Knowing Your Child's Eczema

What is eczema?

Eczema is a common skin condition affecting ten to twenty per cent of children. The exact cause of eczema is not known. However if there is a history of eczema, asthma or hay fever in the family, your child is more likely to develop one of these conditions. Unfortunately there is no cure for eczema, although there are many ways to keep it under control. Approximately fifty per cent of children will no longer be troubled by eczema by two years of age and eighty five per cent by five years of age.

Eczema is a red, hot, dry and itchy rash that can affect one or many areas on the face and body and it can be mild, moderate or severe. There are often scratch marks on the skin because of the itch. These areas may become infected with bacteria and this can worsen the eczema. If there is an infection, your child may need a course of oral antibiotics.

When the rash begins in the first few months of life it normally affects the face. The cheeks and chin become red, dry, hot and itchy. This is made worse by dribbling, hands touching the face and mouth and saliva irritating the skin. The scalp and facial blood vessels are dilated quickly if baby is overheated. At this age eczema may also affect the trunk and limbs, but the changes in these areas are not usually as severe. As the child becomes a toddler the eczema is less likely to affect the face and more likely to be present on the limbs and trunk. The napkin area is not usually affected. When the child becomes school aged the eczema tends to affect the hot areas of the body, such as the flexures of the neck, elbows, knees and buttocks for similar reasons.

What aggravates eczema?

HEAT, DRYNESS and PRICKLE aggravate eczema. It is important you are aware of these three factors and remove them from your child’s environment. You should keep your child COOL, well MOISTURISED and in LOOSE, LIGHT COTTON CLOTHING and BLANKETS.

Heat and Clothing

The skin of a child with eczema is very hot, and heat increases the itch. There are many things that can make your child hot. Clothing can aggravate eczema. It is best to dress your child in a couple of thin layers rather than a thick layer, as it is easier and more effective to remove the top layer of clothing to suit the environment and stop your child becoming hot and itchy than it is to change the environmental temperature.If your child is participating in physical activities, take a layer of clothing off before doing so to avoid over heating. Educate your child and his/her teachers about this too.

Heat and Bath time

A hot bath can heat your child and cause him/her to become itchy. Bath your child once a day in tepid water adding one capful of bath oil to the bath and use this as a soap substitute. Soaps and some pinetar preparations can be drying to the skin. Your child should be bathed at least two hours before bedtime. The bath should be a pleasurable experience; toys in the
bath are a good idea.

Heat and Car Trips

Travelling in the car can be an unpleasant experience when your child has eczema. The heat generated in the car can cause the child to become hot and itchy. Sunlight shades are beneficial in reducing the heat of the car. Heaters should be used minimally or switched off. It is important to try and predict the occurrence of overheating and also avoid clothing that may be applying pressure or trapping heat. Avoid long car trips if possible and dress your child for the car ride not for the destination. After the trip, assess the heat and itch of your child and institute the appropriate treatments, such as, removing clothing and if needed applying a wet dressing. If a long journey is unavoidable, ensure you take many breaks, use air-conditioning and apply wet dressings and cool compressing often. If your child scratches in the car, canvas armbands may need to be used.

Heat and Bedtime

Children often itch more at night because they get hot under the bed-covers, the skin has more contact with clothing and seams and many children are in a habit of waking. If the eczema is not in good control, children may have difficulty sleeping and may wake a few times each night. Children with eczema should ideally sleep in their own beds, so as not to overheat. Soft cotton or silk sheets and at most one thin cotton blanket are appropriate bed linen. Woollen underlies or blankets, plastic mattress protectors, or doona covers should not be used.

Frequent waking and scratching at night and blood on the sheets in the morning are signs that your child will need a wet dressing just before bed. Wet dressings improve the sleep pattern of children with eczema, by keeping them cool and reducing the itch. Your doctor may prescribe a sedative at night until the eczema and sleeping pattern improves. Antihistamines should NOT be used routinely, or for children under two years of age.

Heat and School

Your child should wear one to two thin cotton layers to school. Woollen jumpers will make them hot and itchy. It is important to educate your child’s teacher about factors that worsen eczema. Ask them not to sit your child next to the heaters. If your child is itchy at school they should apply moisturiser and a cool towel to the itchy area. The teacher should not make a fuss in front of the class. However, they should be aware to remind your child to apply treatment in a private place. On hot days, your child may wet his/her clothes to reduce the heat and itch of the skin.

Heat and Home

The home should be kept cool. Air blowing heaters are the most drying to the skin. It is best if your child’s bedroom is not heated. Remember, your child feels hotter and is more affected by heat than you. It is better to apply another layer of clothing rather than it is to turn up the heater. Do not be concerned about your child catching a “cold” from being under dressed as this is an old wives’ tale.

Dryness and the Skin

The skin should be moisturised many times a day to help with this dryness. There are many things that can dry the skin like water, air-blowing heaters, cleaning agents, soap, swimming and the environment, such as Victoria’s dry winds in summer and winter. Your child’s skin will be dryer in the winter as the humidity is lower and heaters are used more. You may notice the eczema will improve on a tropical holiday.

What moisturisers should I use and how often should I use them?

Children with eczema usually have very dry skin, which worsens the itchiness. Moisturisers are used to prevent the skin from drying and they should be used frequently, and are very important in the management of eczema. Moisturisers can be used alone and can also be applied over the steroid and tar creams and under wet dressings. They are applied as often as required to prevent the skin from becoming dry, which may be three to five times a day every day. And are applied all over the face and body and not just to the areas of eczema. They should be applied on a regular basis and continued until your child’s eczema has resolved. Your child should be encouraged to participate in and recognize the need for the application of moisturisers. If any creams irritate the skin, stop its use, apply a bland moisturiser, preferably in an ointment form and contact your local doctor or dermatologist if it continues. Some of the greasier moisturisers may cause blocked pores. The blocked pores look like small pimples. If this occurs, change the moisturiser to a cream or lotion base.

What clothes detergent should I use?

Detergents aggravate eczema skin and dry it by removing oil. Try to use Lux or Velvet soap in your washing machine and ensure a good rinse. Crepe bandages used for wet dressings may be washed in the washing machine. Disposable towels used for wet dressings should not be washed with detergents or soaps. Dry garments in a tumble dryer if possible, as clothes tend to dry softer than if hung on the line. Try to avoid baby wipes, as they tend to dry and irritate the skin.

Can my child go swimming?

Yes, your child is able to swim, however if they are having a flare of their eczema your doctor or nurse may suggest your child may need to stop swimming until the eczema improves. Prior to swimming apply moisturiser to the skin. After swimming remove the chorine/salt water in a cool fresh water shower with bath oil, and then apply a moisturiser before dressing.

Do dummies aggravate eczema?

Dummies may aggravate eczema around the mouth, chin and chest areas. This is because saliva wells up under the dummy and irritates the skin. Food products may also aggravate the skin around the mouth. This is not necessarily an allergy and the area is best protected with a thick ointment moisturiser. Eczema often gets worse during teething.

Prickle and the Skin

Clothing can worsen eczema especially when it has a “prickly” feeling. Large fibres, especially seams, wool, stitching, tags, frills and lace edges will make your child feel itchier. Small cotton or silk fibres are the fabrics of choice for clothing or bed linen. You need to be aware if your child is becoming itchy from a garment. If the seams are harsh turn the garment inside out and unpick the tags, or line areas with a piece of silk. Undergarments made of silk such as boxer shorts are popular with children with eczema for day and night time use. If you are unsure about a piece of clothing feel it. If it feels slightly rough or prickly to you it will be very irritating to your child.

My doctor has prescribed a cortisone cream. Is this safe?

Your doctor may prescribe a cortisone cream or ointment for areas of eczema on the face and body. These ointments help to settle inflammation and redness of eczema. Cortisone is a natural body hormone and if used as prescribed carefully by your doctor, is completely safe. Avoid strong cortisone ointments on the face and flexures, hydrocortisone is preferred for these areas. Ointments are preferred, as they are more moisturising than creams.

How do I apply cortisone ointments?

When using cortisone ointments apply a layer of the cortisone to the red areas. Cortisone ointments are best used once or twice a day only when the skin is red. Reduce its usage as the eczema settles. Cortisone ointments come in different strengths and your doctor should discuss with you what strength is appropriate for your child.

Is my child allergic to some foods?

Foods are not the single cause or cure of eczema. Only about ten per cent of children with eczema have proven allergies to diet. However if most of these children with food allergies stopped eating the foods they are allergic to they would still have some eczema and require the same topical treatments as other children with eczema. Children who have allergies to foods may be extremely itchy without a lot of redness. Other children with allergies to foods may develop a hive like reaction to foods immediately or within two or more hours after food. These reactions tend to start in the early months of life and are seen less often as children grow out of them. If you are concerned your child may have food allergies, keep a food diary and the reactions to these foods to show to your doctor. Some foods that may cause allergies are; egg, dairy, seafood and nuts, beef, chicken, wheat, citrus fruit and junk food. When starting a new food give only a small amount of each new food, do not give large amounts too quickly. Breast-feeding is the best form of milk for the baby with eczema. Do not restrict your child’s diet without consulting a doctor.

Dust mite and eczema

It would appear that the house dust mite can flare eczema. However, the degree of importance of the irritation of the house dust mite is controversial. Many people without eczema are allergic to house dust mite and many eczema sufferers do not improve greatly when they use anti-dust mite measures. From our experience, we think that house dust mite probably plays a minor role in most children’s eczema, but occasionally can be more important. Please discuss this issue further with your doctor if you are concerned.

Can I use splints/armbands on my child’s arms to stop him/her from scratching?

Armbands/splints may be required at times to stop your child from scratching. Armbands are better than mittens and allow the skin time to heal and improve. They are useful at night and in the car, or when you cannot supervise your child and when the itch is worse. Armbands should not be used all day long. During the day if you can, distract your child with activities to reduce scratching.

Can I immunise my child?

Your child should continue to have all immunisations unless told otherwise by your doctor. If your child is allergic to eggs there are no contra-indications for your child being immunised for measles, mumps or rubella. Although, if the reaction is severe, it is best to have the immunisation performed by your local doctor or immunisation clinic, and your child should not have the flu or yellow fever immunisation.

Wet Dressings for Eczema

Wet dressings are important for the effective treatment of eczema. Wet dressings are essential when your child is itchy and hot and if they are waking from the itch. Your child may need a wet dressing if they itch and scratch during the night, if there is blood in the sheets in the morning, and if the eczema is still present despite treatment with cortisone ointments, moisturisers and bath oils. You will need to apply wet dressings at night for a few nights to get it under control. Initially they may be required during the daytime but should be changed as soon as they are dry. Early use of wet dressings will reduce the amount of cortisone creams needed to control the eczema substantially. Parents who have used wet dressings, generally express great satisfaction with the technique.

Why do wet dressings help eczema?

1. COOL wet dressings help to reduce the itch.
   The itch is worse when the skin is hot.
2. DAMP wet dressings help with the treatment of infection.
   They help to clean the skin’s surface.
3. The skin is REHYDRATED with the moisturiser under the wet dressing.
4. Wet dressings PROTECT the skin from trauma.

What items do I need for a wet dressing?

• Moisturiser (50% soft and 50% liquid paraffin or sorbolene cream)
• Cortisone or tar cream if prescribed
• Tepid water
• Bowl
• Disposable towels
• Crepe bandages

How to apply a wet dressing

1. Wet disposable towels in a bowl of tepid water and one capful of bath oil.
2. Apply cortisone or tar creams, if they are due to be applied.
3. Apply moisturiser to the body and face.
4. Wrap the wet towels around the affected areas gently,using a few layers.
5. Wrap crepe bandages around the wet towels, firmly but not tightly. Avoid direct contact with the skin.

Wet dressings may be applied as often as required to any area of the body with eczema, for example, the elbow or the knee. The wet dressings will dry, please try not to leave the dressings on dry as dry dressings can irritate the skin by causing it to become hot, dry and itchy. Please note the water used in the wet dressing does not have to be cold. Wet dressings cool the skin by the water evaporating just like sweat.

Can I apply a wet dressing to my child’s head, neck or trunk?

No. It is not advised to wet dress the head, neck or trunk.

What can I use if my child’s face, neck, trunk and scalp are itchy?

Instead of using a wet dressing use cool compressing to areas on the face, head or other areas on the body for immediate relief. Wet cool compresses can be applied to the neck as a scarf (only knot once), and a wet bandana can be applied to the head. The scarf and bandana should be applied only under supervision. For the trunk, it is advised for you to apply a wet T-shirt or singlet over a layer of moisturiser if the trunk is red or itchy. A dry T-shirt can be applied over this.

To Cool Compress

1. Fill a bowl with COOL water
2. Add a capful of bath oil to the water
3. Add disposable towels to the water, and soak until wet
4. Apply moisturiser to the areas, i.e. soft and liquid paraffin to the face or scalp
5. Hold the wet disposable towel to the red, hot or itchy areas for five to ten minutes, repeat every half to one hour until the redness, heat or itch has subsided
6. Reapply moisturiser to the skin once the towel has been removed from the area

Wet dressings and cool compressing should not be used as a last resort treatment, when your child’s eczema is at its worse. Use these helpful techniques as soon as the eczema flares rather than leaving it until the eczema becomes severe and infected. Think of the wet dressing and cool compressing techniques as first line treatments when the eczema flares or becomes itchy.

If your child initially refuses to allow you to apply wet dressings or cool compressing, persist slowly with these techniques to keep your child’s eczema under control. Teach your child the value of wet dressings and encourage them to participate with the application or encourage your child to apply wet dressings to their doll. Rewards are important in encouraging the application and continuation of wet dressings and eventually your child will understand the benefits.

How will I know if my child’s eczema is infected and what should I do if it is?

When eczema is infected it is often crusted, the crusts are normally yellow in colour, there may also be areas of weeping, and this is often a sudden change in the normal eczema. Your child may also be itchier than usual and the skin may be painful to touch, when severe your child may find it difficult to extend their elbows or knees. Children with eczema may often get secondary infections if the eczema is not under control. The eczema becomes infected because children scratch and the skin is then broken. One small area of infection can flare the other areas of eczema.

The cold sore virus can also infect eczema.A sudden onset of clusters of blisters will result from this infection, which requires special treatment. Your child should avoid close contact with people with cold sores and school sores. If you think the eczema is infected you should go to your family doctor and have the infected areas swabbed. If your doctor thinks the eczema is infected he/she will start your child on a course of antibiotics. If there are areas of crusts it is very important to remove them, as if you do not remove the crusts you are not treating the infection properly as antibiotics cannot get to the crusts to treat the infection.

To remove the crusts

1. Fill a bowl with tepid water
2. Soak disposable towels in the water
3. Apply the wet towels to the crusted areas for five to ten minutes, while also trying to gently wipe the crusts away
4. Do this half to one hourly until the crusts have been removed. This usually takes between one to five hours and this may also
   be done at bath time.
5. When the crusts are removed you can start the moisturisers and cortisone creams and wet dressings and cool compressing. If there are areas of weeping simply hold a wet disposable towel to the area for five to ten minutes every half to one hour until the weeping stops, if crusts persist you may need to continue to cool compress more frequently. Do not apply creams over weeping areas. Remember, if the skin is dry, moisturise it, and if it is wet, dry it out with wet towels.

My doctor has prescribed an antiseptic wash for my child, how does this help the eczema?

Antiseptic washes are important in the maintenance and treatment of eczema infections. They help to reduce the bacteria on the skin. When your child scratches and breaks the skin’s barrier the skin may become easily infected. By using an antiseptic wash the numbers of bacteria are reduced this helps to reduce the amount of skin infections. When the skin is infected it can be more difficult to keep under control. On the other hand some antiseptics can irritate the skin so it is important to use these only if directed by your doctor.

My daughter with eczema has behaviour that is to sometimes difficult to control, she often scratches to get my attention or to get what she wants, what should I do to help this situation?

Some children with eczema have learnt that if they scratch they will get what they want or attention from their parents. It is encouraged that parents do not give in to their child’s scratching behaviour. Scratching behaviour is often worse when the child is crying, stressed, upset or having a tantrum to get their own way. Treat the tantrum first and later deal with the eczema. When scratching gets attention the behaviour is more likely to be repeated. Avoid always telling your child to stop scratching or giving in; rather use distraction activities, especially ones using your child’s hands. Distraction is always a good way to stop children scratching by taking their mind off the skin and itch. Positive language should be given as often as possible, never use words such as ”bad skin”. It is common for childrens’ behaviour to deteriorate with the eczema. When the eczema is under control the behaviour usually improves. This can be due to many factors such as itchy, hot skin, and lack of sleep. Seek help and talk to your treating doctor or nurse if your child’s behaviour is worsening.

My child is eight months old and has had eczema since five months of age. He is waking four to six times a night, and has not gained weight for the past six weeks. He is eating and drinking well and has not had any vomiting or diarrhoea, why is this and how can I help?

When eczema is not well controlled, children may wake many times a night. This vicious circle can lead to the eczema and sleep pattern deteriorating more, the eczema becoming secondarily infected, and minimal or no weight gain. Poor weight gain can be attributed to poor sleep and feeding. Short and broken feeds can be associated with itch, this can produce broken feeding patterns. A child needs to sleep and feed well to help them gain weight and grow. To help your child sleep well it is important to keep them cool and apply wet dressings just before bedtime. You will need to apply wet dressings at bedtime until the eczema is under control and your child is sleeping well, the weight will also increase with this improvement. If the eczema is under control and the weight has not increased it is important to visit you family doctor for consultation on this matter.

As you can appreciate, eczema is influenced by many factors. Just as the skin is improving it may become worse again for no clear reason. Unfortunately this tends to happen with eczema. Remember to treat the flare as soon as possible with wet dressings, cool compressing and cortisone creams and maintain it with moisturisers and bath oils. Eczema takes a lot of time and attention to keep it under control, however it is easier to keep it under control than to manage it when it is infected or severe.

Written by Emma King, Dr George Varigos, Dr David Orchard and Dr John Su.
We would like to thank the children and their parents for their participation and time spent in helping
with the production of this booklet, and acknowledge the wonderful care given by the nurses and doctors
to the eczema patients admitted to the Royal Children’s Hospital.
This booklet was made possible by the generous support of Dermatec Laboratories,
manufacturers of Dermaveen Colloidal Oatmeal for eczema.
Illustrations by Jocelyn Bell
Designed by the Educational Resource Centre,
Women’s & Children’s Health Care Network, October 1999, 996082