Childhood Atopic Eczema

Your QuestionsAnswered...

Contents Page

Your questions answered 1

Basic questions 1

Treatments 6

Emollients 6

Topical steroids 10

Topical immunomodulators 13

Antihistamines 14

Paste bandages and wet wraps 14

Treating infection 15

Additional treatments 16

Complementary therapies 16

Diet, breastfeeding and weaning 17

Diet 17

Breastfeeding and weaning 18

Practical advice 19

Home, school and play 19

Further information and support from the National Eczema Society 24

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Childhood atopic eczema

Your questions answered

When a child is first diagnosed ashaving atopic eczema, parents andcarers often have a whole range ofquestions they would like to ask, butas we all know, there is rarelysufficient time to ask them.

For over 40 years, the NationalEczema Society’s helpline has beenproviding information and advice toparents and carers of children witheczema. During this time the type ofthings we are asked about hasremained very much the same: carerswant more information about thecondition itself, treatments, ideas forhelping their child feel morecomfortable, and advice on diet,sleeplessness, itching and infection.

Childhood Atopic Eczema aims to givethe answers to some of the mostcommon questions.

Basic questionsMy doctor has diagnosed myson as having atopicdermatitis. Is it the same asatopic eczema? What does‘atopic’ mean?The words ‘dermatitis’ and ‘eczema’mean the same thing. The word‘atopic’ means ‘out of place’. It is aword used to describe a group ofconditions which include eczema,asthma and hay fever.

Atopy, or any atopic condition, iswhere the body’s immune systemoverreacts to things that would notnormally do any harm – oftenenvironmental factors that are allaround us. For many children,especially those with more severeatopic eczema, the skin is alsoaffected by genetic changes. Oneexample is filaggrin, a structural

Eczema Helpline: 0800 0891122(Mon-Fri 8.00am to 8.00pm)Email: helpline@eczema.orgwww.eczema.org

protein in the skin that actsdifferently in atopic eczema, resultingin a defective skin barrier. This causesthe skin to be very dry and allowsentry to triggers – irritants (e.g. soaps,fragrance, detergents) and allergens(e.g. animal dander, house dust mitedroppings and pollens) – which makeyour child’s skin inflamed and itchy.

What is it like to havechildhood atopic eczema?Atopic eczema is a dry skin conditionthat may be red, sore and dry. Its chiefcharacteristic is the ‘itch’, which attimes can become almost unbearable,causing a child to want to scratchconstantly, especially at night, therebyinterfering with sleep. If a child hasmoderate to severe atopic eczema,they may have red patches of skin(inflammation) and scratch until theirskin bleeds. However, since the skin isvery dry, it can also crack and bleed ofits own accord. Any cracked, raw orbleeding areas are especiallyvulnerable to infection.

Atopic eczema usually appears duringthe first few months of life, oftenstarting on the face and scalp. It canbe present on any area of the body,but in white children it usually affectsthe skin creases, neck, back of kneesand inside of elbows. There may alsobe roundish, 50p-shaped areas ofeczema, known as ‘discoid eczema’.

Children from Asian, African or Afro–Caribbean families often havedifferent patterns to white children

with eczema. These include eczemaaround the front of the knees and theback of the elbows (called the ‘reverseflexural pattern’) as well as in thecreases, as seen on white skin. Apapular pattern, which appears as finebumps over the chest and tummy, isalso common.

Eczema usually presents with dry skinbut it can also be wet and weepy andthere may be small blisters. Please seepages 15–16 for information onrecognising and treating infection ineczema. If a child has infectedeczema, it may be very red and weepyand there may be small blisters.

If the eczema has been persistent, theskin may feel and look thickened inareas where there has been lots ofrubbing and scratching. There may becracks and splits, which can be verypainful, especially on the hands,making it difficult to hold a pen orpencil.

Atopic eczema can vary in severitybetween different children. Somechildren have dry skin and eczemathat can be kept under control withsimple treatments, while others mayneed a variety of more complextreatments. You will get to know whatyour child’s eczema looks like, whattreatments will be needed for flares(when the skin becomes hot, inflamed,itchy and sore) and when your childneeds to visit a healthcareprofessional. However, if the eczemagets worse or looks different, youshould always ask for medical help.

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Is there a cure for atopiceczema?Unfortunately, at present there isn’t,but it can usually be well managed,allowing the majority of children tolead a normal life. The nature ofeczema is a cycle of controlledeczema and ‘flares’.

Why does my child haveeczema?Hereditary factors seem to play arole in the development of childhoodatopic eczema. There is often afamily history of eczema, asthma orhay fever, but this is not always thecase. There are also manyenvironmental factors that may playa role. These often include climate,temperature, house dust mites andpollen, as well as individual triggers.

What are the most commontriggers and how can I avoidthem?Triggers are environmental factorsthat might cause a child’s eczema to

worsen or ‘flare’. These vary fromindividual to individual and it can bedifficult to identify them as theymight not trigger an immediate ornoticeable reaction. Some of themost common triggers are:

l Soap and water – Avoid normalsoap, and also plain water, whichcan further damage the alreadydefective skin barrier in peoplewith eczema, causing the skin tobecome dry and irritated.

l Fragrance – Watch out forfragrance, whether in the formof liquid, powder, paste orairborne.

l Temperature – Being too hot ortoo cold or going from onetemperature to another cantrigger a bout of itching. Manychildren with eczema get hotquickly, so dressing in thin layerscan help. Also try setting yourcentral heating thermostat lowat around 18°C. You may besurprised at the difference thismakes. Meanwhile, familymembers without eczema canalways wear an extra layer!

l Sweat – Aside from avoidingbecoming hot and sticky, cottonclothing can be helpful.

l Wet and messy play – E.g. sand,water, paint, clay, some foodsand items on the nature table atschool. Hands should bemoisturised before these kinds ofactivities, then washed with asoap substitute and moisturised

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with emollients (see page 6)afterwards. PVC gloves with acotton glove liner can help.

l Clothing – Wool and syntheticmaterials can be particularlyuncomfortable. 100% cotton,bamboo or silk garments worn underabrasive materials are best. Avoidgarments with seams or labels thatcan chafe, or cut labels out.

l Pollen – If your child’s eczema isaffected by pollen, it is advisableto keep the windows closed in theearly mornings and evenings whenpollen levels are highest. A liberalamount of emollient applied tothe skin half an hour before yourchild goes out (see page 21 foradvice on using emollients andsunscreen) will help to provide abarrier against pollen when yourchild is outside, and washingafterwards will remove any pollenparticles that have stuck to theskin or hair. Long sleeves andtrousers, a hat and sunglasses, andavoiding bare feet and open-toesandals will offer furtherprotection. You can use a weatherforecasting app to predict thelikely pollen count.

l House dust mites – House dustmites are present in all homes andit is impossible to eradicate them.They thrive in warm, moistenvironments, particularlymattresses. House dust mitedroppings can exacerbate eczemaand 80% of children with eczemaskin prick test positive to them, so

may be allergic to them. Washingclothing and bedding at 60°C killsthem. For more tips, see page 19.

l Animals – If you have pets, makesure they are kept away from yourchild’s bedroom. Animal dander,saliva and fur can all be irritants,so make sure you clean roomsregularly and that your childwashes their hands after strokingor handling animals.

l Food – A few children have foodtriggers for their eczema, the mostcommon being egg, nuts, sesameand cow’s milk. Generally a foodallergy is identified before a childis 2 years old. It is important forchildren to have a good, balanceddiet.

l Damp and mould – Spores fromrotting vegetation and mould inbuildings can cause a reaction insome children with eczema.

l Swimming pools – Chlorine andother chemicals added toswimming pool water can have anadverse effect on the skin, soalways apply a protective layer ofemollient about 30 minutes beforegetting into the water. Showerwell and apply more emollient onleaving the pool.

Is childhood atopic eczemacommon?Childhood atopic eczema is verycommon and has increasedsignificantly in the last 50 years. Itnow affects 15–20% of UK children.

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My child has a problem withlight and dark patches of skindue to his eczema. Why is this?Some children with eczema developround or oval pale patches thatappear when the redness caused by aflare has settled. This is a normalsymptom of eczema called pityriasisalba. It affects children of all skincolours. Skin colour should graduallyreturn to normal, but the patches canpersist for 2–3 years.

The skin of African, Afro-Caribbeanand Asian children affected byeczema has areas of light and darkskin shades (which are pigmentchanges). The dark patches areusually active areas of eczema, whichmay also be red. The lighter patchesoften occur when your child’s eczemais clearing (and may also be pityriasisalba, as described above). Thesepigment changes may be seen on theskin for several months as they take along time to settle down. Eventuallynormal skin pigment should return.

Can children ‘catch’ eczemafrom a child who has it?No! Eczema is not contagious.

Will my child grow out ofeczema?Eczema improves for most children,as they get older – about two-thirdsare clear by puberty – but they maybe left with dry and sensitive skin.Some children continue to haveproblematic eczema throughout life

while others may find that theireczema goes away sometime duringtheir childhood, only to come back inadulthood. There is no way we canpredict the natural course of yourchild’s eczema – the important thingis to take and keep control of it.

I already have one child witheczema. What is the risk ofmy next child also havingeczema?If you already have one child witheczema, there is a 25% chance thatyour next child will also have it. Therisk increases if one parent haseczema, and it increases still further ifboth parents have the condition.However, if the first child has hadmoderate or severe eczema, it doesnot necessarily mean that the secondchild will also have eczema, or to thesame degree. Eczema varies in severityfrom mild to severe and it is quitepossible for two children from thesame family to have different degreesof eczema or for one child to haveeczema and the other never toexperience the condition.

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TreatmentsEmollientsMy child has been prescribedemollients, but I am not clearabout how often to use them.Most children with atopic eczemahave dry skin. The skin does notproduce enough fat and oils and losestoo much water, so it becomes dryand cracked. This is due to a defect inthe skin barrier. (A simple way tounderstand this is to think of skinwith eczema as a dry stone wall andskin without eczema as a recentlycemented brick wall.) The regular useof emollients (medical moisturisers,which you can get on prescriptionfrom your GP, nurse or health visitor)is essential to constantly repair theskin barrier and to help prevent thisdryness. You will need to replace thegrease and treat dry skin withemollients on an ongoing basis. Inother words, you must use them evenwhen the skin looks good, as this willhelp prevent further ‘flare-ups’ ofeczema and help to keep theimportant skin barrier intact.

Emollients are medical moisturiserswhich come as ointments, creams,lotions, gels and sprays to be left onthe skin, and as washes and bathoils/shower gels to be used as soapsubstitutes.

You should apply leave-on emollient(see opposite) every 3–4 hours ifpossible, depending on the type being

used (e.g. ointment, cream or lotion)and the dryness of your child’s skin.Creams, lotions and gels need to beapplied more frequently thanointments (sprays are ointment-based).

Soap substitutes (which may beemollient wash products or leave-onemollient used as a soap substitute)should be used every time your childwashes their hands or body. Your childshould not use ordinary soap orbath/shower products as thesecontain soap-based chemicals, andoften fragrances, which dry andirritate the skin. Using water alonewill make the skin dry out and shouldtherefore be avoided. After pattingthe skin dry with a soft towel, yourchild should then immediately reapplytheir leave-on emollient.

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In some situations, such as coldweather, or mealtimes in the case ofbabies and small children, eczema canget much worse on the face andhands, so apply plenty of leave-onemollient in advance to protect theirskin. Always apply emollients about30 minutes before swimming, andthen shower and reapply afterwards.

Ask your doctor, nurse or healthvisitor to prescribe large quantities ofemollient at a time – a child withatopic eczema will need to use about250g of leave-on emollient per week(or up to 500g/per week for a biggerchild), and more if the eczema issevere. When you find an emollientthat your child likes and that suitstheir skin, ask for it to be on repeatprescription and in large amounts (e.g.a 500g pump or tub and a 200mlbottle for wash products) so you neverrun out. Small dispensers or tubs arealso useful for taking to school andwhen you are out and about. Largepharmacies sell smaller emptydispensers and tubs.

Which emollients should Iuse?As mentioned above, emollients comein the form of ointments, creams,lotions, gels and sprays, which are lefton the skin, known as leave-onemollients, and as bath/showerwashes, which are used for washingand rinsed off. Local healthauthorities often have a shortlist ofemollients selected for doctors andnurses to prescribe from. Ask your GP

surgery for the local prescribingguidelines.

Ointments are the greasiest type ofemollient. They contain fewerpreservatives than other emollientsand do not require stabilisingadditives, which creams, gels andlotions do. (Preservatives andstabilising ingredients can cause anirritant or allergic reaction in somechildren.) Ointments come in tubs oras sprays. They can give a good sealon the skin and are excellent atrestoring barrier function to the skin.They do make clothes oily, but theyare a good choice for bedtime andwhen not wearing special clothes.

Understandably, many parents preferto be prescribed a cream for theirchild, which is lighter and is absorbedmore quickly into the skin. Gels aresimilar in consistency to creams.

Lotions are the lightest type ofemollient. They are good for areas ofinfected eczema or for very hairyareas, such as scalps or under thearms.

If your child has moderate to severeeczema, the solution may be to use acream during the day and anointment at night.

Some emollients contain addedingredients, such as the humectantsurea or glycerol (natural moisturisingfactors), anti-itch and anti-bacterialadditives. Creams and lotions mustalso contain preservatives andstabilising additives (to keep the oil

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and water mixed), which in a fewchildren can cause an allergic orirritant reaction, but preservatives areall essential for product safety andpreventing contamination.

Most emollients are available onprescription for children and can alsobe bought from chemists. Your doctor,health visitor, nurse or pharmacistshould be able to advise you. Thesecret is to find those which suit yourchild, and this can only be done bytrial and error. It is quite possible thatyou will find that a combinationworks best – for example, a greasierointment where the skin is very dry,and a cream or lotion if the eczema isa bit weepy. Try to use any newemollient for at least a month unlessyou can see it is making the eczemaworse. It is a good idea to patch anew product on a small area ofeczema-free skin every day for 5 daysand check for signs of an allergic orirritant reaction. If the skin reacts,stop using the product.

*You can contact the National EczemaSociety for a list of emollient productsbroken down into the different types.

My daughter says that hercream stings when I put it onher – could she be allergic to it?Some children have sensitive skin andcomplain of stinging or itching whenthey have their cream put on. Thisoften happens when their skin is verydry, but the feeling should go awayafter a few minutes. If it does, this is

a sign that it is not an allergy. Evenso, you might like to try to find anemollient which doesn’t cause thissensation as then your child will bemuch happier using it.

A few children may have a skinreaction to the preservatives used increams and lotions, in which case youneed to change which ones you use orswitch to an ointment instead.Ointments contain fewerpreservatives. Examples of ointmentsthat do not contain any preservativesare 50% liquid paraffin in 50% whitesoft paraffin, white soft paraffin BP,yellow soft paraffin BP, Diprobaseointment, Zeroderm ointment andHydromol ointment.

Aqueous cream has been found tocause stinging in some children witheczema. This was the subject ofresearch and it was found that theculprit could be a ‘soaping agent’called sodium lauryl sulphate (SLS),which is present in the cream. Furtherresearch shows that SLS weakens theskin barrier. Several emollients have

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been reformulated in recent years toremove SLS, and most emollientsavailable on prescription in the UKdon’t contain it.

How do I apply the leave-onemollient?Apply large ‘dots’ or ‘blobs’ of theemollient on to the skin generously afew centimetres apart and thensmooth it in, using gentle downwardstrokes in the direction of hairgrowth. Never rub it in, as thickemollients sometimes block the hairfollicles in the skin, which may causea mild inflammation or infection ofthe affected hair follicles. There isgood evidence that less topical steroidmay be needed if the skin is regularlymoisturised.

If you use pots, decant the cream orointment with a spoon beforeapplication to avoid contaminatingthe product with your fingers. If usingcreams, a good alternative is to usepump dispensers.

Bandages and clothing in contact withointments (paraffin-based products)are easily ignited with a naked flameor cigarette, so please avoid your childgoing anywhere near naked flames orcigarettes.

I have been told to use a soapsubstitute. Will my child beproperly clean?Ordinary soap and bubble bathsdegrease the skin and damage the

skin barrier, leading to drying out ofthe skin. You should also not washyour child with water alone, as watercan be very drying.

Soap substitutes are used with waterand will clean the skin just as well assoap. A soap substitute may be anemollient wash product or your child’sregular leave-on emollient. To useleave-on emollient as a soapsubstitute, simply apply it to yourchild’s skin and then rinse it off. Bathoils can also help cleanse the skin.

What about bathing?Daily bathing is considered optimalfor most children with eczema.Bathing should be for less than 20minutes, as after this time the skinbecomes more fragile and subsequentscratching will cause more damage.

The bath water should be warm butnot hot – if the water is too hot thismay trigger itching. Never use bubblebath as it can be very drying andirritating to some skins. Also, do notwash your child with water alone –plain water can be very drying to theskin. Instead, apply your child’smedical moisturiser all over their bodybefore they get into the bath andthen simply let them soak and rinseoff in the bath. As an alternative tobath oil, add a tablespoon ofemollient to the bath as you fill it. Theoil and water mix will clean the skinas well as coat it with a film of oilwhich traps water and prevents theskin drying out.

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Emollients can make the bath slippery,so be sure to use a bath mat andclean baths and showers daily toprevent accidents and the build-up ofgrease. White vinegar is a goodcleaning product for the bath.

After bathing, pat the skin dry with asoft towel and reapply the leave-onemollient.

Can my child shower insteadof bathing?Generally, bathing is recommended, asimmersing in an emollient bath is agood way to help moisturise andcleanse the skin. If you do not have abath or prefer other methods ofwashing, it is acceptable to applyemollients and then rinse them offusing a shower or a bucket of waterand a scoop, for example. Youngerchildren may also be ‘bucket bathedand rinsed’. Water used for showeringand rinsing should be warm but nothot. Ordinary shower gels should beavoided as they can be very dryingand irritating to some skins; instead,use emollient shower or washproducts or a leave-on emollient as asoap substitute – but take care asthey can make the shower floor veryslippery.

After washing or showering, pat theskin dry with a soft towel and reapplythe leave-on emollient.

*The National Eczema Society’sfactsheet on emollients gives furtherinformation about emollients and howto use them.

Topical steroidsWhat are topical steroids andare they safe (I heard thatthey thin the skin)?Topical steroids are treatmentsapplied to the skin to treat eczema; ifused correctly, they are safe andeffective. The human body producesits own steroids and these keep anyswelling, redness and inflammation incheck. The steroids that are used totreat eczema are very like the onesthat the body produces.

Topical steroids come in the form ofcreams, ointments, gels and tapes.They have a generic (drug) name anda product name, and in the UK comein four different strengths (mild,moderate, potent and very potent) –for example, hydrocortisone is mild,Eumovate is moderate and Betnovateis potent (check the patientinformation leaflet or ask thepharmacist if you are not sure). Thechances of any side effects occurringincrease with the strength of thesteroid.

Topical steroids have been around forover 50 years. In the beginning theywere used on children in much greaterquantities and potencies than theywould ever be used today. Much ofthe current concern about skinthinning is based on history ratherthan on how children are treatedtoday. Dermatologists will prescribetopical steroids at the correctstrengths and quantities, taking intoconsideraton how severe the eczema

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is, how long the topical steroid will beused for, the age of the child and theareas of skin affected, to ensure thatskin thinning does not occur, so thisproblem is very rare nowadays.

Parents and carers who do not use theprescribed topical steroid because offears of skin thinning, mayunwittingly be prolonging theinflammation of the skin and causingneedless distress to the child.Scratching and rubbing are almostinevitable if eczema is left untreatedand both can cause long-termdamage to the skin.

My doctor has now prescribeda moderately potent steroidfor my child, but previously Iwas given hydrocortisone,which is very weak. Can youexplain why?Eczema flares can be treated withprescribed topical treatments, whichwill be used to reduce theinflammation (redness). The choice ofprescribed treatment – e.g. topicalcorticosteroids and/or topicalcalcineurin immunomodulators (seepage 13) – will depend on your child’sage, the area of skin affected and howsevere the eczema is.

Eczema can vary in its severity.Hydrocortisone is usually all that isneeded for babies and children withmild atopic eczema, but for thosewith moderate to severe eczema astronger topical steroid may beneeded. Doctors may decide to startwith a weak topical steroid and, if

that does not clear the eczema, moveup to a moderately potent topicalsteroid. Alternatively, the doctor mayprefer to ‘hit’ the eczema with amoderate topical steroid first andthen, once the inflammation is undercontrol, move down to the weakerhydrocortisone to clear the skin.

Either way of treating theinflammation is correct. However,using a topical steroid that is tooweak should be avoided, as theeczema will not clear and your child’sdiscomfort will be prolonged. It alsomeans that in the long run you willend up using more topical steroid.Prompt short-term treatment with theright topical steroid is key.

How do I apply the topicalsteroid?Topical steroids should be applied asinstructed. This will usually be once a Page 11

day, only to the areas of inflammation(i.e. the areas of active eczema). Applyas a thin layer and in smooth,downward strokes. The surface of theskin should ‘glisten’ once the topicalsteroid has been applied. Anothermethod of applying topical steroids isthe fingertip unit (FTU) application,which is described below.

How much topical steroid do Ineed to use?The amount of topical steroid neededis measured in grams. This can bedone by squeezing a strip of cream orointment along the length of the endjoint of an adult’s forefinger. Thisamount is equivalent to half a gram(0.5g), or one fingertip unit, which

will treat an area about the size oftwo flat adult hands with the fingerstogether.

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Do I put both moisturiser andtopical steroid on the areas ofinflammation at the sametime? If not, does it matterwhich I put on first?It is important that you leave a gap –ideally 20–30 minutes – betweenapplying the two treatments so thatthe steroid is not diluted by theemollient. There are no set rules aboutwhich to apply first, i.e. emollient firstand steroid second, or vice versa. Themost important thing is to alwaysleave a time gap between applications.However, do not worry if your doctoror nurse recommends putting on thesteroid first – both methods arecorrect, so long as you leave a gap.

*The National Eczema Society’sfactsheet on topical steroids givesmore information about the differenttypes of topical steroids and how touse them.

Topical immunomodulatorsI have heard about Elidel andProtopic – what are they?Elidel and Protopic are the tradenames for Pimecrolimus cream andTacrolimus ointment. They are topicalcalcineurin immunomodulators (TCIs),also known as ‘topical calcineurininhibitors’. They are prescribed forchildren and adults as an alternativeto topical steroids, especially whenthe eczema is not being adequatelycontrolled by topical steroids or onareas of the body where the skin is

very delicate, such as the face, neckand groin areas.

In addition, TCIs can be used twiceweekly for maintenance treatment.TCIs are licensed for children over theage of two years, but younger childrenmay have them prescribed ‘off licence’by dermatologists.

There are no concerns about skinthinning with TCIs. However, they dohave some side effects, such as skinirritation and burning sensations. Theyalso increase sensitivity to the sun.Clinical trials have shown them to besafe in the short to medium term, butas they are newer treatments thantopical steroids, having been usednow for 18 years, it will be a littlewhile before we know if they haveany long-term side effects.

*The National Eczema Society has afactsheet on the TCIs Elidel cream andProtopic ointment.

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AntihistaminesCould antihistamines help mychild?Antihistamines do not actually treatthe itch, as eczema – unlike urticaria(known as skin hives) – is not causedby histamine. However, your doctormay prescribe sedating antihistaminesfor your child to help them sleep atnight. These are meant to be used for ashort time when the eczema has flaredup, and not as a long-term measure.Antihistamines should be given to thechild at least half an hour beforebedtime, so that they are not sleepy inthe morning. Antihistamine creams arenot effective for treating eczema (theycan cause a contact allergic reaction).

Paste bandages and wet wrapsWhat bandages can be usedfor my child’s eczema?Bandages are not in themselvestreatments or a cure for eczema. Thebandages used in eczema areimpregnated with a paste containingzinc oxide or zinc oxide andichthammol, which are soothing,cooling and relieve irritation. Pastebandages are particularly helpful forrough patches of eczema where theskin is quite thick (calledlichenification). They are messy, so asecondary bandage is needed to coverand secure the paste bandage. Theycan be used for entire limbs orpatches of eczema (for example,wrists and ankles).

What are wet wraps?Wet wraps use viscose tubularbandages or ready-made garments.They provide a protective, comfortinglayer and prevent damage fromscratching. Wet wrap bandaging iswhere two layers of bandaging areput on over a layer of emollient. Thefirst layer is a wetted bandage andthe second (outer) layer is dry.

If your doctor or nurse recommendsbandages for your child, make surethey teach you how to apply them.

Wet wrapping and bandaging can bevery time-consuming and need agreat deal of commitment on the partof the parent or carer.

How do wet wrap bandageswork alongside eczematreatments?Wet wraps, bandages and garmentshinder scratching, help the skinabsorb the creams and ointments,cool the skin’s surface and reduceitchiness, preventing skin damage.They are prescribed for children who

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have moderate to severe eczema,especially those who have severeeczema with abnormal reddening,flaking and thickening of the skin.They are particularly helpful when puton at night as they can help the childto sleep and prevent them scratchingwhile asleep. Wet wraps are a verygood way of controlling the eczemaquickly. However, if a topical steroid isused under the bandages, more of thesteroid is absorbed, so using steroidsunder wraps or garments shouldalways be medically supervised. Wetwraps can be used without topicalsteroids longterm to maintain theskin. Wet wraps are not necessary forchildren with only mild eczema. Theyshould never be used on infectedeczema.

*The National Eczema Society’sbooklet Paste Bandages and WetWraps has lots of advice and tips,including step-by-step instructionsfor bandaging and wrappingtechniques.

Treating infectionHow can I tell whether mychild’s eczema is infected?The skin barrier in eczema iscompromised (or not as effective asskin without eczema). This, as well asbreaking the skin through scratching,makes it very easy for germs to getinto the broken areas. Scratchingcreates further damage and allowsmore bacteria to enter the skin.

Infection can cause the skin tochange, making it look more red, itchyand swollen and may even cause it toweep and form a yellow crust. Theskin may also feel hot to the touchand may be more difficult to controlwith your usual treatments.

If you think your child’s eczema maybe infected, you should see your GP assoon as possible.

Infection of atopic eczema is usuallywith a bacterium calledStaphylococcus aureus, which makesthe eczema worse and slower to healin some children. Staph. aureus hasbeen found in greater numbers on theskin of patients with eczema than skinwithout eczema.

Bacterial infection of atopic eczemain smaller areas can be treated withantibiotics, in the form of a cream,ointment or lotion. A doctor mayprescribe a cream which combines asteroid (to damp down inflammation)with an antibiotic. Alternatively,particularly if the infection iswidespread, antibiotics to be taken bymouth may be prescribed.

Children with atopic eczema may alsohave fungal infections, such ascandida (thrush) and tinea (known asathlete’s foot, although it can affectany area of the body), and a yeastinfection (malassezia). Fungalinfections usually affect only one partof the body and are red and slightly

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scaly. They are treated with anti-fungal creams and sprays, and veryoccasionally tablets.

Viral infections seen in atopic eczemainclude molluscum and eczemaherpeticum. Molluscum appears onthe skin as white pearly noduleswhich gradually disappear overseveral months. This is a harmlessviral infection which is common intoddlers and children of primaryschool age, but is likely to be morewidespread in children with eczema.Occasionally, it can take many monthsto clear. Eczema herpeticum can becaused by the cold sore virus andspreads very quickly in atopic eczema.It makes you feel unwell and the skinwill be sore and tender. Eczemaherpeticum is potentially life-threatening, so if you think your childmay have it, you should seek urgentmedical advice.

If your child has several infections ina short period of time, a skin swabmay be taken to identify thebacterium or virus which may be

causing the problem and to ensurethat your child receives the correcttreatment.

Additional treatmentsI am following all theinstructions my GP anddermatologist have given me,but my child’s eczema showsno sign of improving. Arethere any other treatments Ican ask about?There are a number of othertreatments available to treat moresevere atopic eczema which cannot bemanaged just with the treatmentsreferred to earlier in this booklet.These include steroid tablets, UVBlight treatment, Ciclosporin,Azathioprine and Methotrexate. Thesetreatments are usually only prescribedby a dermatologist.

Complementary therapiesCan you please advise meabout complementarytherapies for treatingeczema?Although complementary therapiesare not a cure for eczema, some canbe helpful. However, what benefitsone person may not necessarily helpanother. You should let yourdoctor/nurse know if you are thinkingof trying any kind of complementarytherapy, and you should not suddenlystop using the treatment prescribedby them.

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Safety is also a consideration. Peopleoften think that because a cream orproduct is labelled ‘natural’, it is safeto use. Herbal remedies can havepowerful, and even dangerous, sideeffects. In addition, some homeopathycreams and Chinese and Africanherbal creams have been found tocontain potent topical steroids andeven life-threatening ingredients (e.g.arsenic). If you want to try acomplementary therapy, make sureyou go to a properly registeredpractitioner and check that theproduct you are given has aningredients list on the pot or tube. Askin advance how much the treatmentcourse is going to cost.

*The National Eczema Society has afactsheet giving more informationabout complementary therapies.

What about Chinese herbs?Scientific trials have found that Chineseherbal medicine may sometimes beuseful in treating severe atopic eczemawhere conventional treatments havefailed. Unfortunately, most of thescientific trials have been with oneproduct, Zemaphyte, which is no longermanufactured. The general benefits andrisks of Chinese herbal medicine aredifficult to assess, because a herbalistusually makes up a differentcombination of herbs for eachindividual. There have been cases ofliver or kidney damage resulting fromChinese herbal medicine, so talk to yourdermatologist or GP first and haveregular blood tests to check for earlysigns of possible liver damage. Because

of the potential risks with liverfunction, Chinese herbal medicines arenot advised for children under 5 years.Again, it is important that you go to apractitioner who is properly registered.The Register of Chinese Herbalistswww.rchm.co.uk can help you findsomeone in your area.

Diet,breastfeedingand weaningDietI think my daughter is allergicto something she is eating,which is making her eczemaworse. How can I find out?We still do not know enough aboutthe role of diet in eczema. Manyparents and carers believe that theirchild’s eczema is caused by somethingin their diet; however, researchsuggests that children with eczemahave a slightly higher chance ofhaving a food allergy but, for the vastmajority, food is not an associatedfactor. Food allergy is also much morelikely under the age of 2 years.

Keeping an accurate diary of whatyour child eats and of the condition ofthe eczema can be useful. Signs thatfood may be playing a role in a child’seczema include worsening of theeczema, itching or abdominal pain, ordiarrhoea. If the skin suddenlybecomes very red, itchy and swollen, Page 17

especially if the lips and breathing areaffected, urgent medical attention isrequired.

Talk to your doctor if you think foodallergies may be a factor. Some foodscan cause irritation, rather than anallergic reaction, around children’smouths. Never cut out important foodgroups (e.g. dairy products) withoutthe help of a state-registereddietitian, as children need adequatenutrients such as calcium for theirbones, teeth and growth.

I am giving my child soya milkinstead of cow’s milk but theeczema has not improved.What else can I try?Children who are allergic to cow’smilk are often also allergic to soyamilk. Sheep and goat’s milk, rice oroat milk are not suitable for childrenunder the age of 1 year as they arenutritionally inadequate. It is highlylikely that if a child is allergic to cow’smilk, they will also be unable totolerate sheep, goat or buffalo milk.

Should I put my child on aspecial diet?A child should not be put on a specialdiet unless their history is stronglysuggestive of a specific food allergy,or where there is widespread activeeczema which is not getting betterusing emollients and topical steroids.In general, restricting a child’s diet isof no benefit in older children withatopic eczema. In infants a 4–6-weektrial of egg and milk exclusion may be

recommended by your dermatologistor GP, if allergy is suspected. Adviceand supervision from a state-registered dietitian is essential.

Breastfeeding and weaningShould I breastfeed?Yes, if you can. Although there is noevidence that breastfeeding preventsthe development of eczema,breastfeeding does seem to have aprotective effect in relation to theseverity of eczema during the earlymonths of life. Where possible, youshould breastfeed until the baby is atleast 6 months old. Do not alter yourdiet as a breastfeeding mother unlessadvised to do so by yourdermatologist or allergy specialist.

How should I wean my baby?

The World Health Organizationrecommends that, whenever possible,breastfeeding should continue for thefirst six months of life.

Any infant with atopic eczema is atincreased risk of food intolerance, sointroduce solid foods one at a time insmall quantities so that the effects onthe eczema can be noted. Good earlyfoods to introduce are baby rice, purefruits, vegetable and potato purée.

It is recommended that infants areweaned from 6 months of age. Cow’smilk, egg, peanuts, tree nuts, sesameseed, mustard seed, soy, celery, lupin (alegume commonly used in France andMediterranean countries), sulphites (anagent commonly found in dried fruit),

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molluscs, wheat, fish and shellfish arefoods that have been identified asbeing the source of the majority ofadverse food reactions. They should beintroduced in very small amounts (e.g.½ teaspoon), and no more than oneallergenic food at a time. Ideally, allowat least 3 days between these foodgroups because it can take 3 days for anon-IgE allergy reaction to show. Allhigh-risk foods should have beenintroduced by the age of 12 months.

Whole nuts should not be introducedto any child, regardless of whetherthey have eczema, until after the ageof 5, as they can be a choking hazard.

If your baby is in a high-risk group forfood allergy, discuss with your GP anyconcerns relating to weaning.

Practical adviceHome, school and playHow can I get rid of housedust mites?House dust mites live unseen in allour homes. They are tiny creaturesfound in large quantities in itemssuch as mattresses, carpets and othersoft furnishings, and in surface dust.It is not the mites themselves that arethe problem but their droppings.When scratched into the skin they willworsen the eczema.

It is impossible to get rid of housedust mites altogether, but there are afew simple measures you can try.

l Wash clothes and bedding at 60°C.

l If your child has soft toys, you canput them in the freezer for 12hours to kill off the house dustmites.

l Replace old bed mattresses.

l Special mattress and pillow coversare available to protect againstthe house dust mites. (Make surethey cover the whole mattress/pillow.)

l Vacuum weekly includingmattresses and pillows.

l Damp dust all surfaces.

You can consider the following, butthey may not be effective for you:

l Keep soft furnishings to aminimum.

l Replace curtains in the child’sbedroom with plain roller blinds.

l Wooden, lino or resin flooring ispreferable to carpet, but for manypeople this may not be a practicalor financial possibility; it is notnecessary to make a change whena child has only mild eczema.

Does smoking affect a child’seczema?Cigarette smoke in an enclosed spacecan irritate the skin, so avoid smokingaround your child. Smoke outside thehouse and ask relatives and friends todo the same. For advice on stoppingsmoking, visit www.nhs.uk/live-well/quit-smoking

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My child’s eczema is muchworse in the winter – why isthis?It seems that people with eczemahave difficulty controlling their bodytemperature, which means that theycan feel heat or cold much more thanthe rest of us. Becoming hot andsweaty may make the itching worse,while cold weather will make the skindrier and more likely to crack andbecome sore. Problems with winterskin are further exacerbated bycentral heating and the lack ofhumidity in the home. In general,sunshine improves eczema in mostchildren.

Dress your child in layers, so that theycan take them off or put them on asnecessary. You may also need to usemore emollient in the winter to helpprevent the skin from drying out.

What sort of clothing should Ibuy?100% cotton or bamboo clothing isbest for a child with eczema, butsome children can also tolerate silkand smooth, modern man-madefibres, as it is the softness of thematerial that is important. Woolshould be avoided as it is ‘scratchy’and can irritate the skin. Nylon nextto the skin does not allow it tobreathe and so it, too, should beavoided. It can also help to cut thelabels out and to buy clothes with noseams as these can also irritate.

How should I wash clothesand bedding?There is no scientific evidence that anon-biological washing powder isbetter than a biological one, thoughmany people with eczema say thatthey prefer non-bio. Wash bedding ata temperature of at least 60ºC as thiswill kill off the house dust mite.Always rinse well, if possible with adouble rinse cycle, and avoid fabricconditioners, as these can irritate theskin. As emollient clogs up washingmachines, about once a month do anempty wash at a very hightemperature, using biologicaldetergent to cut through the grease.

My son has eczema and isrequesting a pet – should weget him one?It is advisable to spend time with ananimal before investing in one, to seewhether your child is allergic to theanimal in question. Visit friends withpets to see if your child reacts.

We already have a much-loved dog and my little girlwould be very upset if we gotrid of it - what can we do?The answer really depends on howbad your daughter’s eczema is. If shehas severe eczema and it is obviousthat being in contact with the dog ismaking the eczema worse, thenrehoming the dog may be your best

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option. If, however, she only has mildto moderate eczema, then try thesetips:

l Keep the dog out of yourdaughter’s bedroom.

l Put a cotton sheet over theanimal’s favourite chair andremove the sheet before yourdaughter sits there.

l Brush the dog regularly to removeany loose fur.

l Wash the dog’s bedding regularly.

l Vacuum more often.

(All the above points apply just asmuch to families who have a cat!)

Can I take my child swimming?The chlorine and other chemicals inswimming pool water can irritate theskin. Ensure that you put a thickmoisturiser, such as Epadermointment, Hydromol ointment or50/50 white soft paraffin/liquidparaffin, on your child 30 minutes to1 hour before they get into the pool.Alternatively, a sunscreen thatcontains silicone can be an effectivebarrier, but make sure your childdoesn’t react to it by applying it on apatch of skin with no active eczemafor 5 days. Shower thoroughly afterswimming and apply plenty of yourchild’s usual moisturiser. If the skin iscracked or sore, swimming is bestavoided until the skin has healed.

Bathing in the sea often helps eczema,but try it out carefully, especially whenthe skin is badly broken as the saltwater can really sting.

*The National Eczema Society has afactsheet on Swimming and Eczema.

We want to take a holiday inthe sun – are there specialmeasures we should take?Many people find that their child’seczema improves in the sun, but it isimportant to understand that forsome children the sun makes theeczema worse. All children need to beprotected from burning. Sunscreensare rather like emollients – sometimesit takes some trial and error to findone that suits. However, many peoplewith eczema find that mineral-basedsunscreens (containing titaniumoxide), which block out the sun, arebetter than chemical absorbers. If youcan, put on a little moisturiser half anhour before putting on a sunscreen asthis will prevent the sunscreenbecoming diluted by the moisturiser

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and will make sure that the sunscreenkeeps its protective ingredients. If youare using a moisturiser that is greasyor oily, be careful not to overdo theapplication of the moisturiser beforegoing out in the sun as this can causea ‘frying’ effect. A better solution maybe to buy a UV sun suit to minimisethe need for sunscreen.

Many children find that heat is a keyfactor in triggering their eczema.Covering up in light trousers and topswill not only protect against sunburnbut will help to keep them cool.Cotton and bamboo clothing are thebest materials for keeping a childcool. A wet T shirt can also be usefulto cool the skin, but take care in thesun and apply sunscreen underneathas wet material offers less UVprotection than dry.

*The National Eczema Society has afactsheet on Eczema and the Sun.

My daughter is alwaysscratching! What can I do tohelp?There are a number of things you cando to reduce itching and scratching:

l Encourage your daughter to askfor her leave-on emollient to beapplied if she starts to feel itchy.Keep cream-based emollients inthe fridge. Applied cold they canhelp more with itching.

l Have a regular skin care routine.

l After washing, pat the skin dryrather than rubbing it.

l Use cotton or bamboo clothingand bedding. (Wool can make theskin itch and synthetic materialstend to make the child feel hotand sweaty, also triggering theitch.)

l Avoid substances that can affectthe skin, such as soap anddetergents. Some people find thatnon-biological products causefewer problems than biologicalones.

l Wash clothes and bedding at60ºC to kill house dust mites, andset your machine for an extrarinse cycle. Do not use fabricconditioner.

l Try to distract her from scratching,e.g. with games that occupy herhands, such as cooking, playingcards, jigsaws, lego, etc.

l Try not to say ‘Don’t scratch’, butreward positive behaviour thathelps with the itching, such asgetting cold emollient from thefridge and applying it.

l Aim for a room temperaturebetween 16°C and 18°C. A warmerroom temperature may cause herto itch more.

l The bedroom should be cool andwell ventilated, but not cold.

l If you have pets, keep them out ofyour child’s bedroom.

l Encourage her to rub or pinch theitch gently, rather than scratch.

l Keep her nails short to minimisedamage to the skin.

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l Consider garments such as‘scratch sleeves’ at night.

*The National Eczema Society has abooklet called Itching and Scratching.

Does stress cause eczema?Stress alone does not cause eczema;however, it can make eczema worse.Equally, eczema is a cause of stress.Learning practical ways of copingwith stress can make it moremanageable. Try to identify whatcauses your child stress and work outways of avoiding or dealing withthese situations in advance.

My daughter is startingschool and I am worried hereczema will get worse when Iam not there to take care ofher. Have you any adviceplease?School or nursery should not presentproblems for the child with eczema iftime is taken to ensure that theteachers and nursery staff haveeczema explained to them and aregiven written information about it.

l Well before her first term,approach the school and ask for ameeting to be set up. Explain thatyour child has eczema anddescribe what things can be doneto manage her skin during theschool day. This will help theteacher to understand your child’seczema needs at school. Theschool nurse may also get involvedif a child has severe eczema and

other allergies. If you are at allconcerned, contact the schoolnurse.

l If the teacher can ensure that shedoes not have a desk in directsunlight or next to a radiator, thiswill help prevent her getting toohot and itchy.

l Provide the school with a pumpdispenser of her emollient.

l If your child has eczema on herhands, cotton gloves may have tobe worn during certain activitiessuch as wet and messy play.However, it is important thatchildren with eczema are helpedto lead as normal a life aspossible.

l Tell the school if your daughterhas to take sedatingantihistamines to help her sleep atnight, as sometimes they canmake a child a little drowsy firstthing in the morning.

l Getting a teacher to explain toother classmates about eczema,and that it cannot be caught fromsomeone, can be very useful andhelp them to understand andaccept the child.

*The National Eczema Society hasdeveloped a schools pack for teachers,parents and children called All AboutEczema – an information pack forschools.

Visit www.eczema.org for pdfversions or call the NES helpline for aprinted pack.

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More information than can be given ina booklet of this size is available fromthe National Eczema Society. We haveother booklets including:

l Itching and Scratching

l A Guide for Teenagers with Eczema

l Living with Eczema

Booklets can be ordered from ourwebsite or from our Helpline.

Website: www.eczema.org

Helpline: Telephone* 0800 089 1122(Monday to Friday 8am to 8pm) * Calls are free from UK landlines. Chargesvary from mobiles.

Email: helpline@eczema.org

We are proud of the wealth ofinformation available on our websiteand recommend you visit it wheneveryou need information. It is updatedfrequently.

Our confidential telephone and emailHelpline is at the heart of our work,providing information, support andreassurance to thousands of peoplestruggling to cope with eczema. Weare not medically qualified and do notdiagnose, prescribe, give medical

advice or opinions on treatmentsprescribed by your healthcareprofessional. We do, however, offer awealth of practical information aboutthe day-to-day management ofeczema and the different treatmentoptions available.

The Helpline is open to all UKresidents who are affected by eczema.Please allow five working days for usto reply to you if using email. We arenot able to answer queries from non-UK residents as terminology,healthcare systems and treatmentsmay differ in your country ofresidence, which may causeconfusion.

In addition, the National EczemaSociety publishes Exchange, a quarterly magazine packed with:

l articles on eczema management

l features by people with eczemasharing their experiences

l treatment and research news

l experts’ replies to your questions.

You can subscribe to Exchange for£20 p.a. at www.eczema.org or bycalling our membership team on020-7281 3553.

Further information and supportfrom the National Eczema Society

National Eczema Society11 Murray StreetCamdenLondon NW1 9RE

Eczema Helpline: 0800 0891122e-mail: helpline@eczema.orgwww.eczema.org

The National Eczema Society isregistered as a charity in England andWales (No.1009671) and in Scotland(No.SCO43669) and a company limitedby guarantee (No.2685083). RegisteredOffice: 11 Murray Street, Camden,London NW1 9RE.

The information in this booklet is only a general guide.Individual circumstances differ and the National

Eczema Society does not prescribe, give medical adviceor endorse products or treatments. We hope you will

find the information useful but it does not replace andshould not replace the essential guidance given by your

doctor and other healthcare professionals.

Booklet written by Sue Ward, former Information andEducation Manager, National Eczema Society.

Revised edition reviewed and updated in May 2018 byHelen Dennis, Dermatology Nurse Adviser to

the National Eczema Society.

Designed and produced by www.dewinter.agency

©The National Eczema Society 2018.

All rights reserved. You must have our writtenpermission to electronically or mechanically reproduce

or transmit this publication or any part of it.