Allergy GPSI Dr Adrian Morris’s hints on managing eczema in children
1. Ointments reduce skin dryness and provide better barrier protection than creams.
Plenty of ointment and greasy emollients should be used as often as possible – every four hours if necessary.
Children should be bathed daily with bath emollient and soaked for up to 20 minutes. Aqueous cream is a poor moisturiser but an excellent soap substitute.
Preservatives, fragrances and other excipients may start to irritate the skin, so it may be necessary to change emollients periodically.
Prescribe at least 250g emollient per week for children (600g for adults). Parents could consider installing a water softener if household water quality is poor.
2. Don’t be afraid to use topical steroids to treat active eczema.
The only effective treatment for active eczema is a moderately potent topical steroid for periods of three to seven days.1 Emollients alone will not clear eczema.
Reassure parents that intermittent use of topical steroids will not retard growth or lead to skin thinning.
Unfounded fear of steroids often leads to suboptimal treatment in eczema.
3. Suspect a skin infection if eczema rapidly deteriorates.
Staphylococcal and streptococcal skin infections are common complications of infantile eczema and will result in rapid skin deterioration with weepy, crusted and erythematous areas.
Swab and culture the skin and nose, but start treatment immediately. Apply mupirocin or fusidic acid topical antibiotics to localised lesions as well as in the nose. Systemic flucloxacillin or erythromycin will be necessary for larger lesions.
4. Any child with extensive eczema should undergo allergy testing.
Infants with eczema are at increased risk of developing food allergies. House dust mite and pet allergens as well as common food allergens (cow’s milk, hen’s egg, wheat and peanut) play a trigger role in up to one-third of infantile eczema. Discourage hit-and-miss elimination diets as they can lead to malnutrition.2
5. Children with infantile eczema are likely to be atopic.
Eczema is the first manifestation of the so-called ‘allergic march’ in atopic families. Be vigilant for the development of asthma, allergic rhinitis and food and nut allergies in children with eczema, especially when parents and siblings also suffer with allergies.
6. Break the itch-scratch cycle with antihistamines.
Low-dose cetirizine or loratidine helps to reduce skin inflammation and the itch-scratch cycle. The Early Treatment of Atopic Child (ETAC) and Early Prevention of Asthma in Atopic Child (EPAAC) clinical studies also suggest cetirizine may slow the progression from atopic eczema on to atopic asthma and urticaria.3
7. Parents should be wary of unsubstantiated alternative treatments.
Miraculous herbal cures for eczema are often laced with crushed prednisolone. Evening primrose oil, flaxseed and omega-3 oils don’t actually help eczema. There is growing evidence that, if given early, lactobacillus supplements may reduce eczema in infants by altering the gut immune responses.
8. Pseudo-allergens in the diet should be avoided.
Pseudo-allergens such as vasoactive amines or acidic/histaminic foods may aggravate eczema and enhance itching. Contact with these foods may trigger localised facial and circum-oral eczema. Marmite, strawberries, chocolate, cheddar cheese, tomato, pineapple and citrus fruits may trigger eczema by releasing histamine, which promotes itch.
9. Recommend occlusive ‘wet wraps’ for extensive and difficult-to-treat eczema.
Wet wraps are effective in severe exacerbations of eczema not responding to regular treatment. First apply steroid ointment with plenty of moisturising emollients. Two layers of Tubifast elastic tubular bandages are applied over the affected limbs. The inner layer of Tubifast is applied wet to aid absorption of emollients and the outer layer applied dry.
10. Refer unresponsive eczema to a paediatric dermatology centre.
If all else fails, then refer to a paediatric centre of excellence for third line treatment such as ultraviolet phototherapy and immunosuppressive drugs, as there may be an underlying immune deficiency contributing to the eczema. Steroid-sparing topical tacrolimus and pimecrolimus can be used on resistant facial eczema, but may cause some initial redness.
Dr Adrian Morris is an allergy GPSI in Surrey and clinical assistant in allergy at the Royal Brompton Hospital, London
Competing interests None declared
Children with extensive eczema Children with extensive eczema