Eczema is the most common skin condition in children we see in our clinic. The persistent itching can result in a disruption of daily activities, and understandably, can cause distress to both the child and the parent.
A dermatologist is a qualified skin specialist who has undergone board certification for diagnosis and treatment of all skin, hair and nail conditions. Pediatric dermatology is the diagnosis and management of common dermatological conditions that occur in childhood.
What are some of the common dermatological conditions that can affect children? In this article, we’re going to focus on the treatment and diagnosis of eczema in children by a pediatric dermatologist.
1. Know the Location and Type of Eczema
First of all, how does a pediatric dermatologist diagnose eczema? The clinical pattern of eczema, is as follows. The commonest type of eczema, is a “dry” type of eczema. It occurs generally over the flexures or the extensors of the elbows and the knees. It can also occur on areas which are a bit more sensitive to friction such as the neck and the back of the ears.
Some individuals may have a form of the disease that occurs around the mouth, known as perioral dermatitis. In children who suffer from facial eczema, it is important to rule out if there is an element of irritant contact dermatitis. Very young children who drool may develop facial eczema due to salivary enzymes that cause skin irritation on contact.
The ‘wet’ type of eczema is also known as exudative or discoid eczema. Discoid refers to “coin-like” referring to the round, well-demarcated lesions of discoid eczema. The diagnosis is sometimes confused with other types of skin diseases, such as skin infections i.e. impetigo is a secondary skin infection of the skin can occur together with eczema, causing pus and yellowish discharge. Discoid eczema is a wet type of eczema that is particularly stubborn and may need treatment with oral steroids together with potent topical steroids.
2. Understand Triggers for Eczema
During your consultation with your pediatric dermatologist, it is important to identify triggers for eczema flares. Some of the common triggers would include dust mite allergies, pet fur, carpets and environmental pollution. Stress can also affect eczema flare ups. A HEPA filter may help remove allergens. Stuffed animals can be washed at high heat, sunned or removed to reduce exposure to house dust mites, a known trigger for eczema.
3. Distinguishing Irritant Contact Dermatitis from Allergic Contact Dermatitis
There are two main types of dermatitis. The first is known as irritant contact dermatitis and the second type is allergic contact dermatitis. The two categories are different, because of the way the skin reacts to environmental exposures. In an individual with irritant contact dermatitis, it is a result of accumulated exposure to a substance that breaks down the skin barrier over time. In an individual with allergic contact dermatitis, the key difference is that it is not due to the accumulated damage on skin due to a caustic substance for example, in soaps, or disinfectants.
Rather because of the individual’s true innate allergy to the substance. This means it doesn’t matter if you’ve used the product once or if it’s your 100th time using it—you will still develop an allergic reaction. In fact each allergic contact dermatitis reaction may become more severe. Is it possible to develop allergic contact dermatitis even if you have previously tolerated the product? The answer is yes.
This is due to a process known as skin sensitization. Over time your body’s immune cells build up a memory to these substances that trigger off an allergic reaction in your skin. Common examples of allergic contact dermatitis would be that induced by metals in the environment. Nickel contact dermatitis is due to the presence of the environmental contaminant nickel, in a lot of metal alloys, for example in costume jewelry. Children can become sensitized to the presence of nickel, if they wear costume jewelry from an early age.
The types of irritant contact dermatitis that we encounter in a dermatologist practice are commonly due to cleansing agents, the use of harsh soaps in individuals who have to do a lot of wet work. Working in the kitchen or doing housework, such as laundry or dishwashing without gloves, predisposes to developing irritant contact dermatitis.
The location of the dermatitis will give us a clue as to the cause of it.
Sodium lauryl sulfate, or SLS for short, when it is present in high concentrations without moisturizers in the cleansing formulation, is a major risk factor for the development of irritant contact dermatitis. Irritant dermatitis can occur on the hand and body parts that come into contact with the irritating substance.
Atopic dermatitis is a type of genetically inherited eczema, these individuals have what we termed the atopic triad, which refers to allergic rhinitis, asthma and eczema. A positive family or personal history of any one of these three conditions is a risk factor for the disease. Individuals who have atopic eczema have a genetic predisposition to defective ceramide production, due to a genetic mutation in the gene known as filaggrin.
4. Pathogenesis of Eczema including bacterial infection
The pathogenesis of eczema is best understood via the brick and mortar module of the skin wall. The bricks represent the individual keratinocytes, which form the barrier against the external environment, and the mortar would be the “cement” that holds the keratinocytes together, providing an effective protective barrier against the environment. Now, this cement, is actually the ceramide that “glues” skin cells together in individuals with atopic eczema. The defect in ceramide production leads to a “leaky” wall, which means that if you are exposed to dust, pet fur or other environmental triggers, your skin is more likely to mount an immune reaction trying to fight off these external triggers.
This immune reaction then causes skin inflammation, which leads to the signs of eczema. Signs that your dermatologist would look out for would include symptoms such as flaking, skin swelling and redness. In discoid eczema, pus formation and skin infection, which manifests with yellow crusts.
The role of bacteria in atopic eczema
Bacteria is usually present in healthy forms on a normal person’s skin. In an individual with atopic eczema or other types of acquired forms of the disease such as irritant contact dermatitis, allergic contact dermatitis, there is a disruption in the skin microbiome.
Microbiome dysbiosis refers to a disruption in the healthy balance of the skin bacteria in eczema patients. What dermatologists know is that there is an increase in the bacteria known as Staphylococcus aureus, which is otherwise harmless on normal person’s skin. However, in diseased patients, this causes a superantigen effect, meaning that on its own, the bacteria drives inflammation.
For this reason, skin infection occurs together with eczema and must be treated with all antibiotics in acute flare-ups of the disease.
General measures that can prevent worsening of skin infection in an individual with dermatitis include gentle effective cleansers, such as the Miel Honey Cleanser with medical grade honey with natural anti-bacterial effects. This helps to restore the skin microbiome.
Patients can consider bleach baths, or in the local Singapore context, the dermatologist usually advises patients to go for a weekly swim, as the chlorine present in pool water can reset the skin bacteria.
The role of food allergy in eczema
Food allergy in adults is extremely uncommon, and especially so as a trigger for eczema. However, in a child under the age of four years old, there are cases where foods can trigger off eczema. In this case, your dermatologist will advise you to keep a food diary, which helps to record the intake of specific foods and find a pattern of what may be causing the disease.
True food allergy, presents with the following symptoms. Eye and lip swelling, difficulty breathing and diarrhea, which occurs within four hours of exposure to the suspected food. It is important to manage this with appropriate appropriate dermatological care.
Investigations for Suspected Food Allergy
Skin prick tests can be performed in suspected cases of food allergy.
Other types of tests that will be useful include the RAST test for food allergy to detect specific serum IgE concentrations. A food challenge, can also be performed to determine if an individual should have a specific allergy to food.
5. Management of Eczema
Your dermatologist will first establish a diagnosis based on the clinical features, the pattern of involvement and determine if there are any environmental factors that are constantly triggering off the eczema.
A strong family history is indicative of a genetic mutation. This means the condition is likely lifelong. However, most patients do not display signs or symptoms of eczema if the condition is well controlled and treated. This is especially true for children under the age of 12, it is very important to get the disease diagnosed and treated. This is because by the time they reach adolescence, oil production begins, they have a good chance of outgrowing their eczema.
Lifestyle Measures to Prevent Eczema
Additionally, lifestyle measures to reduce the environmental triggers can be helpful. The application of moisturizers is important – the gold standard of moisturizer therapy is known as Prescription Emollient Devices (PED). PEDs are not normal moisturizers. The Multi-CERAM cream is a type of PED, the best moisturiser effective for eczema treatment. It has been formulated with the optimal lipid ratio that replicates the natural lipid barrier of the healthy skin. The moisturiser also contains antioxidants anti inflammatory ingredients that help to reduce the inflammation in skin.
The Multi-CERAM moisturiser is formulated as a Prescription Emollient Device (PED), the gold standard in eczema management. Dermatologist formulated to treat eczema, dry sensitive skin and to prevent skin ageing. Botanically derived anti-oxidants to improve the appearance of cellulite. Suitable for face and body.
Steroid Therapy for Eczema
An important point to consider is the use of medications. It is very critical to understand that eczema must be treated with prescription creams i.e. topical steroid creams. These must be used under medical supervision.
Steroid Withdrawal and Steroid Phobia
The phenomenon of steroid withdrawal and steroid phobia are commonly reported in the internet because of a poor understanding of how topical steroids work. Using steroid creams without the supervision of an accredited dermatologist can be dangerous. Inappropriate use of steroid creams can cause skin thinning, ulcers, prolonged redness and broken blood vessels. It can cause tachyphylaxis, whereby the individual develops “resistance” to steroid treatment. This is dangerous because there are a limited number of steroid classes available.
Equally, having steroid phobia, where an individual suffering from the disease refuses treatment with medicated creams such as steroids, can be dangerous. It is important to know that there are steroid-sparing alternatives such as calcineurin inhibitors, tacrolimus (trade name Protopic) or pimecrolimus which do not have steroid thinning side effects but can be more costly. These treatments can also cause burning and irritation of the skin. Consult with your dermatologist to determine if this is the best treatment for your eczema.
Steroid phobia or steroid withdrawal in an individual with eczema can lead to extreme inflammation. Worst cases end up as generalized exfoliative dermatitis, a form of Erythroderma that is potentially life threatening. It is a form of skin failure, which can lead to loss of electrolytes, dysregulation of body temperatures and overall organ failure in extreme cases.
Proactive Management of Eczema
Your dermatologist will advise you how best to control your eczema using a prescribed prescription steroid cream. A common method for long term maintenance is known as proactive management. Proactive management of the disease involves a program whereby the dermatologist instructs you how to cut down the topical steroid strength and frequency of application, in order to prevent flare ups of your condition. Gold standard moisturiser therapy with PEDs, wet occlusion therapy with double pajamas and antihistamines are also essential for management of eczema.
Dr. Teo Wan Lin is an accredited adult and pediatric dermatologist in Singapore who specialises in the diagnosis and treatment of eczema, moles and birthmarks, allergies, and skin infections in children. She is also the founder of cosmeceutical skincare line Dr.TWL Dermaceuticals, which develops evidence-based cosmeceutical actives for the adjunct treatment of eczema. She is also the author of Skincare Bible: Dermatologist’s Tips for Cosmeceutical Skincare.Atopic Dermatitis / Eczema, Sensitive Skin