The Itch Factor
Children with eczema struggle every day with painfully irritated skin -- but the right drugs can give many kids real relief.
Last year, 3-year-old Anthony Quear was covered with a red, scaly rash that kept him scratching all through the night. "I was up with him every two hours -- sometimes he'd scratch so hard that there'd be blood all over his sheets, and we'd both be exhausted and grouchy the next day," recalls his mom, Angela. She had to keep him inside on hot summer days, and he couldn't even go in the pool to cool off because the chlorine burned his irritated skin. "For a few months, I felt like taking care of his skin was a 24-7 job," says Quear.
Anthony has eczema, also known as atopic dermatitis, a disease that causes itchy, inflamed skin and often starts in infancy. It's estimated that 17 percent of children have eczema, and about one-third of them experience severe symptoms like Anthony's. "We're seeing more eczema in kids than ever before -- the incidence has more than doubled since the 1970s," says Parents advisor Amy Paller, MD, chair of dermatology at Northwestern University's Feinberg School of Medicine, in Chicago. And because many parents worry unnecessarily about the safety of the drugs that ease itching, their kids don't always get the relief they desperately need.
Eczema is more than just sensitive skin. "Normally, the skin should act as a barrier to environmental irritants such as dust, pollen, and animal dander, but when a child has eczema, his skin acts like a sieve that lets irritants pass through into his body," explains Adnan Nasir, MD, a dermatologist at The University of North Carolina at Chapel Hill and coauthor of Eczema-Free for Life. "These foreign substances cause his immune system to go into attack mode, triggering an itchy rash." In fact, scientists have pinpointed why some kids are more susceptible: They have a genetic condition that inhibits production of filaggrin, a protein that normally creates a protective layer over the skin's surface.
Although the disease tends to run in families, experts say one reason there's been a rise in eczema is the same reason there's been a rise in allergies: "Kids in Western societies aren't exposed to as many germs as they were 50 years ago," says Julie Schaffer, MD, director of pediatric dermatology at New York University. "If a baby's immune system is not busy building resistance to childhood infections, it may be more likely to overreact when she's exposed to harmless foreign substances." Not surprisingly, up to 80 percent of kids with eczema also have another allergy-related condition, such as asthma or hay fever.
Eczema usually begins on the scalp, forehead, ears, neck, cheeks, or in the crooks behind elbows or knees. However, the first signs of the condition in a baby may be as subtle as fussiness. "Technically, eczema is only the rash that's created by scratching, but infants don't yet know how to use their hands to scratch their itchy skin, so they can get eczema on their face and scalp from rubbing their head against linens or even their parents," says Dr. Nasir. If you notice that your baby is wiggling a lot, see your pediatrician. If he rules out other conditions like colic, consult with a dermatologist, who can examine your baby's skin for subtle signs of eczema. Older babies and children tend to have more classic symptoms: dry, scaly, red skin. Also, they're better able to describe the itchiness. It's important to get a diagnosis early, because your child can fall into a vicious cycle of itching and scratching that leaves her skin raw and painful.
Beneath the Surface
Last summer, Cindy Melvin's sons, Kendall, 12, and Coby, 4, didn't make it to the beach. They didn't play in their neighbors' yards, and they didn't get to go to camp with their friends. The boys have severe eczema that's aggravated by sweating and outdoor allergens like grass. "In September, we had a birthday party for Kendall outside," says Melvin, of Lakewood, California. "Halfway through, he started itching so badly that he had to go inside and watch the rest of his party from the kitchen window. He was devastated."
Stories like these make it clear that the impact of eczema is more than skin-deep. One study found that kids who'd had the condition for more than six months gave a lower rating to their quality of life than did kids with epilepsy or asthma. "Children with eczema usually have to learn to live with the discomfort of itching," says Sarah Chamlin, MD, associate professor of pediatrics and dermatology at Children's Memorial Hospital, in Chicago. "Their parents try to stop them from scratching, and it may become a power struggle. And since kids also have trouble sleeping, they're often irritable and unable to concentrate in school." Unfortunately, anxiety can also make symptoms worse.
Whether your child has mild redness or a scaly rash from head to toe, her doctor may prescribe different types of safe and effective drugs.
Topical corticosteroids. These over-the-counter and prescription medications reduce the inflammation associated with eczema. "Parents often panic because they associate the word steroids with performance-enhancing, muscle-building steroids, but those anabolic steroids are completely different from the creams we prescribe for eczema," says Helen T. Shin, MD, chief of pediatric and adolescent dermatology at Hackensack University Medical Center, in New Jersey. The creams mimic cortisol and hydrocortisone, two steroid hormones your body naturally produces to control inflammation. In fact, the biggest problem doctors often see with topical corticosteroids is that parents are reluctant to apply them to their child's skin when eczema flares up. "As a result, the eczema lingers and worsens so that a child eventually needs even more potent corticosteroids to get her symptoms under control," says Dr. Schaffer. With uninterrupted use over long periods of time, topical corticosteroids can cause side effects such as thinning of the skin and stretch marks. However, short-term daily use (for up to a month at a time) or long-term intermittent use (two days a week) hasn't been associated with these complications.
Immunomodulators. These newer topical anti-inflammatory medications, Elidel and Protopic, were approved more than five years ago for kids over age 2. Because they don't have the potential side effect of thinning of the skin that is associated with corticosteroids, they're particularly useful for fragile areas such as eyelids, armpits, and groin. However, many parents and doctors stopped giving children these topical medications when the FDA issued a black-box warning last year, citing evidence that the drugs increased the risk of lymphoma in animals. Both the American Academy of Dermatology and the American Academy of Allergy, Asthma and Immunology say the drugs haven't been shown to cause immune suppression or an increased cancer risk in humans. "The amount given to animals was up to 47 times higher than the maximum recommended dose for humans," says Dr. Paller. "But it seems like a lot of pediatricians have been scared away from using these valuable drugs."
Antihistamines. Over-the-counter drugs like Benadryl can help relieve itching because of their sedative effects, says Dr. Paller. "If you give your child an antihistamine before he goes to bed, he'll probably sleep better." However, if he's really itchy, he might still start scratching later during the night.
Although medicines play an important role in relieving symptoms, there are other crucial ways to prevent flare-ups.
Moisturizers. "They replace missing lipids and seal the skin off from external irritants," explains Dr. Shin. Apply one whenever your child comes out of the tub and after she goes swimming. Moisturizers can sting kids who have a bad case of eczema, so you'll have to experiment with different brands. The best over-the-counter choice: a thick ointment like petroleum jelly or Aquaphor. If your child complains that it feels too greasy, try an OTC cream such as TriCeram, which contains a natural oil found in the skin called ceramide. In the last few years, the FDA has also approved new prescription moisturizers, such as Atopiclair, which are made of fatty acids that form a strong barrier against the skin.
Taking baths. "Many parents mistakenly skip their child's bath because they are worried that the water will dry out his skin," says Dr. Nasir. However, bathing (for at least 10 minutes) actually keeps the skin hydrated and washes away germs that cause infections. Ideally, your child should take a bath and wash his hair right before bed, to get rid of any allergens or irritants that have accumulated on his skin or hair during the day. Bathing your child with oatmeal, such as Aveeno Bath, may also be soothing.
Comfortable clothing. Kids with eczema need to wear soft fabrics. "Cotton or light synthetic fabrics are more breathable than heavy fabrics or irritating wool," says Dr. Chamlin. "I advise parents to turn clothing inside out, when possible, so the seams and tags won't rub the skin." One new clothing line to try: DermaSmart, made of lightweight microfiber polyester. "The fabric also contains silver, which has anti-inflammatory and antibacterial properties," explains Dr. Paller. "There haven't been many studies of these clothes, but parents say they seem to help." You can also put cotton gloves on your child's hands at night, to help keep her from scratching.
Fortunately, many babies with eczema improve by age 2, and about 40 percent of kids with eczema outgrow the condition by the time they're young adults. Until then, parents say, relief comes with the right therapies. "It took time and patience, but we finally found a treatment plan that works for Anthony," says Angela Quear. "Now we can both sleep through the night -- which is a real victory."
The Food-Allergy Connection
While many dermatologists are skeptical that certain foods can cause eczema, research by Parents advisor Hugh Sampson, MD, has found that about one third of kids with moderate to severe eczema have a food allergy that may trigger flare-ups. Eggs are the most common culprit. Other offenders: milk, peanuts, wheat, and soy. "Some kids are so sensitive that touching the hand of another person who recently ate peanut butter can cause a local reaction," says Dr. Sampson, chief of pediatric allergy and immunology at Mount Sinai School of Medicine, in New York City. If your child has moderate to severe eczema, allergy skin tests can help pinpoint whether any of these foods are the problem. Just remember that although many kids with food allergies also have eczema (one study found that about 83 percent of infants with severe eczema had food sensitivities), making dietary changes won't improve skin symptoms for about two-thirds of kids.
Copyright © 2007. Used with permission from the October 2007 issue of Parents magazine.
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