Atopic eczema is the commonest type of eczema and is particularly widespread among babies and young children. Over the past 30 years there has been a large rise in the condition, which now affects 10 per cent of children. Fortunately, 60 to 70 per cent of children grow out of it by their mid-teens.
Atopic eczema usually appears in the first year of life and is sometimes called infantile eczema. Atopic means a family or hereditary tendency to asthma, eczema and hayfever. The cause of atopic eczema and the reason for the increase in the condition is not known, but environmental factors are thought to play a part. For example, central heating and carpets, which are now standard in most homes, have increased children's exposure to allergens such as the house dust mite.
THE SKIN
The outer layer of the skin forms a protective waterproof coating and acts as a barrier against bacteria. The inner layer of skin contains the oil (sebaceous) glands. These produce an oily substance called sebum, which forms a protective moisture film over the skin, preventing it drying out.
The skin of children with eczema is generally paler than that of others and does not provide the same protective function. It tends to be excessively dry and cracks easily. The dryness is thought to be due to a reduction in the size and number of the oil glands, and the fact that the skin retains less water and loses more than normal skin. The dry skin is a major cause of itching.
Signs and symptoms Atopic eczema begins before the age of two years and often in the first few months. In babies it often begins with patches of dry, irritable, itchy skin on the face. The skin behind the knees and ears, and the neck, elbow and wrist skin folds are commonly affected, but in severe cases the rash may cover the whole body. The rash also fluctuates and can be more widespread at some times than others.
Other signs of eczema are: redness and inflammation tiny pimples or blisters which can erupt into weeping or sore patches severe itching and the skin may scale in chronic eczema, scratching may lead to thickening of the skin (lichenification). This is the body's internal defence mechanism to prevent further damage to the skin oedema (swelling) in severe cases.
ECZEMA AND INFECTION
Although eczema is not infectious, a child with severe eczema is more prone to skin infections. It is thought people with eczema may have a slightly lower resistance to infection because of a minor deficiency in the immune system. Scratching can result in skin abrasions and allow the penetration of Staphyloccuss aureus bacteria that is present on the skin. This can give rise to infected eczema. One way to help avoid scratching is to suggest older children pinch their skin when it is itching.
Viral infections such as warts are also more common and the cold sore virus can trigger off a serious infection called eczema herpeticum, which usually requires hospital attention. Because of this risk, people with a cold sore should never kiss children with eczema.
CRADLE CAP
Cradle cap in the form of non-itchy thick yellow scales on the scalp is common in young babies and usually starts at around two months of age. It causes little discomfort to the baby, but sometimes cradle cap spreads down the face and becomes itchy and red. Recent research has found that one in two babies with cradle cap will go on to develop atopic eczema.
ECZEMA AND DIET
Although research has found some foods can trigger eczema, only a small number of children with eczema are helped by diet. For most, diet is not a factor, but children with, or at risk from eczema, should not be given cow's milk, wheat, eggs, fish and citrus fruits, until they are at least six months old.
In older children, cutting out food additives or drinks such as orange squash or cola is fine. But it can be dangerous to cut out important foods such as wheat or dairy products without advice from a doctor and a dietitian.
Soya milk formula which parents sometimes substitute for infant formula milk can also cause allergies and because it is very sweet, may cause tooth decay. Goat's milk can also cause allergies. It should not be used for children under the age of one year as it is not nutritionally sound, and it must always be pasteurised.
Nut allergy, especially peanut allergy, is becoming increasingly common in children. To reduce the risk it is recommended that nuts, and especially peanuts and peanut butter, should be avoided until at least age three in children from families with a history of eczema, asthma or hayfever.
THE TREATMENT OF ECZEMA
Because eczema is a dry skin condition the mainstay of treatment is to keep the skin soft and moist. Frequent bathing and the applicant of emollients can achieve this.
EMOLLIENTS These are available either as liquids for use in the bath or as creams or ointments to apply to the skin. Finding the right one is usually a matter of trial and error. A cool bath daily with a suitable bath oil can soothe the skin. Bubblebath and soap should be avoided and soap substitutes used. The skin should be patted dry.
Emollients should be applied after a bath and as frequently as possible. Four times a day is a minimum and eight times is not too much. The cream should be smoothed on in downward strokes. Older children should take the cream to use at nursery or school. If the child wants to go swimming, Vaseline applied beforehand will prevent the chlorine from irritating the skin.
TOPICAL STEROIDS Steroid creams do not cure eczema, but they reduce inflammation and help heal damaged skin. Parents often worry about using these but they are safe when used correctly (once or twice a day) and for short periods. The best way is to ask the doctor or pharmacist how much to apply using the fingertip unit method. This is the amount of cream required to cover the tip of an adult finger to the crease of the first joint and equals 0.5 g. Emollients should still be applied.
WET WRAPS These are warm wet stockinette dressings which are applied over the body after using large amounts of emollients. Dry wraps and normal clothes are then put on top and the wraps changed after 24 hours. Their purpose is to cool the skin, prevent itching and help healing.
CLOTHING Cotton clothing is best. Rough clothing such as wool next to the skin can cause irritation, and some man-made fibres can cause sweating and make the eczema hot and itchy. Cotton gloves or mittens can be useful on young children at night when the itching is usually worse. Biological and perfumed soap powders and perfumed fabric conditioners are best avoided and clothes should be thoroughly rinsed.
THE ENVIRONMENT The bedroom should be kept cool and an over-dry atmosphere avoided. Damp dusting and vacuuming should be carried out as frequently as possible, preferably when the child is out of the room. Soft toys collect dust mites, so these should be limited to a favourite one if possible which should be washed regularly or put overnight in the freezer weekly to kill the dust mite. Studies have found using anti-allergy bed covers is the most effective way to reduce dust mites.
COMPLEMENTARY THERAPIES
Complementary therapies such as acupuncture, homeopathy and herbal medicines are often tried as treatments for children with eczema. Although some therapies can be effective for some children, practitioners should be properly qualified and the GP informed of any other treatment the child is having.
In particular, herbal remedies or Chinese medicines should be used only on the advice of a specialist. Some remedies have caused liver damage and others have contained dangerous amounts of steroids.
FURTHER INFORMATION
The National Eczema Society has a series of information packs on eczema. For details send an sae to National Eczema Society, Hill House, Highgate Hill, London N19 5NA. Helpline: 0870 241 3604 (1 to 4pm.) June Thompson is a health visitor and medical journalist
