Eczema/Atopic Dermatitis Kids get a lot of rashes, but the most common diagnosis is probably eczema.
This is one of those topics that I routinely get questions about year round. It doesn’t appear to have a season.
The term eczema is broadly applied to a range of persistent skin conditions.
There seems to be a hereditary component so it is pretty common for eczema to run in families.
One piece of good news is that some kids can grow out of it!
Some babies have buttery soft skin. Others are not so lucky.
My patients with the diagnosis of eczema generally have fairly dry skin with rough patches.
Learning some basic facts about the skin can help you understand what is going on and how to deal with it.
For the data nerds among you, the next paragraph is for you; for the rest of you, sorry if this makes your head spin...
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.)
Skin Care
The obvious focus is to try to re-balance and add back some of those deficient ceramides. Thus, the key to treating basic eczema is moisturizing!
Well lubricated skin does not get as itchy and doesn’t break down as easily. It is important to moisturize at least once a day, (twice a day is better!) but there is no downside to greasing up your kid more often than that. It is really important to break that itch cycle.
Aside from causing misery, scratching can tear the skin, and an infection can occur.
There are some very good products that can make a big difference. Dr. Lawrence Cheung is my go to dermatologist. He lists the following products as some of his favorites:
Cetaphil Restoraderm
Cerave Hydrating Cleanser and Moisturizing Cream
Aveeno Eczema Therapy.
Dr. Cheung particularly likes this Aveeno product for hands. With people washing their hands more than ever these days, the dry hands can tend to get rashy.
The Aveeno does a great job of protecting that can last through several washes.
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.
A local pediatrician, Dr. Jessica Kaplan, 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.
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.
Do you have some extra breast milk leftover that is out of the safety range for feeding?
Dump it in the tub! Milk baths are great for the skin.
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:
Use regular strength (6 percent) bleach for the bath.
Do not use concentrated bleach.
Use plain bleach; avoid those with various scents added.
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.
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.
Obviously these are approximate measurements since baths will have varying amounts of water.
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.
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!!!
Identify Triggers
I tend to refer to atopic dermatitis as ‘reactive skin’.
It will be under control for a while and then something will come along and ‘flare’ it up. I refer to these as triggers.
Playing detective and learning to recognize what triggers are aggravating the rash is another important key to management.
Triggers can range from changes in temperature, dry air from heating the house, a new detergent, teething or a new food.
Acidic foods seem to be a big culprit for some kids.
Berries and citrus are big offenders.
Dairy and eggs are way up on the list as well.
When food sensitivity is to blame you will often see chapped cheeks and a red ring around the anal area.
Treat inflammation
There is absolutely no downside to lots of moisturizing and/ or eliminating the triggers that are flaring up the eczema.
But if those measures are not taking care of things, it is really important to take steps to minimize inflammation.
Think of it in this way - a mild rash is like embers; add inflammation and it becomes a wildfire.
Once you have an actual fire, the entire body becomes more reactive and even more food reactivity can take place.
I like to take the natural route as much as possible, but sometimes it is necessary to use medication or topical creams.
Don’t hesitate to treat and ‘put out the embers before things get out of control’.
As I already mentioned, it is essential to minimize itching.
If your child is doing a lot of scratching, they can break through the skin; infection and inflammation ensue.
Make sure you keep their nails trimmed to minimize damage to the skin from the scratching.
Your doctor will likely suggest 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 sleepiness or the jitters.
Although the label will warn you to check with your MD if your child is under 2 years, most pediatricians have no hesitation giving Zyrtec or Benadryl to kids as young as 6 months if necessary.
Both of these come in a liquid form.
There are dosage charts at the bottom of the post.
Hydrocortisone creams or ointments can also be used to spot treat especially itchy areas. 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.
There are several options of different prescription strength ointments, creams and oils that can be tried. Most of the time simple eczema can be handled by your pediatrician's office.
Once in a while complicated cases that are not responding to treatment may end up at the dermatologist.
If the eczema is mild to moderate and not responding to simple moisturizing and OTC hydrocortisone, there are prescription medications available that range from topical to injection options and even phototherapy.
Dr. Cheung mentioned to me that there are all sorts of new treatments now available, with more coming within the next couple of years.
For severe cases, it is absolutely worth seeing a dermatologist who is current with updated treatment options.
If you like to think out of the box, I have seen some patients have a big improvement in their skin from some treatments from the folks at Advanced Allergy Solutions.
They are not the magic wand for everyone, but have been very helpful for many of my patients.
There are also some ongoing studies about gut health and eczema; it makes sense that there is a connection.
The studies are speculating that probiotics containing Lactobacillus might be helpful, but there are no official guidelines yet.
For your little ones who are eating solid foods, adding fermented foods, and decreasing sugar are easy and worthwhile things to consider.
In summary:
Keep your child moisturized daily with one of the recommended lotions or creams
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.
See if you can figure out what the triggers are and avoid them. Sometimes it is simply cutting out berries.
Zyrtec and Benadryl are fine for itching but don’t treat the underlying cause.
Don’t be hesitant about treatment.
In a risk/benefit calculation, taking appropriate steps to decrease the inflammation is the right thing to do
Zyrtec Dosage Chart
The dose of cetirizine depends on age as below:
6 - 12 months of age: 2.5 mg given once daily (maximum dose 5 mg daily)
12 - 24 months of age: 2.5 given once or twice daily (maximum dose 5 mg daily)
2 - 6 years of age: 2.5 - 5 mg given once daily (maximum dose 5 mg daily)
Over 6 years of age: 5 - 10 mg given once daily (maximum dose 10 mg daily)
Zyrtec comes in a 1mg/ml solution (so 2.5 mg = 2.5 ml). There is also a 10mg/ml oral drops preparation (so 5 mg is 1/2 ml).
Make sure you check the strength of the solution.
