HEALTH What causes eczema in children, and how do you manage it?

CORNERSTONE?Applying emollients frequently is the most important treatment for eczema.

Itchy scratchy little ones


What causes eczema in children, and how do you manage it?

Doctor's insight
Dr Ronan Clancy

Atopic Eczema is an allergic disorder of the skin. The most simple explanation is that the skin becomes allergic, ceases to produce enough of its own moisturise barrier, starts losing water and dries out. It becomes dry, red and itchy. Scratching further disrupts the water barrier and protective function of the skin, worsening the condition in what is known as the itch scratch cycle.
Similar dryness and irritation of the skin can be caused by exposing skin to caustic and oil stripping  chemical agents such as detergents ( irritant dermatitis) or by skin exposure to chemicals which cause allergic reaction within the skin ( allergic contact dermatitis). In these conditions, the location of the offending chemical contact (e.g. hands / eyelids) is often obvious. In atopic eczema there often appears no obvious culprit or cause.
Atopic eczema is present in up to 20 percent of infants and tapers to less than 1- 15 percent by adolescence. It is an abnormal immune response in the skin to a broad range of dietary and environmental allergens resulting in a defective moisture barrier as above. As an allergic condition, it is closely related to asthma and hay fever.
Many patients with eczema will test positive to common aeroallergens such as house dust mite, grass pollens and animal dander and also certain food types. Unfortunately, these findings tend to correlate poorly to the behaviour of the condition and often exhaustive efforts to eliminate such an allergen (e.g. house dust mite) from a child’s environment yield little or no substantial improvement in skin condition. This causes more parental sighs and soul searching!
Certain food types can exacerbate eczema, the most common being eggs, milk, peanuts, fish, soya beans and wheat. However, elimination diets are generally not advised because as is the case above, elimination diets tend not to be beneficial and can affect nutrition and growth. Specialists may advise such diets but only if there is a very clear association between a certain food type and worsening of eczema.
Factors that are known to exacerbate eczema include; wool and other rough clothing, sweating, stress, the premenstrual period, chlorine and cigarette smoke.

Locations
Atopic eczema appears as dry red itchy rash. In infancy it can appear anywhere as red scaly lesions and can be very widespread. As a child gets older, it tends to gravitate to the commonly affected areas such as the elbow and knee creases, wrists, hands, ankles, the neck and eyelids.
Persistent itching and scratching (even during sleep) causes worsening of redness and irritation. Skin weeping and bacterial infection of the skin can occur and over time with scratching, the skin may thicken in a process called lichenification.

Treatment
The key to effective eczema management is the restoration of normal moisture levels in the skin. This is achieved by replacing the missing natural barrier with an artificial one. Commonly used emollients such as silcocks base and emulsifying ointment are used to create this artificial barrier. These really do need to be applied frequently and often to succeed and should also be used as an alternative to soaps and shampoos when bathing or showering as these are detergents which strip eczematous skin of the little moisture barrier it has left.
emollients should also be applied after bathing to lock in the moisture.
Although very labour intensive and unglamorous, this simple treatment is the corner stone to sorting eczema at its root. It tends to be a bit of a chore and is heavily opposed by little happy scratchers!
Occasionally antibiotics may be required to reduce bacterial colonies on the skin or treat infected eczema.
When eczema is flared up and inflamed, different types or immune suppressing creams are used to reduce redness. Even when things settle down, I cannot highlight enough that frequent emollient applications must continue even during the good periods. Without artificial barrier replacement, relapse is inevitable. This is many a parents downfall!

The itch-scratch cycle
The avoidance of scratching is paramount. Kids need to be reminded often of this if old enough to understand. ‘Easier said than done’, I hear you say, ‘What planet does this guy live on?!’
A well ventilated and cool bedroom, cotton pyjamas and few blankets is advised to minimise itch. Cotton mittens can be of benefit in smaller children who scratch at night. Sometimes a doctor may prescribe an antihistamine as well as skin lotions to help alleviate itching during the day and night.
In summary, atopic eczema is a common childhood problem of dry itchy skin with multifactorial causes coming together to cause the condition. It generally improves with age.
Allergy testing and elimination of particular allergens and foods from the diet are unlikely to improve things unless there is a very definite association between exposure to a suspected allergen and a deterioration in skin condition.
The complex regimes and labour intensive rituals of the creams and emollients conspire to cause confusion and make treatment compliance difficult for battle worn parents!
The key is to understand the what and when of the treatment plan, and to stick with it even in the good times!

Dr Ronan Clancy is a GP at the newly opened Clancy Medical Practice, James street, Westport (www.westportgp.ie). He is in practice with Sarah Kavanagh, chartered physiotherapist.