALLERGY?

No, eczema is not caused by one specific allergy.

Children with eczema have a hypertensive skin, which reacts to many different environmental allergens, such as grass pollen, house dust mite, dander from cats and dogs, and feathers. Young children may react to certain foods, in particular eggs, cows' milk, peanuts and fish. The pattern of allergic reactions from one child to another is not consistent and may alter as the child gets older.

WILL ALLERGY TESTS HELP?

No.

Children with eczema usually demonstrate multiple positive skin reactions on skin tests, which are of little guide to treatment. Blood allergy tests are similarly unhelpful.

GUIDELINES TO TREATMENT
There is no single medication which will cure eczema. However, for most children, it is possible to treat eczema effectively and keep it in check, using a simple regime of treatment as follows:
Emollients
These are products which moisturise and soften the skin. They restore the elasticity and suppleness and help to reduce the itching and scratching. Emollients are safe and should be used frequently, as first-line treatment. These should include:

• a bath oil, with regular once or twice daily baths
• a soap substitute, such as aqueous cream
• a moisturiser applied liberally to all areas of dry skin, at least twice daily and if possible more frequently.

A topical steroid cream or ointment
The use of an appropriate topical steroid is safe and an essential part of treatment. This should be applied once or twice daily specifically to areas of inflammation, that is the red or pink areas, immediately after a bath and not at the same time as the moisturiser. The use of a mild topical steroid, such as 1% hydrocortisone, is usually sufficient for most children. Occasionally, a stronger steroid cream may be required for the treatment of more severe eczema.
An antihistamine medicine
Given just before going to bed, this will help the child settle and have a more comfortable nights sleep.
Other treatments
The following may be used for difficult eczema, which has not responded to the more simple measures:

• wet or paste medical bandages
• evening primrose oil capsules (taken as a 3 month trial of treatment, initially)
• dietary manipulation under the supervision of a doctor or preferably a dietitian.

ARE THE BACTERIA THAT LIVE IN ECZEMA IMPORTANT?

Yes.

Eczema seems to attract certain bacteria, in particular Staphyloccocus aureus, which are found on the surface of the skin of the majority of children with eczema. The presence of Staphyloccocus aureus on the skin does not necessarily indicate infection. It has been suggested that children with eczema may be "allergic" to some of these bacteria and that this may aggravate the condition. This is one important reason for frequent bathing.

INFECTION
Children with eczema are susceptible to skin infections, because of the scratching and splitting of the skin. An acute flare-up of eczema is often associated with a secondary bacterial infection and usually requires treatment with an antibiotic medicine. For localised areas of infection an antibiotic cream may be sufficient.
For children with difficult eczema and recurrent infections the use of an antiseptic oil-based additive can be helpful.
Children with eczema are especially susceptible to cold sores (caused by herpes simplex virus). Contact with the virus may result in a widespread infection, which may make the child feel very unwell. If this is suspected, you must contact your doctor as soon as possible. It is important to keep children with eczema away from anyone with an active cold sore.
Children with eczema are also susceptible to warts and mollusca contagiosa (water warts). These are often numerous and persistent - it may take 6 months to 1 year, and sometimes even longer - but eventually they do disappear - with or without treatment!

WHAT IS THE DIFFERENCE BETWEEN AN OINTMENT AND A CREAM?
An ointment is greasy (like vaseline) and is appropriate for "dry" scaly areas of eczema.
A cream contains water and is much thinner in consistency (like aqueous cream). Creams are more suitable for "wet" weeping areas of eczema.

ARE STEROID OINTMENTS DANGEROUS?

Essentially no, if used correctly.

Topical steroid preparations vary in their strength. The use of a mild or moderately strong topical steroid is generally safe, as detailed in the section "Guidelines to Treatment".
Parents are often anxious about the use of topical steroids, but these worries stem from misuse of very strong steroids, which may cause problems, such as thinning of the skin, and should not be used routinely to treat children.
The long-term use of a mild topical steroid, eg 1% hydrocortisone ointment, applied once or twice daily to the areas of eczema, is safe. On the face of the very young, it is better to use this for short periods only, as necessary.

HOW MUCH STEROID OINTMENT SHOULD I PUT ON THE SKIN?
Cover the eczema (the red and pink areas of the skin) evenly with a fine film of ointment so that the surface of the skin glistens in the light. The words "use sparingly" on tubes of steroid creams or ointments worry parents and can lead to under-usage. It is important to use steroid preparations "appropriately".

IS IT HARMFUL TO HAVE A BATH?

No, in fact just the opposite… frequent baths are a rule.

• At least once daily, twice daily is even better.
• Bathing keeps the skin clean and free from crusts and scales, which helps prevent infection.
• It is necessary to add a suitable bath oil to the bath water, to precent the skin from drying out.
• Soaking in the water for 10 minutes will help the skin considerably.
• Avoid ordinary over-the-counter soaps, which are irritant, alkaline and often perfumed. It is best to use aqueous cream to cleanse the skin. This is well tolerated by children and easy to used.
• The temperature of the water should be cool and the bathroom warm. Avoid any sudden changes in temperature which may make the skin itch.
• Afterwards dry the skin by patting gently with a soft towel.
• Bathing is better than showering, but is only a shower is possible, then use an appropriate emollient shower gel and rinse well before drying.

ARE ANTIHISTAMINES DRUGS OF ADDICTION?

No.

Antihistamine medications are not addictive and there is no evidence that long-term use is dangerous.
Antihistamines reduce the itching and act as a sedative. They are therefore useful at night to help sleeping. The bedtime dose should be given at least half an hour before the child goes to bed.
Non-sedative antihistamines are sometimes prescribed during the day. These may help and are especially useful for those children who suffer with hayfever during the summer months.
Antihistamine creams should not be used on eczema as they may cause an allergic reaction.

IS IT BETTER TO BREAST FEED?

Yes, if possible.

Although there is no evidence that breast feeding will prevent your child developing eczema, breast feeding does seem to have a protective effect in relation to severity during the early months of life and should therefor be encouraged.
However, sometimes, severe eczema can occur in babies who are being breast feed. This can be complicated by loose stools and failure to gain weight satisfactorily and may be related to the mother's diet. This poses a difficult problem because suggesting that the mother restricts her own diet usually doesn't help the situation and may reduce the nutritional value of the breast milk. It is important the mother has a well balanced diet with no excess of potentially troublesome foods, such as milk and egg products (see later section); but, if the eczema continues to be a significant problem, it may, rarely, be necessary to feed the infant with a hydrolysate formula such as Pregestimil or Peptijunior, and gradually reduce and stop breast feeding.

SHOULD MY CHILD BE ON A DIET?
It is the generally accepted view that children with eczema should not automatically be put on a special diet. Many parents are concerned that eczema is caused by something the child is eating; however, routine exclusion diets are usually unhelpful. Often parents have already tried soya milk. This should not be encouraged. A significant proportion of those babies who are allergic to cows' milk are also allergic to soya milk. It is essential to seek medical advice.
Diets should be reserved for the very young with severe eczema non-responsive to the standard treatment regime and for those who have a clear history of food intolerance. The diets employed are usually avoidance of dairy products (substituting a hydrolysate milk formula for cows' milk) and sometimes avoidance of foods containing artificial additives. This should be for trial period of 2 months and supervised by a dietitian to ensure that the child is not at risk of nutritional deficiency.

WHAT ABOUT WEANING?
It is important not to introduce solid foods before 4 months of age. Each item of food should initially be given one at a time, in small quantities and gradually increased, slowly varying the diet. The relative risk of an allergic reaction is shown in the table below. Allergic reactions to foods occurs only in a small proportion of children with eczema and the majority will be able to tolerate a normal diet.

ECZEMA IN THE SUN
Eczema usually improves in the sun, especially on holiday. It is important that children with eczema "keep cool" in the hot weather and wear loose cotton clothes. It is suitable sun-screen product.
It is sometimes helpful for the child to wear a loose wet t-shirt in hot weather and to cool down the skin and relieve the itching.

SWIMMING
Swimming in the sea is excellent for eczema.
In a pool, the chlorine may irritate the skin. In an attempt to prevent this, apply a thick moisturiser, such as vaseline (50/50 mixture of white soft paraffin and liquid paraffin) beforehand, and afterwards soak in a bath with an oily bath additive.
Taking babies with severe eczema into a swimming pool is not a good idea.
Children over 4 years should be actively encouraged to learn to swim and participate in all sporting activities.

IMMUNISATIONS
Your baby should receive all the routine immunisations, like any other baby. There is no cause for concern.
In children with eczema in whom there is a history of egg allergy, the MMR and measles vaccines are safe, but if there is a serious concern then these injections should be administered under close medical supervision at the local hospital.
Occasionally any of the immunisations may aggravate eczema for a few days afterwards, but this is not usually a problem.

WHAT THINGS MAKE ECZEMA WORSE?
Eczema is influenced by many environmental factors, which are important to take into account in the day to day management of eczema.
Aggravating factors include:

• synthetic or woollen fabrics- children should be dressed in cotton clothes.
• biological detergents or fabric conditioners- use non-biological products.
• irritant foods- foods such as citrus fruits and tomatoes can cause eczema around the mouth. This is often made worse by lip-licking and dribbling. It is helpful to apply a protective barrier of vaseline around the mouth, 2 to 3 times daily and prior to meals.
• cigarette smoke- in an enclosed room, fumes will irritate the skin. It is best to ban smoking within the home!
• cats and dogs- virtually all furry pets will produce an allergic reaction in a child with eczema. Cats and dogs leave dander everywhere and so the child is always at risk, even if the animal itself is not around. Avoid dogs and cats in the house and if necessary get a goldfish!
• house dust mites- these are microscopic creatures that are found in large numbers in old mattresses and within the dust in carpets and other surfaces. When scratched into the skin they will worsen eczema and, if inhaled, will provoke asthma. Simple measures to reduce the risk of house dust mite allergy should include: a newish mattress, regular use of an appropriate vacuum cleaner, damp wipe surfaces and keep furnishings simple to avoid dust traps. Wooden or lino flooring is preferable to carpeting. Another source is soft furry toys, which should be kept in a cupboard and washed regularly.

Special mattress covers are available to protect against exposure to dust mites. These are particularly useful for children when they are away from home, for example on holiday, staying with friends or family or at boarding school, when the nature and age of the mattress are unknown.

• Grass pollen- most children with eczema are allergic to grass pollen. This is a problem during the summer months. It is not advisable for children with eczema to be present in the garden when the lawn is being mowed and ideally this should be done in the evening when the child has gone to bed. If the bedroom window faces the garden make sure it is shut. Also keep away from fresh cut grass in the park.

OTHER PRACTICAL ADVICE
In addition to the above, nails should be kept short and excessive heat should be avoided. Bed linen should be cotton. Pillows and duvets should be feather-free and covered in cotton. Good general ventilation in the house is important. Damp will encourage the growth of fungi and moulds, which may cause allergic reactions. Hard water may irritate the skin and the use of a water softener may help.
School can present problems and it is important to liaise closely with the teacher. It is best if the child is seated in the centre of the class, away from the door, windows and radiators. They must avoid contact with any guinea pigs, hamsters or rabbits in the school. They should take their own special soap and moisturising cream. Most children will apply their own creams at break and lunch time, but this must be supervised. If properly informed, most schools will cooperate and help in this situation. It is important that children do not miss school because of their eczema.

WHAT IS THE RISK OF MY CHILD DEVELOPING ASTHMA?

There is a risk. Children with eczema have a three-fold increased risk of developing asthma compared to other children. This should not cause undue anxiety. In most cases the asthma is mild and easily controlled with appropriate treatment. It is only in the minority that asthma is troublesome.

WHAT IS THE RISK OF MY CHILD HAVING A SEVERE ALLERGIC REACTION (ANAPHYLAXIS)?
Fortunately this problem is very rare. In exceptional cases a severe and potentially dangerous allergic reaction can be caused by an insect bite (eg. wasp or bee sting), a particular food (eg. peanuts, shellfish, eggs) or a medicine (eg. penicillin). If a child is at risk parents should have a pre-loaded adrenaline injection at home for emergency use. This should be discussed with your doctor.

WHAT IS THE RISK OF MY NEXT CHILD HAVING ECZEMA?
If you have one affected child then the risk of your next child having eczema is of the order of 25%. If both parents are affected the risk rises to 40%. It is important to remember that the severity of eczema can vary within the same family, so even if the next child is affected it may be much less of a problem.

ARE ALTERNATIVE OR COMPLIMENTARY TREATMENTS HELPFUL?
Homeopathy. Many parents have already tried homeopathy by the time I first see the child. Three is no convincing evidence that homeopathy benefits eczema. However, it is safe and for that reason I have no real objections, apart from the fact that it usually involves stopping conventional treatment and this can result in a deterioration of the eczema.

Traditional Chinese Medicine (TCM). There has been recent interest in the use of TCM for the treatment of eczema. The treatment involves taking a "tea" prepared from 10 or so plants. These medicines can improve eczema, but there is concern about possible side effects, in particular adverse effects on the liver. In my opinion, this type of treatment should be restricted to those children with severe eczema that does not respond to conventional treatment and should be under medical supervision. With future research, it is possible that from these plants new and better standardised treatments for eczema will be developed.
Psychotherapy. In eczema, itching is highly susceptible to psychological influences. Relaxation techniques can be used to help eczema sufferers. The aim of the treatment is to distract the mind from the skin.
Acupuncture. It is an integral part of Chinese medicine, but its role in the treatment eczema is uncertain.

RECOMMENDED DAILY SKIN CARE REGIME

Further information and help can be obtained from:Eczema Association Inc
PO Box 1784, Cleveland D.C., QLD, 4163, Tel: (07) 3821 3297