Pediatricians can play an essential role in diagnosis, counseling, and management of atopic eczema. Your decision to treat these children and adolescents in your practice largely depends on your comfort level and the progression of their condition over time. In general, referral to a dermatology colleague is not warranted unless you are unsure about some aspect of the condition, or the eczema fails to improve.
To diagnose atopic eczema, look for the telltale signs, especially the cracking and fissuring of the skin on the flexural folds of the arms and legs. Besides the flexural areas of arms and legs, atopic eczema often presents on the cheeks, but can manifest anywhere on the body.
Counseling is paramount because eczema is not an individual patient disease; it affects the entire family. Parents must spend an inordinate amount of time taking care of the affected child, thereby reducing time with siblings. In addition, the condition is very, very itchy. The extreme pruritus that characterizes atopic eczema often keeps the child and parent awake at night, which can, in turn, negatively affect the next day for children at school and parents at work.
Provide information on eczema to educate everyone in the family, extended family, and anyone who participates in the child’s care. From the outset, they need to understand that optimal outcome will require a long-term commitment. Atopic eczema needs to be managed and controlled for years because there is no magic bullet or cure.
Realistic expectations, therefore, are important. I tell families that I do not want “perfection to be the enemy of very good.” An acceptable goal, for example, is a child who still has minor areas of involvement that do not interfere with the child’s or the family’s normal activities.
The good news is that the majority of eczema patients will improve over time. For young children, this can take many years, usually into adolescence. Even so, I explain that the child’s skin will always be more sensitive than the skin of an unaffected person.
When I speak with a parent who is learning for the first time that their child has atopic eczema, I say that it’s as if your child were having “asthma of the skin.” Most parents can relate because either they or someone in the family has asthma. The analogy also works because symptoms will wax and wane, certain triggers can worsen the eczema, and there is a shared genetic etiology. When the genes are expressed in the lungs, asthma is the result; when the genes are expressed in the nasal passages, we call it hay fever or allergic rhinitis; and when the genes manifest in the skin, we call it atopic eczema. Some children have a combination of these disorders.
Stress the importance of keeping the skin hydrated to minimize flare-ups. I recommend liberal application of a moisturizing emollient twice daily, including immediately following once-daily bathing. Instruct patients to dry themselves gently with a cotton towel. Parents often ask how much moisturizer to apply. Sometimes I jokingly tell parents that if they give their child a hug and the child has is covered with so much moisturizing cream that she squirts up out of the parent’s arms, then enough moisturizer has been applied.
This regimen also can help repair the skin barrier to optimize control of the atopic eczema. I recommend use of a newer emollient cream rich in lipids and ceramides, such as Coria Laboratories’ CeraVe. I also suggest nondetergent cleansers like Pharmaceutical Specialties’ Vanicream cleansing bar, Galderma’s Cetaphil, Unilever’s Dove cleanser, and the like. These products cleanse without harsh detergents that take away the skin’s natural moisturizing oils.
Winter can be a particularly challenging time for eczema patients because of illness and dry skin. Although a meticulous skin care program is always important, it is especially so when the child is fighting an upper respiratory infection or other illness because it can help prevent a tremendous flare in the atopic eczema.
Maintenance of skin hydration also decreases the ability of protease enzymes (produced by bacteria in the skin) to enter the microcracks and fissures and exacerbate the eczema. In more severe presentations, consider an anti-Staphylococcus antibiotic such as Keflex for 7-10 days to decrease the bacterial skin load.
A dilute bleach bath once a week also can help decrease this bacterial load and prevent flare-ups. Emphasize that only a small amount of bleach (add 1/8 cup to a full bath) is necessary; it should not smell as strong as a swimming pool. On the same day, bed linens and pajamas should be washed with bleach as well.
You as a pediatrician can help to dispel an overemphasis on food and other allergens as eczema triggers. Instruct parents that if they notice a consistent flare-up after certain exposures, these may be triggers for their child’s eczema My philosophy is to “test and adjust,” but not to eliminate things across the board just because families read on the Internet that a food or substance causes atopic eczema. In my experience, fewer than 20% of patients with atopic eczema actually have true allergies and/or triggers for their condition. I also provide a prescription for a mild (group VI) steroid and moderate (group IV) steroid to use twice daily for 7 days with mild and moderate flare-ups.
Additional resources on atopic eczema are available online from the American Academy of Dermatology (www.aad.org/skin-conditions/dermatology-a-to-z/atopic-dermatitis). I also have a video on my website called “Power Over Eczema.” I encourage the patient’s parents to watch this video and to show it to anyone involved in the care of the child, including older siblings, nannies, babysitters, and grandparents.