Sleutelwoord: Skin conditions

Written by Dr Nické Theron, Pediatrician.

Eczema is a chronic disease and sadly it is not (yet) curable. It is however possible to control the symptoms. The aim is to get the acute inflammation of the skin under control (usually with topical steroids added to your normal regime), and then maintaining a healthy skin barrier by keeping the skin hydrated. It is thus very important that you understand the disease and what causes flare-ups in your child (see previous post) so that you can create the best management plan with your doctor.

…being strengthened with all power according to His glorious might so that you may have great endurance and patience…

Col 1:11

General Tips and Tricks:

• Avoid triggers as far as possible. Triggers differ for each child and can be as simple as: extreme cold or dry environments, sweating, emotional stress or anxiety or exposure to certain chemicals or cleaning solutions eg soaps, perfumes, cosmetics, wool, synthetic fibres.

• Keep the skin hydrated:
This is a very important part of the management plan. It is not necessary to buy the most expensive ointments; research show they do not necessarily work better than the ones you can buy in Dischem.

Your moisturizer needs to tick the following boxes:

• It must be an emollient or ointment, lotions can worsen the dehydration of the skin.
• Contain cetomacrogol (emulsifier), urea or glycerol (locks in moisture on the skin)
• Contain NO colourants or fragrants. Be careful of any ointments containing “Sodium Lauryl Sulphate” as this can also break down the natural skin barrier.
• E.g. in South Africa: Cetaphil, Epimax, Epiderm
  Best results when applied twice a day. Important to apply directly after bathing.

Bathtime talk: Lukewarm baths / showers soothe the skin but avoid long (10-15min) baths. Use a non-soap cleanser sparingly (you can use the same ointment that you apply after bathtime). In some cases a specialist may prescribe a “bleach bath” to decrease the amount of bacteria on the skin. Use a ¼ cup of bleach in a full bathtub (+- 150L) twice a week. (Discuss this with your doctor first.)

Medical treatment

• Topical Steroids
Most children with eczema will use topical steroids at some point during the disease. The anti-inflammatory effect is very effective in the treatment of the itch and the inflammation of the skin and most mild and moderate cases of eczema respond quickly to these ointments.

There are many different types of topical steroids and they are classified according to their potency. Examples you may know is Hydrocortisone (Mylocort) which is a weak steroid, Methylprednisolone (Advantan) moderately strong, and Betamethasone (Repivate) one of the strongest steroids available to use on the skin. Your doctor will help you to weigh up the risks and benefits to decide which steroid cream to use.

When there is a flare-up of the eczema, use a stronger steroid cream once daily for 7-14 days, then switch to a weaker steroid until the lesions are gone

Steroids in general has a bad reputation because they have the potential to cause some nasty side effects. However, only 2% of the topical steroid is absorbed, and if you use it safely it can bring a lot of relief to your child. It is important to use the ointment sparingly (apply only a pea-size per affected area), apply only once a day, limit the duration of strong steroids to 14 days, use the weakest effective ointment, be careful in the face and skinfolds as these areas are more prone to side effects. Long term use of strong steroids may cause a steroid-crisis because the body stops making its own steroid-hormones that are vital in times of illness / surgery / injury.

Common side effects can be thinning of the skin (atrophy), small red / purple spider-veins (telangiectasia) or stretch marks may develop in the affected area or the steroid can irritate the skin causing a contact dermatitis.

Once you have control of the acute flare, it is important to maintain the control by using emollients consistently and in moderate / severe eczema you can also use intermittent topical steroids for 2 days in a week to minimise the side effects.

Sometimes it may be necessary to give a short course (3 days) of oral steroids to get control of a severe eczema flare, but this should be the last resort!

• Topical calcineurin inhibitors
This is a relatively new class of treatments that are very expensive. Tacrolimus ointment (Protopic) / Pimecrolimus cream (Elidel) are effective to manage eczema and it has fewer side effects, but it does not work as quickly as steroids. It is better to use in sensitive areas such as the face and groin in children over 2yrs. There are still some concerns about long-term use (possible link to cancers later in life, this is still being investigated) and it is thus mostly used as a second line of therapy for children who does not respond to topical steroids.

• Relieving itching
It is important to relieve itching as this is usually the most bothersome symptom and keeps children awake at night. Scratching also worsens the eczema lesions, so keep finger nails short!

Oral antihistamines such as Hydroxyzine (Atarax) may cause drowsiness which will improve sleep. Cetirizine (Zyrtec) can also be used.

Wet dressings/wraps (the topical steroid and emollient is applied under a wet gauze covered with a dry dressing) is very effective to soothe and hydrate the skin, loosen crusts, reduce itching and prevent scratching.

Alternative treatments:

• Probiotics – research shows a small reduction in the symptoms which is not statistically significant. No serious side effects were noted so it may be worth it to test it in your child.
• Melatonin – In two small randomized trials, melatonin supplementation reduced disease severity and improved sleep in children with eczema. Melatonin is a hormone and as such has its own risks and side effects. Please discuss with your doctor

Prevention of Eczema:

• Use of emollient therapy from the first week of life has proven to reduce the risk of developing eczema before 1yr of age. This is a safe, cost-effective measure to use if you know your baby may be at risk.
• Use of probiotics in the mother and the baby may prevent the development of eczema but more studies are necessary. This is also a relatively safe precaution to take.

Life with a child with eczema can be hard, but if you stay positive, build treatments into a fun routine and walk this road with your health care provider, there is light at the end of this tunnel.

Worry does not empty tomorrow of its sorrow. It empties today of its strength.

Corrie ten Boom

♡

Pediatrics and Playdough & Medicine Mommy

Resources:

• Miller DW, Koch SB, Yentzer BA, Clark AR, O’Neill JR, Fountain J, Weber TM, Fleischer AB Jr; “An over-the-counter moisturizer is as clinically effective as, and more cost-effective than, prescription barrier creams in the treatment of children with mild-to-moderate atopic dermatitis: a randomized, controlled trial.”; J Drugs Dermatol. 2011;10(5):531
• Coondoo A, Chattopadhyay C; “Use and abuse of topical corticosteroids in children”; Indian J Dermatol. 2014 Sep-Oct; 59(5): 460–464.
• Michail SK, Stolfi A, Johnson T, Onady GM ; ”Efficacy of probiotics in the treatment of pediatric atopic dermatitis: a meta-analysis of randomized controlled trials.”; Ann Allergy Asthma Immunol. 2008;101(5):508.
• Chang YS, Lin MH, Lee JH, Lee PL, Dai YS, Chu KH, Sun C, Lin YT, Wang LC, Yu HH, Yang YH, Chen CA, Wan KS, Chiang BL; “Melatonin Supplementation for Children With Atopic Dermatitis and Sleep Disturbance: A Randomized Clinical Trial.” JAMA Pediatr. 2016;170(1):35

Written by Dr Nické Theron, Pediatrician

Red rashes… there are so many things that could look the same, and each child’s rash reacts a little differently. Even in the Bible many chapters in Leviticus was devoted to different skin lesions. There is only a small amount of treatments available…but oh so so soooooo many “boererate” and little ointments, potions and lotions that everybody swears worked for their child. Luckily eczema is one of the rashes we actually do have some answers for, so let me share what I do know:

What is Eczema?

Eczema (also called atopic dermatitis) is a chronic inflammatory skin disease that usually starts before the age of 5 years. It affects up to 1 in 5 children worldwide, and it seems as though it is becoming even more common in developed countries. You are not alone in your struggles!

Genetics play a strong role so there is usually a family history that one or both parents have atopy (this means they are prone to food-allergies, eczema, allergic rhinitis and asthma). An abnormality in the outer barrier of the skin, the epidermis, leaves the skin vulnerable. Environmental irritants (such as grass, dust, heat, cold), allergens and microbes (such as bacteria and fungi) can now pass through, and the skin loses more water. Some children also have an abnormal immunological response to foreign proteins, worsening the inflammation of the skin. This cycle is a little like the debate about who comes first, the chicken or the egg. It is still unsure whether eczema starts “inside-out”, or “outside-in” and although specific food or aero-allergens can make it worse, it is not always the cause of eczema.

There is evidence that the microbiome on the skin (the “normal” bacteria and fungi that live on your skin in harmony) is disrupted in a child with eczema. This causes an overgrowth of bacteria (usually Staphylococcus Aureus) which could worsen the inflammation of the eczema. It is thus not a cause of eczema, but it can make it worse.

Although tonsils play a part in the immune system of the body, I could not find any information suggesting that it could play a role in the development of eczema.

Symptoms:

Dry skin, intense itching, patches of red skin with small bumps and some flaking of the skin can be seen in children with eczema. There can also be some blistering and watery fluids leaking from the lesions, causing crusts on the skin. Itchiness is often worse at night. Scratching can worsen the inflammation and introduce infections. The skin can become thickened or darkened or even scarred from the constant inflammation and scratching.

Eczema usually start before one year of age, and the area of the body affected by the eczema can differ between children but can also change in the same child over time. Infants most commonly have patches on their arms and legs, their cheeks or scalp. Older children are more affected on their backs and the creases of their elbows and knees. Some children are only affected on their hands, or around their eyes or lips.

The Eczema Journey:

Most children will outgrow their eczema by late childhood (80% clears up by 8years of age). If your child has a mild eczema and was diagnosed before 2yrs of age, the chances are good that your child will be eczema free soon.

However, if the eczema started before 2yrs of age, your child has a higher risk of developing other allergies and asthma. We call it the “allergic march”, meaning that if your child’s immune system is prone to over-react to foreign proteins encountered via the skin as a baby (resulting in eczema), it will probably overreact to food proteins encountered via the gut (resulting in food allergies), pollen proteins encountered via the nose (resulting in allergic rhinitis) and proteins encountered via the lungs (resulting in asthma) as your child grows. This does not mean that every child will develop all of the above, but we need to keep our eyes open for the signs and symptoms.

Children and adolescents with eczema can also develop ADHD, depression or anxiety disorders. This is thought to be caused by the lack of sleep due to night-time itching, the psychological stress of having a chronic disease as well as the effect of chronic inflammation on the developing brain.

There is also an association between Autism Spectrum Disorders and eczema. Children diagnosed with eczema before the age of 2 has a slightly higher risk to be diagnosed with autism later in life. This relationship is still being investigated, but it is thought that the different inflammatory markers (especially the cytokines) may play a role.

Eczema can thus affect all areas of your child’s life and they need close follow-up and care.

“Cast all your anxiety on him because he cares for you.”

1 Peter 5:7

Making the Diagnosis:

Your GP can make the diagnosis by taking a good history and doing a quick examination of the skin. General practitioners should be able to treat mild cases, but if initial management does not work, it is better to follow up with a dermatologist and/or pediatrician to ensure good control of the disease.

Some diseases that could mimic eczema or that should be excluded are:

• Allergic or Irritant Contact dermatitis: This is when the skin reacts to a known allergen (eg a piece of fish touches your child’s hand he will get a rash only on his hand) or an irritant (eg your child wears new shoes and the rash is only visible where the shoe touched the foot.)
• Seborrheic dermatitis: mostly in infants. They develop a greasy red rash with scales on their scalp, eye brows and in their skin folds that is not itchy.
• Psoriasis: chronic auto-immune skin disease with red skin patches with a silvery scale. Rare in children
• Scabies: infection of the skin, very contagious, also very itchy. Usually there is a specific rash on the palms or in between the fingers.
• Certain drug reactions
• Primary immunodeficiency syndromes: here a lack of a certain part of the immune system may result in a rash on the skin.

Thank you for all your questions that helped me to write this post, I have also learned a thing or two while reading the latest research. I hope that you will feel more confident in understanding what eczema is and how it works and that this will empower you to tackle this journey with your child. Find a caregiver that you trust and will take alongside you on this journey. Treatment is available, and we will discuss it in tomorrow’s post.

“He who has a why to live can bear almost any how.”

Friedrich Nietzsche

♡

Pediatrics and Playdough & Medicine Mommy SA

Resources:

• Thorsteinsdottir S, Stokholm J, Thyssen JP, Nørgaard S, Thorsen J, Chawes BL, Bønnelykke K, Waage J, Bisgaard H; “Genetic, Clinical, and Environmental Factors Associated With Persistent Atopic Dermatitis in Childhood.”; JAMA Dermatol. 2019;155(1):50
• Kim JP, Chao LX, Simpson EL, Silverberg JI; “Persistence of atopic dermatitis (AD): A systematic review and meta-analysis.”; J Am Acad Dermatol. 2016;75(4):681. Epub 2016 Aug 17.
• Wan J, Mitra N, Hoffstad OJ, Gelfand JM, Yan AC, Margolis DJ; “Variations in risk of asthma and seasonal allergies between early- and late-onset pediatric atopic dermatitis: A cohort study”; J Am Acad Dermatol. 2017;77(4):634. Epub 2017 Aug 14.
• Yaghmaie P, Koudelka CW, Simpson EL;” Mental health comorbidity in patients with atopic dermatitis”; J Allergy Clin Immunol. 2013 Feb;131(2):428-33. Epub 2012 Dec 13.
• http://www.uptodate.com
• Thank you to the “National Jewish Health” site for the illustration.