Eczema is an allergic skin condition seen in allergic people which causes the skin to be dry, sensitive and feel rough and scaley. This allergic process can progress to a generalized rash which is scaly, red, itchy and sometimes even broken open or weeping. Eczema tends to occur in people with a family history of allergy (asthma, hayfever, eczema, and/or itchy, watery eyes). The treatment of eczema is primarily directed at keeping the skin well hydrated and oiled up. A major problem with eczema is that the normal skin barrier, which is composed of layers of skin cells covered with specialized oil on top of it, gets damaged due to allergic reactions. This damage to the skin barrier leads to skin that is dry (little oil) and broken open. A cascade of problems result from the loss of the normal skin barrier including further activation of inflammation (redness), itching, dryness and even secondary infections. Scratching tends to make the loss of the skin barrier even worse. Skin oil found in ointments, which are placed on the skin provides a barrier to to further allergic reactions and a barrier to infection. This is essential to healthy skin function.
There are two complications of eczema that are important to understand. The first is skin infection with Staph Aureus and strep. This condition is called impetigo. Skin infections are a problem for people with eczema because the condition has damaged the skin barrier which protects the skin from infection. Skin infections can become serious if they are not treated promptly, so it is important to recognize the signs of staph and strep infections:
- Increased redness
- Pus-filled bumps or oozing fluid
- Skin tenderness
- Honey-colored crusts or scabs
If you see any of these signs, make an appointment for treatment options.
The second condition is an infection of the skin with a virus known as the pox virus which causes molluscum contagiosum. These are small 1/8 inch sized wart-like bumps which have a central depression. This is not a wart but a wart like infection. Should your child become infected with molluscum contagiosum, come in for an office visit for treatment advice.
Treatment of Eczema
The treatment of eczema depends on its severity. Mild eczema is treated with the use of gentle cleansers and the application of emollients. Severe eczema may require all the treatment modalities outlined below.
To keep the skin well hydrated and protected with oil, we recommend using the mildest and the least amount of soap as is possible. Soap washes away the normal oils of the skin and makes eczema worse. So use as little soap as possible and use the least amount possible. In addition, people with eczema are often allergic to the fragrance used in soaps, so use fragrance free cleansers, clothes detergents and fabric softeners. Skin cleansers and soap should be products that are labeled for use with “sensitive skin”. These are fragrance free. Examples of gentle soaps and cleansers include:
In addition to fragrance free soap, we recommend applying an emollient to the affected skin to further seal the skin from continued water loss. A moisturizer is a skin care product that adds moisture to the skin by sealing the skin with oil. This prevents continued excessive water loss from the skin. Ointments and creams are recommended instead of lotions for people with very dry skin. Products that can help add moisture include:
Emollients are available without a prescription. A very effective treatment strategy for treating eczema with emollients is to alternate applying CeraVe® Moisurizing Cream with Aquaphor® Ointment. Apply one of the creams in the morning and one in the evening. When applying emollients, it is important to apply a thick coating to the skin, much like icing a cake. Most children with eczema come to our office with inadequate emollients on their skin. These must be applied liberally and often, at least twice per day. After bathing is a particularly good time to apply an emollient. This is the most important aspect of eczema treatment: avoidance of fragrances and soap, and slathering the child with emollients at least twice daily.
3. Avoidance of allergens
Sometimes exposures to certain things in the environment and/or diet can make eczema worse. This is particularly true of cow’s milk, soy, peanuts and strawberries. Please refer to the section on this website on allergy for more information. Avoiding certain foods and or environmental triggers can have dramatic effects in helping to improve eczema.
4. Allergy medications
Because eczema is an allergic condition, certain allergy medications such as anti-histamines and leukotriene modifiers can help eczema. Consult us regarding specific recommendations for your child. Cetirizine and loratadine are two such examples which are known to help eczema.
5. Steroid Ointments, Eurissa and Topical Clacineurin Inhibitors
Over the counter strength 1% hydrocortisone ointment may be used to treat this condition. It is safe to be used daily in the treatment of eczema. Make sure to use the ointment version of 1% hydrocortisone. It helps to seal the skin and improves the skin barrier which improves eczema.
If your child’s dry, sensitive skin continues to be a problem despite the above measures, you should bring your child into the office for a routine office visit. There are other effective treatment options available. Some of these treatments options include:
- Medium potency cortico-steroid formulations such as Mometasone, Desonide and Triamcinolone. These are safe, but should not be used every day unless we instruct you to do this for severe cases.
- Eucrissa is a prescription ointment used on the skin (topical) to treat mild-to-moderate eczema in adults and children 2 years of age and older. It is steroid free. It’s safe, but quite expensive. A common side effect of Eucrissa is skin burning. This is usually not a long-lasting problem. So, keep using it despite this side effect. It will diminish with time as the skin heals.
- Topical Clacineurin Inhibitors (TCIs) are also medicines that are applied to the skin to treat severe cases of eczema. TCIs include Protopic® ointment (tacrolimus) and Elidel® cream (pimecrolimus). They control skin inflammation, but are not steroids. Thus, TCIs don’t cause steroid side effects such as thinning skin. A common side effect of TCIs is skin burning. This is usually not a long-lasting problem. These medications do contain a black box warning that they might extremely rarely cause certain tumors and or cancer. Thus, their use should be limited to severe cases of eczema.
5. Wet wrap therapy.
Wet wrap therapy such as recommended by National Jewish Hospital in Denver, Colorado.