ECZEMA – part 2

Written by Dr Nické Theron, Pediatrician.

Eczema is a chronic disease and sadly it is not (yet) curable. It is however possible to control the symptoms. The aim is to get the acute inflammation of the skin under control (usually with topical steroids added to your normal regime), and then maintaining a healthy skin barrier by keeping the skin hydrated. It is thus very important that you understand the disease and what causes flare-ups in your child (see previous post) so that you can create the best management plan with your doctor.


…being strengthened with all power according to His glorious might so that you may have great endurance and patience…

Col 1:11

General Tips and Tricks:

• Avoid triggers as far as possible. Triggers differ for each child and can be as simple as: extreme cold or dry environments, sweating, emotional stress or anxiety or exposure to certain chemicals or cleaning solutions eg soaps, perfumes, cosmetics, wool, synthetic fibres.

• Keep the skin hydrated:
This is a very important part of the management plan. It is not necessary to buy the most expensive ointments; research show they do not necessarily work better than the ones you can buy in Dischem.

Your moisturizer needs to tick the following boxes:

  • It must be an emollient or ointment, lotions can worsen the dehydration of the skin.
  • Contain cetomacrogol (emulsifier), urea or glycerol (locks in moisture on the skin)
  • Contain NO colourants or fragrants. Be careful of any ointments containing “Sodium Lauryl Sulphate” as this can also break down the natural skin barrier.
  • E.g. in South Africa: Cetaphil, Epimax, Epiderm
    Best results when applied twice a day. Important to apply directly after bathing.

Bathtime talk: Lukewarm baths / showers soothe the skin but avoid long (10-15min) baths. Use a non-soap cleanser sparingly (you can use the same ointment that you apply after bathtime). In some cases a specialist may prescribe a “bleach bath” to decrease the amount of bacteria on the skin. Use a ¼ cup of bleach in a full bathtub (+- 150L) twice a week. (Discuss this with your doctor first.)

Medical treatment

Topical Steroids
Most children with eczema will use topical steroids at some point during the disease. The anti-inflammatory effect is very effective in the treatment of the itch and the inflammation of the skin and most mild and moderate cases of eczema respond quickly to these ointments.

There are many different types of topical steroids and they are classified according to their potency. Examples you may know is Hydrocortisone (Mylocort) which is a weak steroid, Methylprednisolone (Advantan) moderately strong, and Betamethasone (Repivate) one of the strongest steroids available to use on the skin. Your doctor will help you to weigh up the risks and benefits to decide which steroid cream to use.

When there is a flare-up of the eczema, use a stronger steroid cream once daily for 7-14 days, then switch to a weaker steroid until the lesions are gone

Steroids in general has a bad reputation because they have the potential to cause some nasty side effects. However, only 2% of the topical steroid is absorbed, and if you use it safely it can bring a lot of relief to your child. It is important to use the ointment sparingly (apply only a pea-size per affected area), apply only once a day, limit the duration of strong steroids to 14 days, use the weakest effective ointment, be careful in the face and skinfolds as these areas are more prone to side effects. Long term use of strong steroids may cause a steroid-crisis because the body stops making its own steroid-hormones that are vital in times of illness / surgery / injury.

Common side effects can be thinning of the skin (atrophy), small red / purple spider-veins (telangiectasia) or stretch marks may develop in the affected area or the steroid can irritate the skin causing a contact dermatitis.

Once you have control of the acute flare, it is important to maintain the control by using emollients consistently and in moderate / severe eczema you can also use intermittent topical steroids for 2 days in a week to minimise the side effects.

Sometimes it may be necessary to give a short course (3 days) of oral steroids to get control of a severe eczema flare, but this should be the last resort!

Topical calcineurin inhibitors
This is a relatively new class of treatments that are very expensive. Tacrolimus ointment (Protopic) / Pimecrolimus cream (Elidel) are effective to manage eczema and it has fewer side effects, but it does not work as quickly as steroids. It is better to use in sensitive areas such as the face and groin in children over 2yrs. There are still some concerns about long-term use (possible link to cancers later in life, this is still being investigated) and it is thus mostly used as a second line of therapy for children who does not respond to topical steroids.

Relieving itching
It is important to relieve itching as this is usually the most bothersome symptom and keeps children awake at night. Scratching also worsens the eczema lesions, so keep finger nails short!

Oral antihistamines such as Hydroxyzine (Atarax) may cause drowsiness which will improve sleep. Cetirizine (Zyrtec) can also be used.

Wet dressings/wraps (the topical steroid and emollient is applied under a wet gauze covered with a dry dressing) is very effective to soothe and hydrate the skin, loosen crusts, reduce itching and prevent scratching.

Alternative treatments:

  • Probiotics – research shows a small reduction in the symptoms which is not statistically significant. No serious side effects were noted so it may be worth it to test it in your child.
  • Melatonin – In two small randomized trials, melatonin supplementation reduced disease severity and improved sleep in children with eczema. Melatonin is a hormone and as such has its own risks and side effects. Please discuss with your doctor

Prevention of Eczema:

  • Use of emollient therapy from the first week of life has proven to reduce the risk of developing eczema before 1yr of age. This is a safe, cost-effective measure to use if you know your baby may be at risk.
  • Use of probiotics in the mother and the baby may prevent the development of eczema but more studies are necessary. This is also a relatively safe precaution to take.

Life with a child with eczema can be hard, but if you stay positive, build treatments into a fun routine and walk this road with your health care provider, there is light at the end of this tunnel.

Worry does not empty tomorrow of its sorrow. It empties today of its strength.

Corrie ten Boom

Pediatrics and Playdough & Medicine Mommy

Resources:

  • Miller DW, Koch SB, Yentzer BA, Clark AR, O’Neill JR, Fountain J, Weber TM, Fleischer AB Jr; “An over-the-counter moisturizer is as clinically effective as, and more cost-effective than, prescription barrier creams in the treatment of children with mild-to-moderate atopic dermatitis: a randomized, controlled trial.”; J Drugs Dermatol. 2011;10(5):531
  • Coondoo A, Chattopadhyay C; “Use and abuse of topical corticosteroids in children”; Indian J Dermatol. 2014 Sep-Oct; 59(5): 460–464.
  • Michail SK, Stolfi A, Johnson T, Onady GM ; ”Efficacy of probiotics in the treatment of pediatric atopic dermatitis: a meta-analysis of randomized controlled trials.”; Ann Allergy Asthma Immunol. 2008;101(5):508.
  • Chang YS, Lin MH, Lee JH, Lee PL, Dai YS, Chu KH, Sun C, Lin YT, Wang LC, Yu HH, Yang YH, Chen CA, Wan KS, Chiang BL; “Melatonin Supplementation for Children With Atopic Dermatitis and Sleep Disturbance: A Randomized Clinical Trial.” JAMA Pediatr. 2016;170(1):35
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