Friday, March 20, 2015

Eczema



Please see the updated post October 2017
This week I am going to talk about eczema.

Some babies have buttery soft skin. Others are not so lucky. The very dry skin is prone to all sorts of rashes. This is one of those topics that we routinely get calls about year round. It doesn’t have a season. Understanding some basic facts about the skin can help you understand what is going on and how to deal with it.

The term eczema is broadly applied to a range of persistent skin conditions.
Eczema actually comes from the Greek word for “eruption”. You may also hear it referred to as Atopic Dermatitis. The top layer of the skin is called the epidermis and the top layer of the epidermis is called the stratum corneum (SC). The SC is incredibly thin but it is the main barrier of the skin. It keeps chemicals that come in contact with the skin from being absorbed into the body, and it keeps fluid inside the skin from leaching out. The SC contains 3 types of lipids that have different chemical compositions and functions; ceramides, cholesterol and free fatty acids. But it gets even more complicated. There are nine different types of ceramides in the SC, conveniently named ceramide 1 through ceramide 9, and they account for 40-50% of the lipids in this outermost layer. Scientists are doing a lot of research on the important function that ceramides play. What they are now discovering is that people with eczema have significantly fewer ceramides in the SC than folks with healthy skin. (Don’t worry there won’t be a test on this.)

The obvious focus is to try to rebalance and add back some of those deficient ceramides. Thus, the key to treating basic eczema is moisturizing! There are some very good products that can make a big difference. Dr Lawrence Cheung is my go to dermatologist who sees a lot of our patients. He lists the following products as some of his favorites:

Aveeno Eczema Therapy
Cetaphil Restoraderm
Cerave Hydrating Cleanser and Moisturizing Cream

Eucerin and Vaniply are a few other good brands. Read the labels and make sure that ceramides are on the list of ingredients.

If you like home remedies, my sister-in-law Barbara swears by coconut oil mixed with a bit of tea tree oil.

Well lubricated skin does not get as itchy and doesn’t break down as easily. Grease up your kid at least twice a day. There is no down side. It is really important to break that itch cycle. Aside from causing misery, scratching can tear the skin, and an infection can occur.

There does seem to be a hereditary component to this condition so it is pretty common for eczema to run in families. My patients with this diagnosis generally have fairly dry skin with rough patches. These kids (and adults) seem to be much more sensitive to various foods and other environmental factors.. Something that is making the skin reactive is referred to as a trigger. Triggers can range from changes in temperature, a new detergent, teething or a new food. Acidic foods seem to be big culprit for some kids.
Every year when it is “easy peel” tangerine season, I start getting loads of calls about patients whose eczema is flaring up like crazy. Other kids seem to react to dairy. My daughter Lauren got horrible eczema when she first switched to cows milk. I stopped it for a while; when we retried it several months later she was fine with it. Sometimes you just need to do some trial and error experiments.

When food sensitivity is to blame you will often see chappy cheeks and
a red ring around the anal area.

People used to recommend infrequent bathing, but it turns out that this is a myth.
If your child likes their bath, you can give one as often as you like. Baths are fine, but sitting in soapy water for extended periods is not such a good idea. Let them do their “fun in the tub” session for most of the bath first and then do the actual washing and rinsing with gentle soap and shampoo right before getting out. Bubble baths and harsh soaps are pretty high on my list of suspects when I am sleuthing around for the cause of a rash.

Some folks find that adding a splash of apple cider vinegar to the bath water (about ¼-½ cup for a big tub) is soothing and may even prevent some rashes. If the eczema is severe, believe it or not a bleach bath is often recommended by many dermatologists.

Here are important steps for giving a bleach bath:

1.      Use regular strength – 6 percent – bleach for the bath. Do not use concentrated bleach.
2.      Use a measuring cup or measuring spoon to add the bleach to the bath. Adding too much bleach to the bath can irritate your children’s skin. Adding too little bleach may not help.
3.      Measure the amount of bleach before adding it to the bath water. For a full bathtub of water, use a half cup of bleach. For a half-full tub of water, add a quarter cup of bleach. For a baby or toddler bathtub, add one teaspoon of bleach per gallon of water.
4.      Never apply bleach directly to your child’s eczema. While the tub is filling, pour the bleach into the water. Be sure to wait until the bath is fully drawn and bleach is poured before your child enters the tub.
5.      Talk with your dermatologist about how long your child should soak in the tub. Most dermatologists recommend a five- to 10-minute soak.

All baths should be followed up immediately with some lotion!!!

Dr Jessica advocates the “greased pajama” method. Put the jammies on right after applying the moisturizer. The pajamas will be a little greasy. As long as they stay clean otherwise, wear those for several nights in a row.

As I already mentioned, we want to minimize itching. If your child is doing a lot of scratching we may end up recommending an antihistamine.  Zyrtec (cetirizine) and Benadryl (diphenhydramine) are the two main brands that we tend to use.  Benadryl is shorter acting. Most of the time it makes the kids sleepy, but once in a while it has the opposite effect (not something you want to find out at night.)  Zyrtec is longer lasting and doesn’t tend to cause either the sleepies or the jitters.
Although the label will warn you to check with your MD if you child is under 2 years, Dr. Kaplan has no hesitation giving the Zyrtec as young as 6 months if necessary. It comes in a liquid form. She would start with ½ teaspoon at bedtime.

Hydrocortisone creams or ointments can be used to spot treat especially itchy areas. I would start with the weaker over the counter strength. If that isn’t helping, it would be a good idea to have a doctor take a look. We have options of different prescription strength ointments, creams and oils that we might try. Most of the time simple eczema can be handled by your pediatricians office. Once in a while complicated cases that are not responding to treatment may end up at the dermatologist. Make sure your kids nails are kept short. Infants can have little mittens on their hands at night if they are doing a lot of scratching.

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