Feeling comfortable in their skin: All about paediatric eczema

Eczema in children is a difficult condition that affects not just the child physically and mentally but also their parents or carers. Quality of life can be significantly affected for all parties involved.

London-based paediatric allergist Dr Helen Brough is a leading name and has some expert, reassuring advice about paediatric eczema that can hopefully be the first step in giving your child the opportunity to be more comfortable in their own skin.   

How early can eczema develop in children?

Eczema often presents within the first three months of life, particularly in the patients that I see in my clinic that have associated food allergies. Most children will develop eczema within the first year of life if they're going to develop eczema. There are some conditions called erythema toxicum neonatorum (ETN) or acne neonatorum (neonatal acne), which occurs in the first few weeks of life which is not eczema, and is more pustular in nature.  There is also dryness of the skin that can occur in infancy, which is also associated with later onset of food allergy.

Can symptoms of eczema improve or disappear with age?

Symptoms of eczema often do disappear and improve with age, so the published data shows that two-thirds of children will no longer have eczema by the time they reach puberty. In my practice, I would say that I often see children under the age of one with eczema and by the time that they're two, most of my children in clinic have improved significantly and maybe just need moisturisers to manage dry skin.

What causes eczema to develop in babies and children?

This is a really important question and it's something that I always discuss with parents in clinic. So, there are several factors that contribute towards eczema. The first is genetics. So, often, when I see a child with eczema in my clinic, one of the parents will have had hay fever during their life. It's often hay fever that I find is associated with eczema in the child, but if a parent or both parents have eczema, the risk of eczema in their child is even greater. This is because we know that there are certain proteins in the skin, for example the Filaggrin protein, which are really important in maintaining the skin barrier. They form the cement inside the outer layer of the skin in between the cells, which then ensures that the skin is robust, doesn't lose water and is protected against irritants and allergens.

If you have a mutation in the gene for Filaggrin or other types of skin barrier genes, then you will have a deficit in those proteins in your skin. This results in dry skin because the skin is very porous and so loses water and also results in where things can get in and irritate the skin, so that can be all kinds of environmental things. For example, we know certain things irritate the skin in children like wool or synthetic clothing, high temperatures but other things in the environment can also cause issues like detergents and bubble bath, and things used to wash the child can break down the skin barrier even further.

Certain creams that are prescribed for children have a very high pH, which also damage the skin barrier. So, all of these environmental factors contribute towards the skin barrier then being disrupted. There are certain things in the environment like bacteria that colonise the skin in a child that has eczema, and this is partly because the skin barrier is disrupted, but also because we know that children with eczema don't have certain proteins in their skin that fight pathogens like bacteria, like fungi and like viruses. So, when I see children in my clinic that have eczema, I'm always looking to see whether there might be something in the skin that's itchy and potentially inflamed with some infection driving it. That is also crucial to the way that I manage children with eczema. So, I've talked about the genetics of eczema, I've talked about environmental factors that can make the eczema worse and then there is also, possibly, food allergy; delayed, mixed, immediate or delayed food allergy.

Now this is something that is quite rare in children. It's much more likely to be either a skin barrier defect or an infection that's causing the problem, but food allergy can sometimes exacerbate eczema in a child and the easiest way to assess that is by doing the right types of tests, and then excluding the food and reintroducing it. This is something that I will do a clinical history of, allergy testing and review. The most important thing is that eczema also can lead to the development of food allergy so it's really important to manage eczema, not just to prevent flare-ups and prevent infections of the skin but also to prevent more allergies from developing.

What are the signs of eczema? When should I take my child to see a doctor?

The signs of eczema can be varied, so dryness is often a sign of eczema and then there's inflammation. That's redness and itching, in different parts of the body the classical parts of the body that are affected in eczema are; in infants, the face where they can get a lot of irritants that affect the face, but also the knee and the elbow flexures. In infants they also get a lot of eczema around the neck when they start teething because they get a lot of wet dribble rash, which also exacerbates the eczema there. Often children that have eczema also have cradle cap so I always make sure that I address that if it's present. In children of darker skin tones, they can sometimes have a different distribution of eczema affecting more of the extensor surfaces of the arms and legs. Classically in eczema the nappy area is spared and that's because the nappy area is quite humid and so because of that, the skin is protected and doesn't dry out.

As the child gets older you have less of the facial eczema and you have more classical distribution of the itching and the redness in the flexures but it can affect the whole body and I do often see children with severe eczema that affects the whole body and it's really wonderful to see how simple strategies can make a massive difference to that child's quality of life, and the parents' quality of life, and their skin condition.

I think if the child has got eczema that isn't being managed with standard eczema moisturising creams, is causing the child to itch or scratch and is interfering with their life, then I think it's important to get advice from a medical person who knows how to manage eczema. However, there's a lot of useful resources on the National Eczema Society website. This is a charity for people who have eczema and parents - and they have a lot of useful information on there, which you could first access and read about all the different things that can help improve your child's eczema.

What are the dos and don'ts of treating children's eczema at home?

Treating children's eczema at home is really important. There are lots of simple things that if done correctly can massively improve the child's skin condition. So whenever I see a child in clinic, I always do a written eczema treatment plan and I go through all of these stages in great detail.

So, the first thing, is that the child needs to have a daily bath once they have eczema. This bath should be in water that is not too hot - tepid water - because otherwise the hot water can irritate the skin and the child can start scratching. The bath shouldn't be longer than 10 to 15 minutes because being in water on its own, or just being in water, can irritate the skin and start itching. The skin will be then more susceptible to scratching because the water makes the skin more vulnerable. Doing a daily bath is very important once the child has eczema because of the fact that the child is unable to clear the skin of bacteria, viruses and fungi from the skin, because it lacks certain proteins in the skin. It's also helpful to have a daily bath so that you are removing residues of other irritant factors on the skin and foods that can potentially sensitise the child through the skin, so when the child has a bath on a daily basis, it's really important also to not use bubble baths or standard soaps or detergents to wash the child. The child once they have eczema should have a non-soap substitute for washing which is a cream that's usually put onto the child's skin and then rinsed off with water. Once they've had their bath, then they come out of the bath ideally in a room that's not too cold and not too hot, and the skin is patted down gently with a towel.

So, these are all practical things that make a massive difference to the skin condition. It's better to have a bath than a shower because the water then infuses the skin with hydration so that's one simple thing about how to bathe your child with eczema. The second thing is using the right type of moisturising creams, so I recommend using proper eczema creams that have been studied and using them in a way that is beneficial for the skin.

So, the first step is how to apply the cream. It's very important to use around 250 grams of the cream in young children and in older children around 500 grams of the cream per week, so you're using a lot of cream. You need to wash your hands before applying the cream onto your child's skin and then you need to put a thick layer all over the child including the face and the scalp if they have a dry scalp. After this it's very important to ensure that the skin is moisturized using a smooth downward stroke so that you're not rubbing the moisturizer into the skin because that can irritate the hair follicles of the skin. Doing smooth, downward strokes in the direction of the hair and then letting the moisture be absorbed into the skin is very important. There are lotions, creams and ointments that are available and different children find them suitable. Also, it can depend on the weather, so if it's very cold ointments can sometimes be better as they are thicker and they trap more moisture in. Lots of children get worse eczema during the winter time and in the summertime, it may be better to use creams because they are lighter and more easily absorbed. Lotions and creams can sometimes be more irritating than ointments because they contain more water and so they often need some preservatives to keep the cream from going bad. It's really important to not use a fragranced cream and to try and use a cream that doesn't have too many products.

I always tell my parents that before putting the cream all over the body they should put a little patch on one area of the child's skin to check that they aren't irritated with that cream.  The second really important thing that I often see in my clinic is that parents are putting their hand inside a pot of an ointment. What happens if they do that, is that they can contaminate the pot with bacteria and then that pot stays at room temperature as lots of bacteria grows in that pot. Then the bacteria then put onto their child's skin and that causes irritation and that is something that is very commonly done so that's a really important point; these are all very simple things that can be done and can massively improve a child's skin condition. Then there are standard things like avoiding all the different irritants that I've mentioned and also if the child's skin is not sufficiently managed with moisturisers, then using appropriate topical steroids of the right potency and under medical supervision is very important.

Therefore, what I would also recommend is assessing in children that have severe eczema, the possibility of food allergy particularly in those children who have developed eczema under three months of age. In a large study done in Australia it showed that in children who had eczema that started under three months of age that had required topical steroids, they actually had a risk of food allergy of fifty per cent by one year of age, so it's important to assess that.

If you’re seeking for top paediatric eczema advice, or related allergy issues, arrange an appointment with Dr Helen Brough via her Top Doctors profile, today.