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Your 13 month old has been off of formula for a month now, and enjoys drinking milk out of her sippy cup. You've noticed a red, raise rash scattered in different places around her body. She occasionally scratches it, which seems to make it even worse.

Your 4 month old has had a red, irritated rash on his face for the past two months. Everyone has told you it's just baby acne. You now start to see the rash breaking out on his arms, legs, and body. It seems to be getting worse. She is exclusively breastfed.

Your 4 year old has always had dry skin, but it never seemed to bother him. Lately, however, he has developed dry, scaly patches on his arms, legs and face.

These are all common scenarios that are typical of a skin condition called eczema. Another commonly used term is atopic dermatitis. It is a very common condition, affecting approximately 10% of infants and children. It can start as early as two months of age.

Eczema is a skin condition that has two distinct components:

• Dry, easily irritated skin – children with this condition have a genetic tendency toward dry skin. Moisture is very important for our skin. It helps skin stay healthy. It prevents irritation. It speeds up healing. Moisture essentially helps our skin function better. With eczema, the skin does not retain moisture very well, thus giving it a dry, slightly rough texture and making it prone to irritation. To further complicate matters, this dry, irritated skin is itchy, causing children to scratch frequently. This further irritates and damages the skin, which leads to worse itching and scratching, and so on.
• Allergies – children with this condition also have some underlying allergies that are manifested in the skin. When exposed to these allergens, the skin over-reacts and breaks out in a rash. The already dry and slightly irritated skin is less able to handle this allergic rash, and less able to heal itself quickly.

Thus, children with eczema have an ongoing battle on two fronts – trying to retain moisture in the skin and prevent irritation and itching, and limiting exposure to allergens and skin irritants. This is a battle we plan to help you and your child win!

• Dry skin – your child will have slightly dry skin with a rough texture. You may be able to see and feel tiny white bumps as you run your fingers across the skin.
• Dry patches – you may see scattered, scaly, dry, white patches anywhere on the body.
• Flare-ups – from time to time you will see some areas of the skin become more irritated and flare up. These will look like raised, red, slightly oozing patches. Flare-ups generally occur near skin creases – most commonly the inside of the elbows and behind the knees, but also in the neck, wrists and hands, and feet. It can also occur of the trunk. One unique aspect of eczema is that it usually does not affect the diaper area.

There are 5 main aspects of preventing and treating eczema.

1. AVOID DRY SKIN – moisturize, moisturize, moisturize! This is the single most important step in minimizing your child's eczema. Do not underestimate this! This needs to be part of your daily routine with your child.
   • Luke warm baths – hot water can dry the skin. Let your child play and soak in the bath. Do not let him soak in soapy water. It used to be felt that frequent bathing made eczema worse. Now we know that lukewarm baths allow water to soak into the skin.
   • Towel off gently by patting the skin. Do not rub dry.
   • Do not use plain soap – soap dries the skin, even liquid baby soap.
   • Use a moisturizing soap with no perfume – unscented Dove works very well. Cetaphil is a cleanser that is also soap-free and good for eczema.
   • Daily moisturizing lotion – this is very important. 2 to 4 times a day apply a moisturizing lotion or cream to the whole body, especially the affected areas. Some good brands include Aquaphor, Eucerin, or Keri lotion. One good time to apply this is right after the bath – it locks in the moisture.

2. AVOID SKIN IRRITANTS – this is the second most important aspect of prevention.
   • Cotton clothing is best. Avoid wool and synthetic materials; they can be more abrasive and irritating to the skin.
   • Use cotton sheets and soft, cotton blankets.
   • Wash new clothes before wearing them – this will get out any chemicals from the manufacturing process.
   • Do not use any perfumed or scented lotions.
   • Do not use bubble bath.
   • Laundry detergents – use a mild, dye-free detergent such as Dreft, Ivory Snow or All Clear. Liquid detergents rinse out better.
   • Double rinse the wash to get out all the detergent.
   • Shower or bath after your child plays in the grass or engages in sports that make him sweaty.
   • Maintain humidity of 25-40% in your home. Buy a humidity gauge. During the dry winter months, use a humidifier in your home. During the humid summer months, the air conditioning can keep the humidity stable.
   • Suntan lotion – use one that doesn't irritate your child's skin. PABA free is better.

3. AVOID ALLERGIC TRIGGERS
   • Food allergies – if your child has any food allergies, then they will play a major role in causing eczema. The problem is, you may not know if your child has any food allergies, and if he does, which foods is he allergic to? Thankfully, there are six common foods that make up nearly 90% of possible allergic foods. These are milk, egg, soy, peanuts, fish and wheat. Eliminate all 6 foods for 2 to 3 weeks. If you see dramatic improvement, then re-introduce each food one at a time to determine which is causing the allergy.
   • Environmental allergies – these include dust, mold, pets, and seasonal outdoor allergies such as pollens. These environmental allergies are more likely to cause nasal allergies and asthma rather than eczema. However, they can contribute to the eczema. Identifying and preventing these allergies is a very complicated process. Click on nasal allergies for a detailed discussion on preventing environmental allergies.

4. CONTROL THE ITCHING – this is a major problem for children with eczema. They are in a continuous cycle of itching and scratching. The dry, irritated skin itches, so your child scratches. The scratching further irritates the skin, which causes the rash to flare up. This itches even more and your child scratches even more. If you can keep the skin moisturized, decrease the rash, and prevent itching and scratching, then you can avoid this endless cycle.
   • Keep fingernails cut short and very clean – when your child scratches, the bacteria that live under his nails and on his skin get pushed deeper into the rash. This can lead to a skin infection. Shorter nails also will lessen the trauma to the skin.
   • Wear long sleeves and pants, weather permitting – this keeps his skin covered so your child is unable to scratch as much.
   • Medications to reduce itching – oral antihistamines are a very effective way to control itching. There are two types:
     • Over-the-counter – Benadryl (diphenhydramine) is the standard for itching. Its only drawback is that is causes drowsiness in many people. At nighttime, this can be an advantage since it will help your child sleep through the itching. But during the day, it can interfere will his daily functioning.
     • Non-sedating prescriptions – Zyrtec, Claritin, and Allegra and the three most commonly used. Zyrtec is currently approved for down to age 2 years. The other two are not. These have two benefits: they are long-acting and last 12 hours, and for most people they do not cause drowsiness. Thus they are very convenient for use during the day.
     • You can alternate between these two. Use Benadryl at night, and a prescription during the day.
     • When to use thes medications – do not just automatically give these to your child every day. When the eczema is under control, the rash is mild, and your child has little or no itching, then give your child a break from the medication. But do not be afraid to use it during flare-ups and for periods of moderate to severe itching. You need to break the itching and scratching cycle before the rash worsens. You can safely use these medications daily for several weeks.

5. TOPICAL STEROID CORTISONE CREAM – although this is a medication to help control itching as in the section above, it deserves its own special section. These creams have long been the gold standard to minimize the rash and itching from eczema. They vary in strength from the extremely mild over-the-counter hydrocortisone cream, to mild, medium, strong, and very strong prescription creams. Here is how to use them:
   • Preventative treatment – if your child's eczema is usually well controlled, with very little itching and rash, then you do not need to use a cortisone cream for prevention. However, if the eczema is moderate to severe and your child continuously has rash and itching despite all possible measures to minimize it, then you can use this cream on a daily basis to try to improve the condition. Use the mildest form that seems to work for your child.
   • Treatment during flare-ups – virtually all children with eczema will experience flare-ups from time to time. They can vary from mild rash, to moderate rash, to a severe flare-up all over the body. What is considered mild versus severe will vary between children, depending on how mild or severe your child's baseline eczema is. Your child may have a few mild areas and other areas that are moderate to severe all at once. Here's how to treat flare-ups:
     • Mild rash – this consists of a few areas of raised, red rash slightly worse than your child's baseline rash. Treat this with the over-the-counter 1% hydrocortisone cream (do not bother with the 0.5% - you might as well not use anything if you use this). It will say extra-strength, but it is really very mild. Use the cream twice a day until the rash subsides. Ask your doctor for a mild prescription cortisone cream if the OTC one doesn't work.
     • Moderate rash – again, what is considered moderate is based upon your child's baseline rash. These areas are often more red and inflamed, may have some oozing from the rash, and may bleed slightly from scratching. Itching will be worse than usual. Treat these areas with a mild prescription cortisone cream. You can also ask your doctor for a medium strength cream if the mild one doesn't work.
     • Severe rash – these areas will be very red and irritated, will ooze, and bleed. These areas will be larger and more widespread than usual. Itching and burning will be troublesome. Treat this with a medium strength prescription cortisone cream. Your doctor may prescribe a strong cream to be used very sparingly for severe areas that don't improve with a medium strength cream.
     • How long to use the cream – only use the prescription cream until the rash subsides. You don't have to keep using the same strength cream until the rash is totally gone. Once you see the rash is somewhat better, then step down to a weaker cream. Use that one until the rash is back to baseline. It is safe to use the mild prescription creams for a few weeks.
     • Helpful tips – after a bath, apply the cream to the slightly damp skin. Apply the steroid cream before applying the moisturizer.
     • Side effects of steroid creams There are two types of side effects:
     • Local side effects in the skin – include thinning of the skin, stretch marks, and infections.

   • Internal side effects – a very small percentage of the steroid is absorbed through the skin into the bloodstream. If enough is absorbed, it can affect certain hormone levels which in very rare cases can cause reduced growth rate. Be aware that this only happens with overuse of the strong steroid creams. There are two factors that determine side effects:
     • The stronger the cream and the longer it is used, the more chance of side effects. Over the counter cream has virtually zero chance of side effects, and so do the mildest prescription creams. The moderate strength creams have a slight chance of side effects. The strong creams have some chance of side effects, especially the longer they are used. The very strongest creams should not be used in children.
     • Different parts of the body are more susceptible to side effects in the skin. These areas include the face, armpits and genital areas. It is generally safe to use the mildest creams on these areas for a few weeks, and use the mild to moderate creams for several days, but it is better not to use the strong creams on these areas at all.

Be aware that children with eczema are more susceptible to bacterial skin infections, especially in areas where the rash is the worst. This infection is called impetigo. Signs that this is occurring are increased redness of the skin around the rash and a honey-colored fluid oozing from the rash or forming a crust over the rash. This is not an emergency and is not a reason to page your doctor after hours. It can wait until the next day to be seen by the doctor.

Tacrolimus ointment – this is an investigational ointment currently being tested in the U.S. for the treatment of eczema. It suppresses the part of the immune system that is responsible for the eczema rash and itching. It is showing great promise, and will hopefully be available soon. It appears to be just as effective as steroid creams, but does not have many of the side effects that the steroids have.

Yes. For most children, eczema improves during childhood. Your child may always have a very slight problem with dry skin and occasional mild rash, but the vast majority of children grow up with very little inconvenience from this condition.