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, often blistering and intense itching. The most common type of eczema in children is atopic eczema (frequently referred to as atopic dermatitis), which may be associated with asthma or hay fever. Eczema is seen in children worldwide, with an incidence of up to 20% in northern Europe.
Atopic eczema is essentially a genetic disorder. Often there is someone else in the family with eczema, asthma or hay fever, but this is not always the case. There are many external factors which may influence eczema on a day to day basis. These will be discussed in more detail.
Yes, for the majority of children. Eczema will gradually improve as your child gets older. The age at which eczema ceases to be a problem varies, but many show a significant improvement by the age of 5 years and most will not have eczema as a problem by the time they are teenagers. Only a few continue to have troublesome eczema in adult life.
No, eczema is not caused by a specific allergy. However, children with eczema are more prone to allergic reactions and this may make the eczema worse. Children with eczema have a hypersensitive 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.
For most cases, routine allergy testing is not necessary. However, in a proportion of children these tests can be helpful. Allergy can be tested by blood tests or skin prick tests to a panel of common allergens. Children with eczema often demonstrate multiple positive results on skin and blood tests, which in itself does not necessarily indicate ‘an allergy’ and does not alter the basic approach to treatment. Conversely some children with eczema may have no reactions to both blood and skin testing. Therefore the relevance of these test results has to be interpreted in relation to the individual child. Allergy testing should be considered in the child with ongoing troublesome eczema which does not respond to first line treatment, in an attempt to identify any factors that could be making the eczema worse. Often there is a clue from the history.
The “skin barrier” relates to the outermost cells of the skin which interface with the external environment. Recent research has shown that there are subtle defects in the protein structure and function of the “skin barrier” in children with eczema. These are genetically inherited abnormalities. If the surface of the skin does not act effectively as a barrier to changes in the environment, the skin is more prone to infection, allergens penetrate the skin more easily and there is increased water loss (sweat) through the skin. Understanding that the ‘skin barrier’ is the primary problem in eczema provides the rationale for the regular use of a moisturizing agent. It also has implications as to what type of moisturizer is most appropriate (detailed in the section on emollients).
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.
In the UK, the NHS National Institute for Health and Clinical Excellence (NICE) has produced guidelines on the management of ‘Atopic eczema in children’ (issue date December 2007) available at www.nice.org.uk/CG057
Emollients are used to try and restore the skin barrier. They are products which moisturize and soften the skin. They improve the elasticity and suppleness of the skin and help to reduce the itching and scratching. Emollients are safe and should be used on a regular daily basis, even when your child has no eczema. These include:
Avoid using heavy greasy ointments as generalized moisturizing agents. Often they can aggravate eczema by limiting sweating and heat loss as well as causing secondary infection, in particular folliculitis. The preferred moisturizers are oily creams which contain some water and are more compatible with the normal physiology of the skin.
Current practice, as detailed in the NICE guidelines, is that a topical steroid is the recommended first line treatment. It should be applied initially daily (either once or twice a day as directed by your doctor) specifically to the areas of inflammation, that is the red or pink areas, immediately after a bath, and not at the same time as the moisturizer. In children with more heavily pigmented skin, the areas of inflammation are less well defined and appear as darker areas usually associated with other skin changes such as blistering, scaling and thickening (called lichenification).
An appropriate strength of topical steroid should be used, such that the eczema is effectively treated within 7- 14 days, and any subsequent eczema should then be treated as soon as it appears. Initially treatment is needed on a daily basis but the ultimate aim must be to keep the skin clear of eczema using the steroid preparation on an intermittent basis. The frequency of usage will depend on the severity of the eczema and choice of topical steroid.
A weak topical steroid, such as 1% hydrocortisone, is usually sufficient for most children with mild eczema. However, for children with more severe eczema, especially if it has not responded to 1% hydrocortisone, a stronger steroid may be required.
A topical steroid preparation is only of value if it works and helps improve the eczema. The ongoing use of a cream that is too weak and ineffective must be avoided. In that situation, it is better to use an ointment or cream that is stronger so as to clear the eczema rapidly, and enable the eczema to be controlled on less frequent applications, ideally once or twice weekly.
Topical steroids are graded into 4 groups: mild; moderately potent; potent and very potent. The main side effect of topical steroids is the risk of thinning the skin at the site of repeated applications. This essentially applies to the most potent topical steroids which should not routinely be used for the treatment of eczema in children.
The other steroid preparations are safe if used correctly.
These topical preparations have become available more recently and are called calcineurin inhibitors because of the way they work. They suppress the immune or allergic responses within the skin and do not cause skin thinning like topical steroids. Clinical trials have shown them to be effective treatments for eczema and safe in the short to medium term.
Concern has been expressed about their long-term safety and whether there is a risk of malignancy, in particular of the skin or lymphoma. No causal relationship has been established to date over a period now exceeding 10 years.
Protopic ointment is available in two strengths: 0.03% and 0.1%. Elidel is a cream and available as one strength. Protopic ointment 0.03% and Elidel cream are licensed for use in children over the age of 2 years in the UK and have an effect on eczema similar to a mild to moderate topical steroid. Protopic ointment 0.1% is not licensed for use in children and has an effect similar to a potent topical steroid.
Protopic and Elidel should be regarded as second line treatments. These products are especially valuable as a replacement for topical steroids in those children requiring daily stronger topical steroids to keep their eczema under control. Also, they have a clear advantage over topical steroids for the more delicate areas of skin: such as the face, especially around the eyes; the neck; the elbow and knee creases and the groin area.
Exposure to strong sunlight should be avoided. In this situation it is advisable to apply the preparation at night only and use a sun-block cream during the day.
Currently the benefits of use outweigh the risks based on available data. Caution should prevail and children carefully monitored.
In March 2009 the European Medicines Agency agreed a new licensed indication for treating eczema. This is based on preventing flares of eczema by using Protopic ointment 0.03% applied twice weekly to designated susceptible areas of skin, after the eczema has cleared. This would be relevant for those children with moderate to severe eczema in whom control of their eczema has proved difficult with simple measures alone.
A sedative antihistamine given just before going to bed will help the child settle and have a more comfortable night's sleep. Non-sedative antihistamines are sometimes prescribed for use during the day. See separate section in ‘Are antihistamines helpful?’
The following may need to be considered for difficult eczema, which has not responded to the more simple measures:
If these measures fail, for those FEW children with VERY SEVERE eczema, there are other approaches to treatment which would need to be given careful consideration:
It must be stressed that these are strong drugs with potentially serious side-effects and would only be considered when all else has failed. They should only be prescribed under the supervision of a Consultant Dermatologist or Paediatrician.
PHOTOTHERAPY is another option, in particular narrow band ultraviolet light B therapy. Eczema often improves with natural sun exposure and therefore the use of phototherapy seems a good idea but it is often difficult from a practical aspect. It requires regular twice weekly treatment, over several months, at a centre that has the expertise and appropriate phototherapy equipment. Often it is not tolerated by children and therefore it has been found to be more useful for older children/adolescents. Given as a limited course of treatment, for most individuals it is safe; however, there is a potential long-term risk of skin malignancy in those who receive prolonged or repeated treatments and especially those who have had previous immunosuppressive oral medication.
Many treatments for eczema are not licensed for use in young children, especially those under the age of 2 years. The license agreement is based on clinical trial data submitted by the pharmaceutical company to the licensing authority. For example, if the product information states ‘not to be used in children under 2 years old’, this does not necessarily mean it is unsafe to use in children under 2 years. The responsibility for the use of the treatment is that of the prescribing doctor and it is very important that parents are fully informed about the nature of the treatment, why it is being used and what are the potential side effects.
There is available a specific prescribing manual called the British National Formulary for Children (2014).
Yes. Eczema seems to attract certain bacteria, in particular Staphyloccocus aureus, which are found on the surface of the skin in the majority of children with eczema. The presence of Staphyloccocus aureus on the skin does not necessarily indicate infection; however these bacteria do play an active role in aggravating eczema by a number of different mechanisms. This is one important reason for frequent bathing.
Children with eczema are susceptible to skin infections, because of scratching and splitting of the skin. An acute flare-up of eczema is often associated with secondary bacterial infection and usually requires treatment with an antibiotic medicine. For localized areas of infection an antibiotic cream may be sufficient; often a preparation containing both an antibiotic and steroid is prescribed. These treatments should not be used for prolonged periods.
Long-term or repeated use of antibiotics must be minimized because this increases the risk of the bacteria becoming resistant to many of the commonly used antibiotics. This has led to the emergence of the super-bug, called MRSA (methicillin resistant Staphyloccocus aureus).
If your child has been found to have MRSA on the skin do not be over-concerned. This has no direct relevance to your child’s health if the MRSA has been identified. It simply means that the choice of antibiotics is limited should your child develop an infection and require antibiotic treatment. The MRSA bugs will not necessarily remain on the skin and often they are replaced eventually by ordinary skin bacteria from outside a Hospital environment in the community.
For children with difficult eczema and recurrent infections the use of an antiseptic cleansing cream or an antiseptic oil-based bath additive can be helpful.
Children with eczema are especially susceptible to cold sores (caused by herpes simplex virus) and therefore it is important for your child not to come into contact with anyone who has an active cold sore. Contact with the virus may result in a widespread infection, which may make the child feel very unwell. This is called eczema herpeticum. If this is suspected, you must contact your doctor as soon as possible.
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 one year, and sometimes even longer - but eventually they do disappear - with or without treatment!
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.
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 on “Guidelines to Treatment”.
Parents are often anxious about the use of topical steroids, but these worries stem from the misuse of the very strong steroids, which may cause problems, such as thinning of the skin, and should not be used to routinely treat children.
The long-term intermittent use of a mild or moderate topical steroid, under regular medical supervision, is essentially safe. On the face of the very young, topical steroids should be used with caution and, when necessary, only for a limited period of time.
Cover the eczema (the red and pink areas of skin) evenly with a clearly visible fine film of ointment such 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”.
Apply the steroid cream or ointment specifically to all the areas of eczema. It is important to treat the affected area(s) until the appearance of the skin returns to normal. If the treatment is stopped prematurely it is likely to result in a rebound flare of eczema. The quantity required will depend upon the extent of the eczema, but should reduce rapidly as the eczema improves. Once the skin is clear then any recurrence should be treated immediately, no matter how small the area of eczema.
Eczema can cause splitting of the skin called fissures. It is perfectly safe and appropriate to apply the steroid preparation on ‘broken skin’ in the absence of any secondary infection.
The application of topical tacrolimus (Protopic®) and pimecrolimus (Elidel®) is exactly the same
Topical tacrolimus (Protopic®) and pimecrolimus (Elidel®), and indeed some topical steroids, can cause a mild transient sensation of “stinging” when first applied to the eczema. It tends to last for only a brief period and seems to occur only with the first few applications; thereafter these products are usually well tolerated. For most children this is not a problem, but it is important that parents are made aware that this can happen.
No, in fact just the opposite...frequent baths are the rule. At least once daily, twice daily is even better. Bathing keeps the skin clean and free from crusts and scales, which helps to prevent infection. It is necessary to add a suitable bath oil to the bath water, to prevent the skin from drying out. Soaking in the water for 10 minutes will help the skin considerably. Avoid soaking in the bath for too long as this may be detrimental.
For babies it is best to use a recommended cream cleansing agent to wash the skin. It is important not to touch the eczema and then put your hand in the tub of cream, as this will risk introducing contamination. Use a tablespoon to take out a measured quantity for the bath. The cream cleansing agent can be applied by hand or using a soft cloth or flannel, whilst the child is in the bath. Ideally these cloths should be freshly hot washed for each bath. Avoid using a sponge as these can harbour bacteria.
When washing the skin this must include all the hidden skin folds, in particular the neck, under the arms and nappy area.
For small babies use the same cream cleansing agent on the scalp as a shampoo. If the scalp is a particular problem there is available a gentle oil-based shampoo containing an anti-fungal agent which is usually well tolerated. For older children, avoid using a standard proprietary shampoo in the bath, as this can have an irritant effect on the skin if it gets into the bath water. The hair should be washed separately, either in the bath after removing the bath water, or preferably leaning over the bath and using a shower attachment.
There are a number of alternative soaps, which include oily shower gels; some contain antiseptic agents, some are skin pH balanced and some contain a moisturizing cream.
The temperature of the bath water should be cool and the bathroom warm. Avoid any sudden changes in temperature which may make the skin itch.
After the bath the skin should be soft and slightly greasy. Dry the skin by patting gently with a soft towel.
Bathing is better than showering, but if only a shower is possible, then use an
appropriate cream cleansing agent or shower gel and rinse well before drying.
Hard water can irritate the skin, but this can be minimized by the addition of a bath oil. A water softener may help but whether it is worth the cost of installation is debatable. It is most relevant to those families who live in a hard water area.
Yes. Antihistamines may be helpful for the treatment of associated allergies. They also act as a sedative and are useful at night to help sleeping. The bedtime dose should be given at least half an hour before the child goes to bed, ideally before 7pm so that they are not drowsy the next morning.
Non-sedative antihistamines are sometimes prescribed during the day. These are especially useful for those children who suffer with hay fever during the summer months.
Antihistamine medicines are not addictive and there is no evidence to suggest that long-term use is dangerous.
Antihistamine creams should not be used on eczema as they may cause a contact allergic reaction.
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 therefore be encouraged.
Sometimes however, severe eczema can occur in babies who are being breast fed. 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 mother restricts her own diet usually doesn't help the situation and may reduce the nutritional value of the breast milk. It is important that mother has a well balanced diet with no excess of “high risk foods” (see later section); but, if the eczema continues to be a significant problem, it may be necessary to introduce a hydrolysate milk formula (see next section) and gradually reduce and stop breast feeding.
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.
Fresh sheep’s and goats’ milk are not suitable for the child under one as they are nutritionally inadequate; however, there are proprietary goats’ milk formulae for infants which are nutritionally complete. Children who are allergic to cows’ milk are likely to also be allergic to sheep’s and goats’ 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 specific food allergy or intolerance. The diets employed are usually avoidance of dairy products, substituting a hydrolysate milk formula for cows’ milk. In some situations it may be necessary to use an elemental feed called Neocate.
The diet should be for a trial period of 2 months and supervised by a dietitian to ensure that the child is not at risk of nutritional deficiency.
If a child needs to be on a diet for a prolonged period, then re-introduction of cows’ milk, should be attempted at one year. This should be done with caution. For those children who have not had an obvious reaction to cows’ milk and for those who have had some dairy products in the past, a small quantity of formula milk (5ml) should be given initially and the amount slowly increased over a period of 2-4 weeks. Thereafter other dairy products can slowly be re-introduced.
For children who have had an allergic reaction to cows’ milk then a formal milk challenge test needs to be performed in hospital under medical supervision. If there is a positive reaction to cows’ milk (on skin testing or when taking a small quantity by mouth), then the diet should be continued and the child subsequently re-evaluated annually.
Most children with eczema “grow out” of their cows’ milk allergy in the first 3 years. Other allergies, such as eggs and peanuts, can continue as a lifelong problem.
Weaning is advised from 6 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 list below. Allergic reactions to foods occur only in a small proportion of children with eczema and the majority will be able to tolerate a normal diet.
As a matter of routine, for children with eczema (even without any history of food allergy), eggs (especially boiled or fried eggs) should not be introduced until after the age of one year.
These are ranked in order from “rarely cause a problem” (at the top) to “may cause a severe allergic reaction” (at the bottom)
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 sometimes helpful for the child to wear a loose wet T-shirt in hot weather to cool down the skin and relieve the itching.
The use of a water spray is another means of keeping the skin damp and cool. The spray containers can be kept in the refrigerator. Children find the cold water mist sprayed on to their skin and clothing very refreshing during the hot weather making their skin much more comfortable.
It is essential to protect the skin from sun-burn, using a suitable sun-block cream or lotion. Ask your GP, dermatologist or local pharmacist for advice on which products are most suitable. As a basic principle use one which has a high sun protection factor and is suitable for children.
Swimwear products are now available, which are almost 100% sun-protective. These are clearly helpful for sun protection, but may aggravate eczema by producing overheating and irritation of the skin.
Small children enjoy playing in a paddling pool (with sea water) on the beach – ideally in the shade under an umbrella – and this can be highly beneficial for eczema. A paddling pool can be taken flat-packed in the suitcase and inflated on the beach.
Children with eczema are prone to insect bite reactions and, depending on where you travel, you may wish to use an insect repellent applied to the cuffs, socks and shoes – not directly on the skin as it may cause an irritant reaction.
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 moisturizer, such as Vaseline or a 50/50 mixture of white soft paraffin, specifically to the vulnerable areas of skin, beforehand, and afterwards wash off the chlorinated water in a bath with an oily bath additive. In an outdoor swimming pool use a thick sunblock cream as a barrier and for sun protection.
Taking babies with severe eczema into a chlorinated swimming pool is not a good idea.
Children over 2 years should be actively encouraged to learn to swim and participate in all sporting activities.
Your baby should receive all the routine immunizations, 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 serious concern then these injections should be administered under medical supervision at the local hospital. If you are concerned discuss with your GP.
Occasionally any of the immunizations may aggravate eczema for a few days afterwards, but this is not usually a problem.
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 wollen fabrics
Children should be dressed in loose cotton clothes. Be careful when holding the child that your own clothing does not irritate the skin.
Biological detergents and some fabric conditioners
Use non-biological products.
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.
In an enclosed room, fumes will irritate the skin. It is best to ban smoking within the home!
Cats and dogs
Virtually all furry or feathered pets will produce an allergic reaction in a child with eczema. Cats and dogs leave their dander everywhere and so the child is always at risk, even if the animal itself is not around. Avoid cats and dogs 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 on the 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 old soft furry toys, which should be kept in a cupboard and washed regularly.
Special mattress covers are available to protect against exposure to house 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.
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.
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.
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 lunchtime, but this must be supervised. If properly informed, most schools will co-operate and help in this situation. It is important that children do not miss school because of their eczema.
The National Eczema Society provides school packs for different age groups with useful information for teachers and other pupils in the school.
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.
Fortunately this problem is very rare. In exceptional cases a severe and potentially dangerous allergic reaction can be caused by an insect bite (e.g. a wasp or bee sting), a particular food (e.g. peanuts, shellfish, eggs) or a medicine (e.g. 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.
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 that even if the next child is affected it may well be much less of a problem.
Many parents try homeopathy. There is no convincing evidence that homeopathy benefits eczema. However, it is safe and for that reason there is no real objection, 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 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. With future research, it is possible that from these plants new and better standardized treatments for eczema will be developed.
Beware: some “natural” products and in particular some Traditional Chinese remedies have been found to contain steroids
In eczema, itching is highly susceptible to psychological influences. Relaxation techniques can be used to help eczema sufferers. The aim of treatment is to distract the mind from the skin.
It is an integral part of Chinese medicine, but its role in the treatment of eczema is uncertain.
Further information and help can be obtained from:
National Eczema Society,
Illustrations by Charlotte Cleveland