Atopic Eczema

Infantile eczema, otherwise known as Atopic Dermatitis or Atopic Eczema, is a chronic relapsing itchy disease of the skin. It may commence after the third month of life as a weepy red rash on the face and outer surfaces of arms and legs and then progress in later childhood as a dry scaly itchy rash commonly of the inner creases of the elbows and knees. There may be associated sandpaper-like roughness of the skin with cracked skin on the palms, around the ears and scaling of the scalp. Very often there is a family history of other allergic diseases such as asthma, hay fever and eczema.  Some children may not outgrow eczema and the condition often continues or relapses in adulthood.  Adult eczema predominantly affects the neck, ankles and wrists.

We tend to institute general allergy prevention measures in high allergy risk new-borns. The risk for developing eczema is high in families who suffer with severe eczema, asthma and nasal allergies. Prevention measures include avoidance of smoking by parents during pregnancy and after birth and breast-feeding until at least 6 months of age. Common allergy-provoking foods such as milk, eggs, fish and peanuts should be avoided in the breast-feeding mother’s daily diet. Avoidance of solid foods in babies up to 6 months of age followed by the careful introduction of the potential allergy-provoking foods such as cow’s milk, wheat and peanut at 12 months, and eggs and fish only being introduced after 18 months. Up to 25% of infantile eczema is food allergy related and food additives and colourings may also aggravate eczema in older children. In addition adverse reactions to citrus fruit, tomatoes, pineapples and Marmite, are common in patients with eczema.

Children should avoid hot humid and cold dry weather, excessive sweating, woollen or synthetic clothing close to the skin and perfumed soaps. Cotton underwear as well as cotton clothing and bed-linen are recommended.

Non-biological washing powders should be used instead of enzyme enriched detergents. Bubble baths, household antiseptics and medicated soaps are best avoided. Swimming pool chlorine may also irritate and dry out the skin. Local household skin irritants include wool, mohair, nylon and feathers. Housedust Mites, Bacteria and dog or cat skin flakes may aggravate eczema.

Bath water should be lukewarm and moisturising emollients must be applied to the skin within 3 minutes of patting the skin dry (never rub the skin dry). If the non-perfumed soaps such as Dove, Pears or Neutrogena irritate the skin then the use of aqueous cream as a soap instead.

As much skin as possible should be covered with non-allergenic lightweight cotton clothing, taking care not to overdress or overheat the child. Cotton night-gloves as well as neatly clipped fingernails will reduce scratching at night whilst asleep. Sometimes elbow splints need to be applied to stop intractable scratching at night.

Routine childhood immunisations should be given. Consult your doctor if you have any concerns about these immunisations.

Young adults should decide on a career that is less likely to expose them to irritant chemicals and should probably avoid nursing, hairdressing, catering, motor mechanics, or the building industry. Protective gloves with cotton inner-linings will help prevent irritant contact dermatitis that is so very common in eczema sufferers.

These skin moisturising creams and ointments, the mainstay of eczema treatment, are completely safe and should be applied liberally at least two or more times per day to hydrate and protect the skin. Some people may find that a few of these preparations irritate their skin; if this occurs another product should be tried. Different emollients include Emulsifying Ointment (HEB), White Soft Paraffin, Aqueous cream (UEA), Diprobase and Lipobase with Cetomacrogol, Epaderm, and Oilatum cream. Sometimes coal tar is applied to treat thickened skin. Oilatum Plus is an excellent bath emollient. Aveeno is an oatmeal based emollient for very dry skin. Balneum contains soya oil.  Beware of emollients containing peanut or Arachis oil - these may trigger peanut allergy. Lanolin containing creams may trigger Contact Dermatitis.

These produce rapid relief and are used for short periods to settle eczema flare-ups. They may also be used for longer periods when diluted in an emollient in which case treatment should be tapered off slowly. However, their long-term use may lead to thinning of the skin. Some of the newer steroid preparations seem to be much safer. Cortisone tablets or injections are very rarely, if ever, used in eczema.

These are applied at night to keep moisture in the skin, aid absorption of creams and to protected against scratching. First of all, emollients and steroid creams are applied to the eczematous areas. Elasticated cotton-based tubular dressings are soaked in luke-warm water and then cut to size so that they cover the affected areas. These can be applied overnight to the limbs, trunk, neck and even face (holes are cut in the dressing to allow apertures for eyes, ears, nose and mouth). This treatment is highly successful for severe weepy eczema, which is non-responsive to emollients and steroid creams.

Eczema sufferers are more prone to skin infections such as staphylococcal bacterial, fungal and viral infections, including the common wart). Antibiotic creams and occasionally oral antibiotics are prescribed to treat infected eczema, which may present with sudden development of crusting, oozing and redness of the skin.

The older sedating type antihistamine tablets or syrup such as Chlorpheniramine (Piriton) will reduce itching especially at night. Antihistamine creams may sensitise the skin and should be avoided. Newer long acting anti-histamines such as Cetirizine, Fexofenadine and Desloratidine have also proved to be very good for reducing skin inflammation. Avoid antihistamine creams on the skin as these can sensitise the skin and actually cause rashes.

Evening Primrose oil (or gamolenic acid) has been tried with little success in the past.Extracts of Chinese herbal teas seem to reduce inflammation although they are quite unpalatable.  Tacrolimus (Protopic) or Pimecrolimus (Elidel), are new cream formulations recently introduced to the UK and clinical results so far have been very impressive.

Written by Dr Adrian Morris     Click here for the Surrey Allergy Clinic.

September 2006

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