Managing Atopic Eczema In Children

Atopic eczema is a common skin problem among children in Singapore. It begins with red rashes, on the neck, face, joint areas-front of the elbows and back of the knees. The red rash may ooze, and the skin appears inflamed. Heat seems to aggravate the rash. The child itches, more in the night and is unable to sleep through the night. The child appears agitated, and the rash can spread to the whole body.

Eczema over elbow bends and back of knees.

​​Eczema is an inflammation, a condition where the skin becomes sensitive and itchy and shows redness, swelling, blisters and crusting. Atopy means a tendency to develop hypersensitivity disorders, and this includes diseases affecting the lungs (asthma), the nose (allergic rhinitis) and the skin (eczema). Atopic eczema can occur with or without asthma and allergic rhinitis; only half of the affected have asthma and/or rhinitis. Doctors may ask if family members are affected to assess how sensitive your child is.

​​​It is usually inherited from parents, often the mother, though the father can be affected. About 1 out of 20 people in Singapore have atopic eczema. The eczema is more severe if it appears early (2 months of age) and 90%, will appear by 6 years old. The eczema may recur for many months. However, advances in medical research now provide effective treatments which can improve the eczema and keep the child free of eczema.

• Hyperlinear palms
• Ichthyosis vulgaris
• Keratosis Piliaris
• Pityriasis alba

​​a) Genes are involved. Recent advances suggest that there is a gene mutation in the skin. This gene is called Filaggrin. Filaggrin breaks down to form proteins, forming Natural Moisturing Factors, which hydrate the skin. With its loss, the skin is unable to moisturise itself and becomes very dry. Eczema skin also lacks a lipid, ceramide, which forms 60% of the skin. Therefore moisturisers should preferably contain natural moisturising factors and ceramides. These are the building blocks to form new healthy skin.

b) The body’s immune system, play a major role and produce certain chemicals (cytokines) that contribute to eczema. A poor skin has lower defence reserves to protect against bacterial infection.

If your child has extensive eczema, consult a dermatologist.

​​This often begins on the joints, the neck, folds of elbow, back of knees as itchy red small bumpy rashes. The skin is generally dry. The child scratches and rubs and the skin becomes excoriated, leading to skin thickening. This may also be complicated by infection.

​​​Diagnosis of atopic eczema is achieved through detailed history and clinical examination. Allergies are not common in most patients with atopic eczema. The doctor will arrange for further testing if there is any suspicion of allergies causing eczema flares.​

Allergy tests in atopic eczema:

• Skin Prick Test
• Allergen specific IgE antibodies

Management should target both

• Underlying skin barrier defect AND
• Skin Inflammation/Infection

Inadequate control of the above can result in eczema flares.

SKIN BARRIER DEFECT

Patients with atopic dermatitis have genetically impaired skin barrier function with increased water loss leading to dry skin. This impaired skin barrier also allows irritants and allergens access into the skin, initiating an immune system response.

Management includes:

• Ideal gentle cleansers would include properties such oil based for hydration or non-soap based. Antiseptic cleansers be added on to avoid repeated skin infections. We suggest short baths with tepid or slightly warm water, followed by immediate moisturizing. We should avoid strong soaps, chemical or bubble baths to prevent further skin barrier damage.
• Moisturizers are an integral part in the treatment of atopic dermatitis as they aid with repair of the skin barrier. Moisturizers should be applied frequently and liberally (even on normal looking skin). It is best to apply moisturizers after a bath, and as often as needed throughout the day whenever the skin appears dry or itchy. Different children / skin condition would require different moisturizing needs.
• Anti-itch measures include oral antihistamines, wet wraps and anti-pruritic ingredients such as menthol found in some creams. We suggest to keep the fingernails short to minimize damage to the skin during scratching.

ANTI-INFLAMMATION

Anti-inflammation topicals includes steroids and nonsteroidal creams. Topical steroids are used to reduce the inflammation of the skin. The strength of steroids will depend on the site and severity. Topical steroids should be applied to red, itchy, bumpy areas, once to twice daily. The strength and frequency of topical steroids should decrease when the skin has improved and stopped when the rashes have resolved. Side effects of topical steroids include skin thinning, easy bruising, stretch marks, increased hair growth, systemic absorption etc.

Topical calcineurin inhibitors are non-steroidal based anti-inflammatory creams and are used in a similar manner to topical steroids. The advantage of topical calcineurin inhibitors is the absence of steroids in these creams. Some patients may experience burning or stinging sensation after application of the cream in the initial few weeks of use. The efficacy and safety has been assessed in clinical trials and post marketing studies. Safety concerns arose in a small number of patients with oral calcineurin inhibitors. Many professional organisations still support and recommend its use.

​Oral antibiotics and / or topical antibiotics / antiseptics may be prescribed if your child has any signs and symptoms of infection.