Medical Edge Newspaper Column

Keeping Eczema Under Control

March 25, 2007
Dear Mayo Clinic:
My 2-1/2-year-old granddaughter suffers very badly with eczema. She has been to several doctors, but nothing has helped. What options for treatment might we want to consider? -- Glen Head, N.Y.

Answer:
Eczema is a commonly used term for atopic dermatitis. Marked by reddened, crusty, and itchy skin, this condition often occurs with allergies and tends to run in families. It typically begins in infancy and may vary widely -- in extent, severity, and responsiveness to treatment -- during childhood and adolescence. It's usually less of a problem in adulthood. While the exact cause of this disorder is unknown, it likely derives from a combination of dry, irritable skin and hypersensitivity of the body's immune system.

Because we can't fundamentally change the immune system's genetically based reaction to the skin, eczema is not curable. But it is highly treatable, in two complementary ways: by making the skin stronger, moister, and hardier to the environment (usually, through low-tech means) and by modestly "dialing down," through medications, the immune system's adverse influence.

The pillar of treatment is what we call "sensitive-skin care," and is centered on preventing dryness and keeping the skin sufficiently moist. The child shouldn't have more than one bath per day, lasting no longer than 15 minutes. More baths are unnecessary and wash excessive amounts of natural oils out of the skin. A bath oil that is as preservative-, dye-, and perfume-free (and therefore as inert) as possible should be added to the warm (not hot) bath water. This oil is very important: the residue it leaves on the skin will admit and help retain subsequently applied lotion.

The soap used during the bath, as well as throughout the day for hand washing, should be mild, too; four leading brands are Dove, Purpose, Cetaphil, and Vanicream. Immediately after the bath (within three minutes), the skin is most receptive to moisturizing lotions; leading brands are Vanicream, Aquaphor, Cetaphil, and Vaseline. Moreover, parents need to be attentive to how they do the household's laundry. Use scent-free detergents, and avoid fabric softeners.

In milder cases of eczema, sensitive-skin care alone may suffice. But in more severe cases it should be complemented with medications. The usual agent of choice is a hydrocortisone-containing lotion. Although this is a steroid, it is only applied to the places of irritation on the skin, not taken orally. Thus it poses none of the problems typically cited with systemic use, such as osteoporosis, diabetes, and infection. Nevertheless, parents may be reluctant to use such drugs, or the child may be allergic to them. Under such circumstances, non-steroidal immune-modulating creams -- tacrolimus (Protopic) or pimecrolimus (Elidel) in particular -- may be used. They are as effective as steroids, but they come with their own potential side effects, such as irritation and stinging.

For more serious cases, wet-dressing treatment in a hospital, for as long as 24 to 96 hours, may be indicated. A steroidal or nonsteroidal immune-modulating cream is applied to the skin, which is then wrapped in cotton material that has been soaked in tap water or an antiseptic solution. This protects the skin from the environment and helps it to absorb the medication, which can be used in lower doses. The process may be repeated, as needed, at home -- usually, for shorter periods.

It's important that patients take antihistamines to relieve eczema's inevitable itching, because telling a child not to scratch usually doesn't work. Scratching will only aggravate the condition, and it may cause sleep deprivation and further compromise the skin barrier.

A dermatologist should examine the child for possible skin infection, which, if found, must be treated with an antibacterial drug. When an infection is present, the skin simply cannot heal on its own. Finally, it is important to seek other opinions, as the problem may not be atopic dermatitis. The rash could come from other types of dermatitis, nutritional deficiencies, or various inherited genetic syndromes, each of which has its own recommended treatment.

-- Dawn Marie Davis, M.D., Dermatology, Mayo Clinic, Rochester, Minn.