Thomas was miserable. Despite the fact that he was solidly built for his 4 months, he had been having a hard time. His mom reported that he howled or barfed when given formula with cowl's milk or soy protein in it, and he had developed a recurring stop'n'gawk caliber rash in his cheeks and arms that was undeterred by daily onslaughts of moisturizers and ointments. Thomas' mother had seen this with her older kids, and she knew what was coming. I've had parents weep when they hear it mentioned.
Eczema, mild bane to some and scourge to others, is a descriptive terms for skin inflammation and irritation that manifests itself in many ways, including blisters, scales, and red, itchy patches. Thomas's persistent rashes and protein sensitivities mean he had the most common form of eczema, atopic dermatitis (AD). Certain triggers, like some foods, would likely set of his rashes in the future, and he's bd more likely to get allergies and asthma, the other two pillars of this trifecta of irascible conditions known as atopy that are as hard to live with as they are to treat.
AD usually begins in babies as patches of bumps or redness on the cheeks, but it can erupt anywhere. (the diaper area is often spared.) In older kids, rashes usually shirt to the crease of the knees and to the scalp, feet, and hands. They come in with a special menu of color palettes. Pizza, with pepperoni or mushrooms. Rose gardens. A bucket of Sherwin-Williams Real Red. Scaly whites. Mottled browns. For some, AD is an occasional dry patch that easily controlled. Other kids look like rashes with feet.
What I Preach
Eczema, asthma, and allergies are on the rise, though we're not sure why. One theory: the so called "hygiene hypothesis," which holds that our society has become too tidy. As a result our immune systems don't get enough experience fighting germs and parasites and so they overreact to otherwise harmless allergens like dust. Lighten up on the antimicrobial wipes? Couldn't hurt.
Because there's no one treatment that works for everyone, treating AD largely means understanding the triggers that make it worse. Extreme heat or cold, synthetics, detergents, dust mites, pet dander, mold, pollen, and stress are frequent culprits. Restricting or eliminating food triggers (like nuts, eggs, milk, or wheat) may be necessary. For bottle-fed babies, this often requires experimenting with formulas based on protein content (cow's milk versus soy versus a hypoallergenic preparation). For older kids, I ask parents to keep notes on how the AD and other allergic symptoms change depending on what a child eats.
What I Practice
Fortunately, for most children avoiding triggers and using some low-tech treatments are enough to keep rashes under control. In medical school, we learn a maxim for skin care: if it's wet, dry it; if it's dry, wet it. Many things that make bath time fun and delicious—fragrant soaps, hot water, and a fluffy towel rubdown—may make AD worse. Use milder soaps like Cetaphil®, if any at all. When kids get out of the tub, pat them, don't rub them, and leave them a little moist. Then lube up! Petroleum jelly (my favorite), vegetable oil, or Crisco (really) used generously two to three times daily work well. Moisturizing creams (think Eucerin®, Aveeno®, Dermasil®) may be used in addition, or solo if the goops are too greasy.
Then there is the steroidal elephant in the room, so to speak. Topical steroids are a cornerstone treatment for AD. Sadly, they often freak people out more than seems necessary; they are absorbed minimally by the body, acting mainly on the immediate upper layers of the skin. Our kids with AD who use them have yet to improve their batting averages. Stronger preparations are used sparingly or for limited periods to avoid thinning of the skin or scarring. Weaker preparations can be used more often, even daily for weeks at a time during a flare-up. And whether you choose a cream or ointment (greasier but longer lasting), apply to hydrated skin, after a shower or bath.
As for alternative therapies for AD, we're starting to see more research on these methods in kids. Some may offer relief, and at worst they won't hurt.
- Massage: A study showed that when parents massaged children being treated for AD for 20 minutes every day for a month, the children's rashes improved more than the control group, and parents reported lower anxiety levels in their kids and in themselves. Conclusion: Massage (gently) away!
- Salt water and sunshine: Studies have shown reduced rates of AD in summer, possibly because of the sea, sun, or higher humidity. Some researchers think that sea salt's antiseptic properties may reduce skin inflammation and the change of infection, and that the brine helps draw out trapped fluid in blisters. The sun's UV rays may soothe eczema by suppressing the immune response that leads to inflammation. Conclusion: Beach as therapy? Sure, but don't soak up the sun for more than 15 minutes without sunscreen. Can you mimic sea and sun at home? Not really. Sun lamps are a no-no, and trying to make seawater in your tub is impractical—you'd need upwards of a 3 pounds of sea salt for a shallow soak.
- Oatmeal Baths: These may offer safe, mild relief. (Overrated, says one dermatology colleague.) Conclusion: Try it and see.
- Watching funny movies: Seriously. In a Japanese study, only four out of 40 children with AD had nighttime wakings after watching >The Best Bits of Mr. Bean, but all 40 children awoke itching after viewing 72 minutes of weather videos. Conclusion: If only we could treat all ailments with Mr. Bean.
Scratch, Scratch Me Back
Many people would choose pain over the torture of an itch they can't scratch. And for kids with AD, scratching only leads to more inflammation, which leads to more itching and potentially infection. Parents may be compelled to trim their kids' nails and hover over them, hissing, "Don't scratch!" But pediatrician-turned-dermatologist Stephen White says that will only frustrate kids. Instead, he suggests soothing the itchiest areas with a balm or ointment containing menthol (but only for kids 2 and up). The cooling sensation can help override the itch.