Survival Guide: Eczema
What Is Eczema?
It’s a condition that causes weakening of the skin barrier and skin inflammation. When the skin barrier’s compromised, it causes dryness, itching and redness. Scratching often follows, which an lead to weeping, scabbing, blisters or infections in the short-term. Over time, it can lead to scarring and skin discoloration.
Who Does It Affect?
It affects all ages, from young infants to adults. The location of eczema “flares” (i.e., when the skin looks angry, red, and is tender) tends to change depending on age. In infants, you’ll commonly see it on the face. In toddlers, it lands more in the flexural areas, which are the elbow creases, behind the knees, and on the wrists and ankles.
There’s often a family history of the disease, and it occurs more frequently in those who also have asthma and food or seasonal allergies (these are known as atopic conditions).
Infantile Eczema
This is an example of eczema on the face. In infants, it tends to affect the cheeks, forehead, and scalp.
What Causes It?
We’re not sure. The thought is an overactive immune system causing exaggerated inflammation of the skin in reaction to some sort of trigger. This could be an irritant (such as an ingredient in a detergent), weather (either hot weather causing sweat, or cold weather leading to dry skin), certain clothing fabrics, or foods. It’s not contagious, though it does tend to cluster in families.
Is There A Cure?
Unfortunately, no! However, there are treatments to help make eczema more manageable and less detrimental to living life normally. It’s also important to note that while this tends to be a lifelong condition, there will be periods where it’s well-controlled.
How Do I Prevent and Treat It?
There are three key steps to managing eczema.
Identify Triggers:
Try to find out what is causing eczema flares. This can be difficult, since sometimes it seems like there’s no pattern. One of the most common triggers is skincare ingredients (soaps, shampoos, conditions, lotions, detergents, fabric softeners, baby wipes, etc.), so if you notice flares almost daily in spite of moisturizing, consider switching out products first. If that doesn’t help, consider seasonality (i.e., if skin looks better in the summer vs. winter), fabrics (in clothing and bedding), household cleaners, metals (such as jewelry), and foods (this is less common, though does happen, and warrants an allergist referral). Once the trigger is identified, avoid it as much as possible.
A Note On Finding Eczema-Friendly Products: One of my favorite resources is the National Eczema Association (NEA) website. They have a database of products that have been rigorously tested and organized into categories (such as age). If you’re trying to find something eczema-friendly, this is my first recommendation. Alternately, you can look for items in the store that are non-scented and have the NEA seal, which looks like a large letter “e” surrounded by a navy border,
Prevention With Moisturizing:
The mainstay of prevention is moisturize, moisturize, moisturize. We want to help restore the skin barrier and minimize dryness to avoid flares. Here’s some tips.
Use a thicker moisturizer (e.g., one that comes in a tub that you need to scoop out, or one that is almost ointment-consistency). Avoid a watery lotion that comes out of a pump if you can, since this’ll be less effective. My preferred options that are cheap and available at all drugstores are CeraVe Moisturizing Cream and Aveeno Baby Eczema Moisturizing Cream. These tend to strike the right balance between thickness and comfort (options like Aquaphor or Vaseline are more greasy / sticky / messy and therefore less enjoyable to apply, though also an excellent option if your kid will tolerate them).
Moisturize at least twice daily (morning and evening). Once is not enough. The more often you’re moisturizing, the better. Apply a liberal amount of moisturizer, as well - this isn’t the time to be stingy!
Shower correctly, and moisturize right afterwards. With eczema, aim for lukewarm showers <15 minutes. Scalding hot water can dry out skin further, and long showers can do the same. After getting out, use a towel to pat dry and immediately apply your moisturizer. You don’t want to dry off completely, since the goal is to retain some of the water from the shower and trap it in the skin.
Treatment:
Topical Steroids: This is the most common treatment for flares. They’re creams or ointments applied twice daily for 7-14 days, and come in varying strengths depending on the severity of eczema and location of the flare. We’ll typically start low, and then work our way up depending on response. Some examples of topical steroids include Hydrocortisone and Triamcinolone / Kenalog.
Avoid Overuse: At first, it’s tempting to want to use topical steroids all the time with how effective they are. However, using them for more than 10-14 days in 1 month can lead to delayed skin healing, weakening and thinning of the skin, and a subdued response to steroids during future flares. It’s important to allow steroid-free intervals where you can.
Avoid The Eyes: Avoid applying steroids anywhere near the eyes (including eyelids or undereyes), since it can rarely cause glaucoma.
Other Topicals (Eucrisa, Calcineurin Inhibitors): Some PCPs are comfortable with this, and some will refer you to a Dermatologist. They’re the “next step up” after steroids, and are an option for moderate to severe eczema or eczema that no longer responds to steroids. They can sometimes be more costly, require prior authorization with documentation of failure with steroids, or have additional side effects,
Biologics: These are medications that try to modulate the immune system so that it doesn’t create as much skin inflammation. The most common is Dupixent, which is FDA-approved for severe eczema down to 6 months, very effective, and is an injection given every 2 weeks. These are typically ordered by Dermatologists, so will require a referral from your PCP if you have an HMO.
Product Recommendations:
In eczema, all prevention and treatments come down to a single goal of restoring the skin barrier.
Additional Notes:
Bleach Baths: These are sometimes recommended by PCPs or Dermatologists to minimize infection risk in those with severe eczema. There are detailed instructions on how to create one (including measurements for bleach vs. water based on age) on the American Academy of Dermatology website. Just make sure this is a recommended treatment before going down this route!
Itching: Sometimes, your doctor may prescribe oral antihistamines (like Claritin, Zyrtec, or Atarax) to help control itching. Make sure to file down your child’s nails (or cut them) to minimize scratching, which can cause infections and scarring.
Hydrate: Make sure to drink lots of water, since eczema is all about hydration.
Unscented: All products used in your child’s regimen should be unscented.
Short Showers: Keep all showers <15 minutes and use lukewarm (not hot) water.
Proper Clothing: You’ll want to have your child wear breathable, light, soft clothing. Tight clothing can irritate the skin through direct rubbing and friction, and certain fabrics like wool can have fibers that cause inflammation of the skin. Make sure that you have the proper number of layers to avoid overheating (sweat can cause flares) or inadequate warmth (since cold air dries out skin further).
