The Itch That Rashes ...
There are many good resources on this topic, so I won't reinvent this particular wheel, but since it comes up so often in our office, let me share my favorite sensitive skin and eczema tips. As to why this this is SO COMMON in our adoptees, particularly those from China, I suppose it's a combination of ethnic predisposition, climate, harsh orphanage soaps and detergents, institutional disinfectants, malnutrition, chronic stress, poor skin care, and lack of appropriate treatment. While atopic dermatitis is a chronic tendency towards sensitive, dry, rash-prone skin, it tends to eventually improve when children come home, especially with the techniques below ...
- Avoid triggers, like perfumed products, non-cotton clothes, dust mites, heat/sweat, bleach, disinfectants, and chemical/fragranced soaps and laundry detergents (try Charlie's Soap ...)
- Do bathe your child 1-2 times per day in tepid-warm water for 10-15 minutes. You can add oatmeal-in-a-stocking or Aveeno to the bath, but oils just make things very slippery. Minimal, if any, soap ... use unscented Dove, Cetaphil cleanser, or similar. Don't use Ivory, scented soaps, or bubble bath.
- Alternately, bathe 1-2 times per week. The "wet" and "dry" approaches to atopic dermatitis both work - it's the hot, soapy baths that aren't followed by moisturizer application that are trouble, as they remove protective skin oils and leave the skin dry and itchy.
- Immediately after the bath, pat your child somewhat dry, apply any necessary topical medication, and then dip your child into a big vat of thick, greasy moisturizer. Seriously, you need to be applying a greasy, scoop-it-out-with-your-hand moisturizing ointment at least once a day, to seal in moisture and provide a protective barrier for the skin. No pump lotions ... you need a TUB, like Cetaphil-in-a-tub, Eucerin, Vaseline, or similar products. Most contain petrolatum - it's been used for centuries and has a good track record. If you must avoid the petroleum products, vegetable shortening, shea butter, or other balms might be an option. Happy to hear feedback on these. Daily, religious moisturizing is the key to this chronic condition, especially in winter.
- Some newer "active" moisturizers are coming onto the market that are touted to be better at retaining moisture in the skin, and restoring the skin barrier. Some are also mildly anti-inflammatory, equivalent to hydrocortisone cream. They may be useful for children with moderate-severe eczema as a way to need topical steroids less often. Some of the ceramide products (CeraVe, Triceram) are over-the-counter; others, like MimyX and Atopiclair are by prescription.
- If you're in a hot climate, creams might be preferable to ointment mositurizers. Lotions still not recommended, since they can actually be drying to the skin.
- All-cotton clothes, ideally. No wool or short-fiber synthetics - they itch. Do thoroughly prewash new clothes to remove sizing and other itchy products.
- Keep nails trimmed and itchy areas covered by clothing.
- For face, neck folds, armpit folds, and groin area, don't use anything stronger than Hydrocortisone 1% ointment (OTC) without discussing the pros and cons with your provider.
- For the rest of the body, prescription ointments like Desonide 0.05% (a low-potency topical steroid) or Triamcinolone 0.025-0.1% (a mid-potency steroid) twice a day will help itchy, inflamed areas that don't respond to hydrocortisone. Apply a thin layer underneath the moisturizer, and use only long enough to control the itchy flare. Not for daily longterm use - if it doesn't help by 1-2 weeks, see your provider.
- For those of you scared by the word "steroid", remember that chronic skin inflammation and itching is miserable, can cause infections, growth failure, sleep & behavioral problems, and overall irritability. Untreated eczema can cause longterm changes to the skin, just like overuse of potent topical steroids.
- I don't use Elidel or Protopic so much these days ... waiting for more safety data.
- For itch relief, an ice cube can substitute for scratching. Benadryl (OTC) or Atarax (Rx) at night (Allegra, Claritin, or Zyrtec during the day) are antihistamines that can help with miserable itching. Sometimes we need to use higher doses for severe itching - ask your provider what would be safe.
- Check behind the ears ... eczema likes that spot too.
- If an area is especially weepy, red, painful, or crusted consider using Bactroban cream for antibacterial help. If this is widespread, ask your provider about using an oral antibiotic to cover staph bacteria.
- Don't forget scabies ... very very itchy bumps on hands, feet, abdomen, or any really prominent, itchy, chronic-looking rash in a child residing in orphanage care could be scabies. Have it checked, and have a low threshold to treat with Elimite.
- Probiotic supplements or daily active-culture yogurt or kefir seem promising for folks with eczema.
- Some studies suggest benefit from Evening Primrose Oil (EPO), which contains GLA, an omega-6 essential fatty acid. Some recent studies don't. Probably safe to try, in moderate-severe eczema, at 3g/day in divided doses. May take 1-2 months to work.
- Don't use tea tree oil - it may be antibacterial, but it can trigger eczema flares (and may have hormonal effects in boys).
- Consider dust mite control measures, like mattress/pillowcase covers, high-filtration vacuuming, and removing frilly dust mite traps in the room. May be more effective for asthma and nasal allergies, but kids with eczema often have those too.
- As for diet, perhaps 10-20% of kids with eczema have associated food triggers; this percentage is higher for infants or children with severe eczema. Generally, unless the eczema is chronic and more than a mild nuisance, I don't go chasing food allergies, since the only reliable test for food allergies is a strict elimination trial, with reintroduction of the suspicious food. Blood tests (RAST) and skin-prick tests can rule out certain allergens, but positive results may not indicate a true food sensitivity, so they are of limited use. Stay alert for quackery when it comes to this issue, consult your provider and an allergist if need be, and please involve a nutritionist if you are considering prolonged eliminations of major food groups, especially in young children.
Atopic Dermatitis Links
- Atopic dermatitis: Taming "the itch that rashes" - Contemporary Pediatrics
- Article about the newer "active" moisturizers
- Diet and Eczema
Overview from the (British) National Eczema Society