Infant and Toddler Eczema
What is eczema?
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Who gets eczema?
Eczema tends to be more common in families that have a history of eczema, hay fever, and asthma. These disorders are all a part of what is called the “atopic triad.” A first or second degree relative with a history of one of these atopic conditions can often be identified in the family of a child with eczema. Children with eczema may be more likely to develop allergies or asthma but one does not cause the other.
How is eczema different in babies, compared with toddlers and older children?
The location and appearance of eczema changes as children grow. In young babies, eczema is most prominent on the cheeks, forehead, and scalp. It may affect most of the body but usually spares the diaper area. At 6 to 12 months of age, it is often worst on the crawling surfaces, the elbows and knees. Around the age of two the distribution changes and tends to involve the creases of the elbows and knees, the wrists, ankles, and hands. It may affect the skin around the mouth and the eyelids. Older children and adolescents may have eczema only involving the hands.
In young babies eczema tends to be more red and weepy. In toddlers and older children it often appears more dry, and the skin may be thickened with prominent skin lines (a skin change called lichenification).
What can trigger a flare of eczema in my baby?
Eczema flares occur when the skin is very dry, it comes in contact with irritating substances or allergic triggers, or when the skin is infected. Eczema tends to be worse in the winter when the air is dry and tends to improve in the summer when it is more humid. In babies, saliva from drooling may cause additional irritation, particularly to the cheeks, chin and neck. In such cases, applying an ointment like Aquaphor or Vaseline can prevent direct contact with saliva and decrease skin irritation. Specific triggers can vary based on the child and can include pets, carpet, dust mites, fabrics (such as wool), cigarette smoke, and scented products (such as perfume, laundry detergent and air freshener).
When the skin is infected your pediatrician or dermatologist may have to prescribe an oral antibiotic to improve the eczema.
Is there a cure for infant and toddler eczema?
Unfortunately, there are no cures for eczema. Fortunately, in most children eczema becomes less severe with time. The good news is eczema can be controlled.
How do I treat infant and toddler eczema?
Treating eczema requires treating both skin dryness and skin inflammation. A good bathing routine is necessary to treat skin dryness. Anti-inflammatory medications, like topical steroids or topical calcineurin inhibitors, are used to treat inflammation. Occasionally, oral anti-inflammatory agents are needed to treat the most severe cases.
How should I bathe my child with eczema?
Daily bathing is recommended for infants and children with eczema. Baths are generally preferred over showers. Baths should be warm, not hot, and they should be short in duration, lasting about 10 minutes. The use of soap should be limited. Bubble bath, epson salts, and some other bath additives should be avoided because they can be irritating to the skin and worsen eczema. Also avoid the use of scrubbers, loofahs, and rough washcloths. Immediately after bathing, a moisturizer should be applied to the skin.
What cleansers are recommended?
Dove© bar soap for sensitive skin, Cetaphil© Gentle Skin Cleanser, and CeraVe© Hydrating Cleanser are examples of cleansers often recommended by dermatologists to treat eczema. Cleansers should only be used to wash the diaper area and areas that appear dirty. They do not need to be used on a daily basis.
What are bleach baths, and why are they recommended for some children with eczema?
Bleach baths may be recommended by your dermatologist if your child has moderate to severe eczema and/or a history of infection. Bleach baths help prevent infections and maintain better eczema control. Staphylococcal aureus is a bacteria that lives on the skin of many children with eczema and can occasionally grow to cause infection and eczema flares. Bleach baths can help control the amount of bacteria on the skin and lead to fewer skin infections. Bleach baths are safe and are similar to bathing in a chlorinated swimming pool. Bleach baths are made by pouring ¼ cup of bleach into a half-filled bathtub. For babies with eczema, 1 to 2 teaspoons of bleach per gallon of water may be added to a baby tub. Always be careful to dilute the bleach before contact, avoid getting bleach water in the eyes, and moisturize immediately after the bath. Bleach baths are usually recommended a few times per week.
How do I moisturize my child’s skin?
Moisturizers should be applied at least twice daily—in a thick layer. Generally two types of moisturizers are recommended for treating eczema: ointments and creams. Lotions are mostly water and are not recommended. It is most important to moisturize the skin immediately after bathing (within 3 minutes) to prevent evaporation of moisture from the skin. Ointments and creams seal moisture from the bath into the skin, much like plastic wraps seal moisture into a cake.
What is the difference between lotions, creams, and ointments?
Moisturizers are classified based on their oil and water content. The more oil a moisturizer has the more effective it is in treating dry skin. Ointments have the greatest oil content, followed by creams, and then lotions. Creams and lotions also often have added preservatives that may burn when applied to scratched open skin. Ointments usually do not burn when applied. Ointment-based emollients and medications are generally preferred over creams for these reasons. Lotions are not generally recommended. During the summer a cream may be preferable to an ointment to prevent miliaria (prickly heat), which can occur after application of an ointment in the summer heat and humidity.
To prevent skin irritation seek out moisturizers that are fragrance- and dye-free.
What moisturizers are recommended?
Moisturizers with few ingredients and without dyes and fragrances are preferred. Examples of recommended ointments include: petroleum jelly (such as Vaseline©) and Aquaphor© Healing Ointment. Recommended creams include CeraVe© Moisturizing Cream, Cetaphil© Moisturizing Cream, and Eucerin@ Original Moisturizing Creme. These are bland white creams. Parents are often attracted to moisturizers with “natural” ingredients, but many of these contain plant extracts that can be irritating to sensitive skin.
What should I do if my child complains of stinging when I apply the moisturizer or when they get in the bath?
Switching from a cream to an ointment will help. Ointments usually do not cause burning, even when applied to scratched open skin. One cup of table salt may be added to warm bathwater to prevent burning.
What shampoos can be used for infants and toddlers with eczema?
Most gentle baby shampoos can be used. Fragrance- and dye-free shampoos are preferred. The fewer the ingredients, the better. One example is California Baby© Super Sensitive™ Shampoo & Bodywash.
Will I need to use steroid ointments on my child?
Very mild eczema may be controlled with a good bathing and moisturizing routine alone. Mild eczema may require the occasional use of a low-potency topical steroid. But the majority of children with moderate to severe eczema (or atopic dermatitis) will need to use low- to medium-potency topical steroids on a more regular basis to control eczema.
Are steroid ointments safe?
Steroid ointments are safe when used appropriately. Some tips for safe application include:
- Apply topical steroids only to rough affected skin and avoid normal unaffected skin.
- Avoid the application of topical steroids to skin folds (armpits, groin, thighs, under breasts) when possible, especially for prolonged periods of time.
- Avoid the use of topical steroids on eyelids.
- Apply milder steroids, which your dermatologist can prescribe, to treat the face.
- Use the mildest topical steroid that controls the eczema, which your dermatologist can help you determine.
- Apply topical steroids no more than two times per day.
- Consider using calcineurin inhibitors (Protopic© ointment and Elidel© cream). These nonsteroidal anti-inflammatory medications are approved for children older than two years, but they are sometimes used “off-label,” especially in rotation with topical steroids, for infants.
When should I use a steroid ointment on my child?
Topical steroids should be applied no more than twice daily. One application should occur immediately after bathing as part of the bathing routine. A moisturizer should always be applied over the topical steroid. Topical steroids should be applied to red itchy skin until the skin is less inflamed and more comfortable. Be aware that the skin may look lighter in color after the redness clears. This is normal and improves with time.
How much steroid ointment should I use on my infant or toddler?
Enough steroid ointment should be applied so that the skin feels tacky immediately after application. Within a few minutes it is will be absorbed by the skin. Topical steroids should be applied only to red itchy areas of skin.
Are there other treatments for eczema on infants or toddlers?
Gentle skin care and the use of moisturizers, and topical steroids are the most important treatments for eczema. But there are other topical medications such as Protopic© and Elidel© that are safe and effective for use on eczema when used as directed by your child’s doctor. Tar preparations can also be helpful.
It is important to prevent bacterial infection of the skin through the use of bleach baths as part of any ongoing skin maintenance routine. When infection is present, it should be treated with topical or oral antibiotics.
Oral antihistamines are very helpful for some children with eczema. They may reduce itch, but perhaps more importantly, they cause drowsiness, which helps children sleep.
Some eczema does not respond as expected to the usual treatments. Such children may be candidates for oral or injected treatments that calm inflammation in the body. Your child’s dermatologist will help you decide if this kind of treatment is necessary.
Will changing my infant’s or toddler’s diet help?
While many parents assume that a particular food is the cause of their child’s eczema, the answer is rarely that simple. Most eczema is unrelated to diet. In fact, parents who remove food from their child’s diet in an effort to clear up the skin can be causing more harm than good. If your child’s eczema greatly improves with gentle skin care and topical medications as described above, it is unlikely that there is a “hidden” food allergy in play.
Some children with eczema have food allergies, but that does not mean that the food allergies actually cause the eczema. If your child gets hives (red, itchy swollen skin bumps that look different from eczema) within one hour of eating a specific food, this is a sign of a food allergy and this food should be avoided until you talk to your child’s doctor.
What if I am breastfeeding? Bottle feeding?
Most infant eczema is unrelated to diet, whether breast milk or formula. Many babies with eczema are incorrectly labeled as “milk allergic.” Do not stop breastfeeding or giving cow’s milk formula without first talking to your child’s doctor. In most cases the skin will improve by using the gentle skin care techniques and topical medications described above.
When should we test a child for allergies?
Because most eczema is not related to diet, and because current allergy tests do not accurately predict eczema triggers, allergy testing is not routinely recommended. However, if your child’s eczema has not responded to standard treatments or your child gets a rash after eating a specific food, allergy testing might be considered.
Can my child have all the usual immunizations?
Children with eczema are encouraged to get all of the usual immunizations. If your child is taking an oral or injectable anti-inflammatory medication, your child’s doctor may recommend avoiding live vaccines.
Can my child go swimming?
Your child should be allowed to participate in normal childhood activities and this includes swimming. However, your child may not tolerate long periods in the water, particularly in pools with chemicals since these can dry the skin. You should rinse your child and apply moisturizer before and after swimming in a chlorinated pool.
Why is my child’s skin paler when the eczema heals?
The cells in your child’s skin that make the normal color (or “pigment”) don’t work properly when the skin is inflamed from eczema. The good news is that these cells will recover and the light spots eventually will return to the normal skin color.
What else can I do?
Encourage your child to participate in their skin care routine (for example helping to apply cream). Establish a reward system if necessary.
What can I do to help prevent eczema?
There is no known way to prevent eczema, but good skin care with a daily bath and use of a moisturizer twice daily can help strengthen the skin against all kinds of irritants. Get to know your child’s triggers and avoid them as much as possible. Finally, treat patches of eczema with medications as soon as they appear, since this can prevent more severe rashes.
The National Eczema Association (NEA) acknowledges Amy Paller, MD; Ingrid C. Polcari, MD; and Heather L. Salvaggio, MD, for their editorial contributions.