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Eczema

Girl_on_swing_medium_size_1_1.jpgEczema is a dry skin condition which becomes red and itchy when inflamed – known as ‘active eczema’. It is also known as ‘atopic dermatitis’, and is a common condition, particularly in childhood but in some cases can persist, present or reoccur in adulthood. Eczema has a high impact on health and quality of life for patients and their families but good management and support can reduce the impact.

The skin has an important role as a barrier and has been described as being ‘like bricks and mortar’. In eczema, there is a problem with the ‘mortar’ and this allows the skin to leak – losing moisture – and allow irritants in which inflame the skin. Because the skin is not able to maintain its barrier function it is also very prone to infections from bacteria on the skin and/or through contact.

The main symptom of eczema that patients experience is itch. The response to this is to scratch the affected area which might provide temporary relief,however scratching damages the skin even further and increases the risk of infections. It is a difficult condition to manage with flare-ups often happening for no known reason., There is no cure, although most children (and adults) will outgrow it with time.

The key aspects of good management are:

i) Maintain treatment to keep the skin under control (see Three Steps section below)
ii) Avoid irritants e.g. the things which irritate the skin, including allergens, where possible (see Eczema and Allergies section below)
 

Three Steps

There are three main steps to controlling eczema through direct  treatment to the skin:

1. Moisturise the skin with soap/detergent/fragrance-free moisturisers* several times a day or more if possible, to help maintain its barrier function (available on prescription from your doctor).

2. Bathing once a day to clean and hydrate the skin. Antiseptic baths twice a week can help reduce infections (see the Eczema Management Plan and Guidelines for Antiseptic Baths section below for more information).

3. Apply steroid creams (called ‘topical steroids’) if the skin becomes inflamed and itchy (active eczema), to bring this under control as soon as possible. Most  active eczema cannot settle without topical steroids. See your doctor if the inflammation does not get better in two weeks.

It is also important to see your doctor particularly if the skin becomes weeping, angry and red; antibiotics and antiseptic baths may be necessary.

Click here to see video footage from the NZ Paediatric Society on the three steps to managing eczema in children. (The messages are the same for adults with eczema).

Click here for an Eczema Management Plan (‘Caring for your child’s eczema’)


Top Tips from Allergy New Zealand

1. Be safety conscious: babies and young children will be very slippery when bathing with moisturisers. Always supervise them in the bath and lift out using a towel. Pat (not rub) dry.

2. Suitable moisturisers, as well as topical steroids and antibiotics, are available on prescription from your doctor.  Ask your doctor to write an Eczema Management Plan for you/your child to follow (available here). Note that – depending on the severity of the eczema - some people will need to use a pot of moisturiser or more per week.

3. Avoid skin products with soap, detergent or fragrances. These can dry and irritate the skin. Look for products which state ‘soap-free, fragrance-free, suitable for eczema’. Do not use bubble baths.  Often the same cream that you have been prescribed as a moisturiser can be used as a soap substitute.

4. Minimise the risk of skin infections by:

  • Washing hands before applying moisturisers, steroids etc onto eczema skin
  • Using a clean spoon to scoop out the required amount of moisturiser onto a clean plate or paper towel – don’t put your hand in the tub of emollient. Some people put the moisturiser in a pump bottle but make sure the bottle, spoons etc are clean when doing this
  • Not sharing towels or bedding with other family members
  • Regularly bathing – daily if possible – to keep the skin clean. Moisturiser can be used instead of soap.

5. Shampooing hair: to avoid getting soap on the skin, lean over a handbasin or tub to rinse off or wash the hair at the end of the bath to avoid sitting in the shampoo in the bath water.  Hair does not need to be shampooed every day.

6. No bath? – if showering, put moisturiser on first then get in the shower to rinse off.

7. Minimise the risk of scratching and causing more damage to skin:

  • Keep nails short (yours and your child’s) but use a nail file instead of clippers or scissors;
  • Provide cotton gloves/mittens and socks to protect skin against scratching especially at night.
  • Babies will often wriggle around until they can rub itchy skin against the side of their basinet or cot. Safety ‘bumper’ pads or infant sleeping bags may help.   
  • A plastic bag filled with ice cubes next to the skin can help to relieve itching.

8. Avoid those things that irritate your/your child’s skin as  much as possible. More information is in Avoiding Triggers section (below).

Eczema and allergies

It was previously thought that eczema was an allergic condition. However it is now thought that it is caused by genetic factors (possibly hereditary) leading to impairment of the skin barrier function. People with eczema are more prone to developing allergies because their skin is porous, letting  triggers and allergens ‘in’. The immune system then develops IgE antibodies to protect the body from a possible threat (the allergen), and the person becomes sensitised. 

However it is important to understand that having IgE antibodies to an allergen does not mean the person is allergic to that allergen. On the other hand eczema skin can be irritated and inflamed by non-allergenic triggers, such as chemicals, heat and stress. For many people there is a process of trial and error to work out what their particular triggers are. However if an allergy is diagnosed by a doctor, such as to house dust-mites or food, then minimising exposure to them will help reduce  active eczema.

Children with eczema are more likely to develop allergies, and, while they may outgrow the eczema, go on to experience hayfever (allergic rhinitis) and asthma symptoms as they grow older.

Food allergy and eczema

Up to one in three (30%) of infants have eczema by 12 months of age. This usually starts with patches on the cheek then moves to parts of the body such as the back, in elbows and behind the knees. The presence of eczema increases the risk of the infant developing allergies, and the risk increases with the severity of eczema.  Most infants will only have mild to moderate eczema and 10 to 20% of these may have a food allergy which makes their eczema worse. However up to a third of infants with severe (widespread) eczema are likely to have food allergies.

Testing for allergies in patients with eczema, particularly young children, is difficult for a number of reasons. Infants and children with severe eczema, and/or where there is clinical evidence of food allergies, and/or inflamed or infected eczema not responding to treatment, should be referred to the local (DHB) paediatric service.
In adults, food additives are a possible trigger for eczema inflammations, particularly artificial colourings and preservatives. These are not food allergies and can’t be diagnosed through skin prick or blood tests. Consultation with a dietitian to trial an elimination diet may help.

Guidelines for antiseptic (diluted bleach) baths 

Diluted bleach (sodium hypochlorite) baths twice a week can help improve eczema and prevent skin infections. There is information included in the Eczema Management Plan here.

i) Choose the right bleach:  the bleach should be plain, without added fragrance or detergent (Janola brand contains detergent and is not recommended)

  • Budget Household Bleach Regular (2.15% or 21.5g/l) is recommended
  • Budget (Extra Strength) or Homebrand (Regular Bleach) can also be used but note these have twice the strength of bleach than Budget Household Bleach Regular
  • Antiseptic bath oils (Oilatum plus or QV Flare up) can be used but are not funded by Pharmac. Follow instructions on the label
  • Bleach gets weaker with time so you many need to get a fresh bottle
  • Make sure you store the bleach where children cannot reach it.

ii) Fill your bath or tub with warm water

  • A full-sized bath filled 10cm holds about 80 litres of water.
  • A baby’s bath holds around 15 litres of water
  • You can work out how much water is in your bath by filling it to a mark using a bucket or large bottle
  • Water should be warm (not hot).

iii) Add bleach and mix well

  • Add 2 ml of 2.15% or 21.5g/l Budget Household Bleach (Regular) for every 1 litre of water (this will make a 0.005% solution).
  • A full-sized bath filled to 10cm deep will need half a cup (150ml of 2.15% Budget bleach); filled to 20cm deep will need one cup.
  • A full baby’s bath will need 30 mls of Budget Household Bleach (Regular) - about 4 caps
  • Other brands of bleach may be a different strength – check the bottles and adjust the quantity added if the bleach is stronger! For example, if using Budget Extra Strength Bleach or Homebrand (Regular) Bleach, the quantity needed is half that for Budget Household Bleach (Regular). For a full baby’s bath, about 2 caps will be needed.
  • Mix well.

iv) Soak in the bath for 10-15minutes.  Wash with the soap substitute (e.g. moisturiser/emollient) towards the end of the soak

v) Rinse off with tap water

  • Pat (not rub) skin dry with a towel. 
  • Don’t share towels with family members as this can spread skin infections
  • Apply steroid and moisturiser creams

vi) Use dilute bleach baths 1-2 times a week

  • See your doctor or nurse if skin is irritated by the bath, or if infection occurs.
  • Make baths fun by filling a paddling pool and allowing your child to bathe outdoors. (This could also be an option in warm weather for young children if you don’t have a bath).

Eczema - Avoiding Triggers

Eczema skin can be triggered (inflamed) by a number of things, some of which may be hard to identify and/or eliminate exposure to. It is therefore important to maintain good skin care as the first step, and then look at avoiding irritants where possible.

i) Food:

  • Most infants and young children with mild to moderate eczema will not have a food allergy. However those with severe eczema should be referred to a paediatrician (or nurse specialist) and reviewed for possible food allergies. If diagnosed, it will be important to remove the foods concerned from the child’s diet. They should be regularly monitored so that the food(s) concerned can be re-introduced to the child’s diet as soon as they have outgrown the allergy to them. More information about food allergy is here.
  • In adults, sensitivity to food chemicals such as salicylates, sulphites or other food additives can contribute to eczema flare-ups. It is recommended consulting with a dietitian to identify foods to be eliminated in a trial diet to see if this helps reduce inflammation.

ii) Eczema skin in children and adults is commonly irritated by things in the environment. These may include:

Soap, detergent and fragrances:

  • Look for products that are soap/detergent/fragrance/perfume-free. If using a new skin product, try a small amount on a small patch of skin before applying it to the entire body to be sure it will not cause a reaction.
  • Talk to your doctor, nurse or pharmacist about whether a particular product may be suitable for your skin or not. You may need to try more than one product before finding one which does not cause further irritation.
  • Sun creams can be used if the skin is not broken. Choose one for sensitive skins with an SPF 30 or more. Test on a small area first.
  • If food allergy has been diagnosed, check skin products for these as some have ingredients from food such as peanut, dairy, wheat and soy.
  • For infants with eczema it is recommended skin products with food allergens (as above) be avoided, such as nappy rash creams, wipes, nipple creams etc, as contact with these may increase the risk of the infant developing allergy to them.

Allergens such as house dust-mites, pet fur, grasses, pollens and moulds: information about avoiding these allergens can be found here.

Overheating:

  • Eczema affects the ability of the skin to control body temperature; people with eczema often feel hot; and heat can make eczema skin feel itchy. Keep your/your child’s bedroom cool and well ventilated especially in summer, and the bedding a light weight.

Rough fibres in clothing and bedding and even carpet can irritate skin with eczema and some people find lanolin in wool can irritate. Find fabrics that work, such as 100 per cent cotton, and use where possible for clothing particularly if next to the skin; bedding including blankets and bedspreads; and as covers on vinyl or leather car seats, kitchen chairs/sofas and on carpet if the child is going to be sitting or playing on this. Remove name/brand tags from clothing to prevent irritations to the neck.

Chemicals contained in aerosol sprays (e.g. insecticides, air fresheners and polishes) and paints, resins, and varnishes can irritate eczema skin in some people. Avoid using or contact with these as appropriate.

Chlorinated swimming pools: look for pools with low chlorine levels, or saltwater pools or the sea. Make sure to apply moisturiser before swimming, rinse off in a fresh-water shower after swimming then apply more moisturiser.

Laundry: Use a gentle laundry product when washing clothes, bedding and towels, avoid use of bleaches or fabric softeners, and make sure to rinse well to remove any soap, detergent or fragrance. Wash new clothes, bedding and towels before use as these may contain chemicals from the manufacturing process. Hot washing bedding at greater than 55c can help remove house dust-mites if these are an irritant.

iii) Eczema skin is prone to infections which will inflame the skin. To avoid infections:

  • Wash your hands before and after applying creams (see Top Tips for more information)
  • Don’t share towels and bedding with others; and wash regularly (see Laundry above)  
  • Young children may pick up infections from playing in sandpits. These should be avoided particularly when the skin is inflamed (sand at the beach is cleaner).
  • Eczema is made worse by infections such as impetigo (school sores); and the cold sore virus. See your doctor urgently if infection from these occurs.

iv) Stress and anxiety can also play a role in inflaming eczema skin, particularly in older children and adults. Allergy New Zealand’s booklet ‘Letting go: teaching your food-allergic child responsibility’ may be of help. (This is free to members or can be purchased for $5 – click here for more information). Constant lack of sleep due to itchy or painful skin can also increase stress for the patient and their family. Use of sedating antihistamines at night might help - discuss this with your doctor.

Eczema playlist

 
Thanks to the NZ Paediatric Society’s Clinical Reference Group on Child and Youth Eczema for these resources.