Eczema, or atopic dermatitis, is a skin disease whose incidence is on the rise. Recent studies suggest that as many as 20% of American children will suffer from some manifestation of eczema with most presenting first with symptoms before five years of age.

Eczema has historically been referred to as the “the itch that rashes”. It presents as a series of red, scaly, itchy rashes that change as a child grows from infancy to adolescence. In infancy, eczema is most concentrated on the face and scalp. Between 12 and 18 months, the eczematous rash favors the folds in front of the elbows and behind the knees. The wrists, ankles and neck are also commonly affected sites during early childhood and adolescence.

What triggers eczema?

There are numerous factors that can trigger a flare of eczema. The most common include the cold, dry, winter climate as seen in places such as the Pittsburgh region, and irritants, such as wool, and fragrances in soap and laundry detergent. Some children, though, can flare more during the summer, as sweat can be an irritant. Children with eczema have a higher incidence of asthma as well as environmental and food allergies. It is even possible, although, not universal, that food allergies can flare eczema, especially during infancy.

How is eczema treated?

The treatment of eczema includes a multi-step process which begins with frequent moisturizing. There are dozens of over-the-counter moisturizers that are available, but most pediatric dermatologists believe that those containing Ceramides are the most effective. Ceramides are the family of proteins that make up the “glue” between all of our skin cells. Children and adults with eczema have a genetic tendency to make less Ceramides, and therefore their skin is less able to hold onto moisture. As the skin dries out, especially in the winter, these patches can develop into eczema. The use of Ceramide-based moisturizers has been shown to decrease the necessity and frequency of use of topical steroid creams and ointments, the next lines of treatment.

Topical steroids have been the mainstay of eczema therapy for more than 50 years. They come in a variety of strengths and forms, such as cream, ointment, lotion, solution, spray and foam. There are seven classes of topical steroids available in the United States and only the weakest strengths are available over the counter. All stronger topical steroids require a prescription. Topical steroid use can be associated with numerous side effects if used too often or in inappropriate strengths. These include thinning of the skin, also known as atrophy, pigment loss, acne-like lesions and the development of excessive hair growth at the sites of treatment. Systemic side effects are rarely seen if topical steroids are used for no more than two weeks for each course of treatment. The use of Ceramide-containing moisturizers usually allows for a break between courses of topical steroids. The choice of which topical steroid to use is based on multiple factors, including your child’s age, the involved body site, the extent of involvement, and your provider’s comfort and experience in prescribing these medicines to children. Your child may receive a mild topical steroid initially and if a stronger topical steroid or a more aggressive non-steroidal therapy is needed, your child may be referred to a pediatric dermatologist.

Complicating Factors

There are several infections that can complicate eczema. The increased incidence of these infections is also related to the decreased amount of Ceramides present in their skin. Just as the decreased Ceramide content keeps the skin from maintaining normal moisture content; it also decreases the barrier function of the skin against a variety of infections. The most common infections seen in children with eczema include bacterial infections, such as staph and strep of the skin, which can cause impetigo, and viral infections such as molluscum contagiosum and herpes.

Additional Therapies

For more severe or widespread cases of eczema, where even the most potent topical steroids are either not effective or are not a safe and appropriate choice, several other therapies exist. These include topical immunomodulators such as Tacrolimus and Pimecrolimus, and systemic therapies including oral prednisone and other oral immunosuppressive agents, such as Cyclosporin, Methotrexate and Azathioprine. The medical professionals most highly trained to diagnose and treat eczema in children through adolescence are pediatric dermatologists, who have formal training and board certification first in adult dermatology and then specialized fellowship training and board certification in pediatric dermatology. A trained and board-certified pediatric dermatologist will review your child’s medical history, examine your child’s skin, and provide a plan of treatment including continued care for this important condition.

Douglas W. Kress, MD (Children's Dermatology Services and Acne Treatment Center)