Atopic dermatitis (eczema)
Introduction
Atopic dermatitis (a-toe-pik duh-ma-tai-tuhs) causes your child’s skin to become inflamed, making it look red and feel itchy. It is commonly also called eczema, and you may know it by this name. It is very common, and you may have more than one child in the family with eczema. It can be uncomfortable, but it can be treated. Although there is no cure, it usually improves as children grow up.
There are many names used to describe dermatitis, which can be confusing (even for doctors!). Dermatitis is a general term that means ‘inflammation of the skin’, often called eczema, and refers to a group of conditions that make the skin look red and feel itchy.
Atopic dermatitis is caused by immune cells attacking your child's skin and is a result of their genetic make up. This is the dermatitis most people mean when they talk about 'eczema'. Other types of dermatitis include those that are caused by contact with something that irritates the skin (irritant contact dermatitis) or something that causes a local allergic reaction (allergic contact dermatitis). Less common forms include nummular dermatitis (also known as discoid eczema), and seborrhoeic dermatitis.
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Infant with atopic dermatitis or eczema on the back of knees
Who gets it?
Atopic dermatitis is very common – it affects as many as 1 in 5 children. Eczema generally affects young children, with most developing symptoms before they turn two, and improves with age. Boys and girls are affected equally. Although the rash may be more noticeable in children with pale skin, children of any ethnicity and skin colour can develop eczema.
What causes it?
Doctors are not sure exactly what causes atopic dermatitis, but we know that there are many factors that contribute. Dermatitis is not contagious. Eczema occurs when the skin’s natural protective moisture barrier is disrupted, causing dryness and a rash.
Genetics: Dermatitis is not clearly inherited, but does tend to run in families, so your child may have brothers or sisters or even extended family members with dermatitis.
Skin irritants: You may find that exposure to certain things causes your child’s dermatitis to worsen. These will be different for each child, but often include dust, dog or cat fur, some soaps or body products/washes, perfumes, sand, wool, carpet, grass or even their own sweat. The area of dermatitis does not necessarily have to be directly touched by the irritant – the presence of these irritants in the air or in your child's environment maybe enough to worsen their eczema.
Heat: Your child’s symptoms may get worse in summer as the weather gets warmer, as both heat and sweat can worsen dermatitis.
Stress: Some young people find that stress worsens eczema. This is less common in young children, but you may notice this if you have a teenager with eczema who finds their rash worsens around school exam time.
Allergies and immune issues (Atopy): Dermatitis tends to be associated with other conditions that are related to allergies and affect the immune system, including asthma and hay fever. Asthma and hay fever do not cause dermatitis, but may indicate that your child is more likely to develop dermatitis.
Food: Rarely, some foods can trigger dermatitis. There are no specific foods that you or your child should avoid because of their dermatitis, but if you notice that your child’s eczema worsens after eating certain foods, you should speak to your doctor, as they may have an allergy. In this case it maybe necessary to get an allergy test. It is important to note that most children with eczema do not end up having any food allergies. So its important to allow your child to eat a healthy and wide range of food. In fact studies show that exposing your child who suffers from eczema to high risk food groups (like peanut, soy, etc) in the first year of life can minimise their risk of developing food allergies later in life.
What does it look and feel like?
Looks like…
Atopic dermatitis looks like a pink or red rash without a clear border and may have overlying flaky dry skin. The rash may only be small (the size of a 20c or 50c coin), but can involve larger areas (more than 10cm in size). If severe, the rash may crack or weep. Because the rash can feel itchy, you may notice scratch marks on top of the rash from your child scratching with their fingernails. If your child scratches their dermatitis often, their skin may feel a bit thicker in the area of dermatitis. This can cause lumps on their skin called 'prurigo'. Dermatitis may affect many areas of your child’s skin, but common patterns include:
In babies and young children, dermatitis most commonly starts with the cheeks, but can affect many areas including the arms, legs and tummy.
As children enter primary school and get older, dermatitis tends to mostly be found inside the elbows and at the back of the knees, as well as the back of the neck and some areas of the face.
Eczema tends to improve as children enter primary and high school, and may resolve entirely in later teenage years and young adulthood.
Feels like…
Dermatitis can feel itchy and dry. It can be itchy enough to make it difficult for children to sleep at night. It is not usually painful, but can be uncomfortable for young children who may find it difficult to stop scratching. Pain in areas of eczema usually suggest that your child has a bacterial or viral skin infection on top of their eczema.
What tests might be needed?
Most of the time, your GP or dermatologist will not need to perform any tests. If your child also has asthma or hay fever, your doctor may perform some allergy and immune system tests, but this is not necessary for most children with dermatitis.
What treatments are available?
What can I do?
Avoid irritants and triggers: Avoiding anything that you notice irritates your child’s skin is important, and will help to improve their dermatitis. This may include changing your child’s clothing (removing prickly fabrics such as wool), choosing gentle soaps and body washes for sensitive skin, not keeping pets at home and avoiding dust (though this may be difficult, and you should speak to your dermatologist first).
Maintain a cool but humid environment: Keeping your child cool particularly overnight and in summer, will also help. Humidity is helpful for eczema so avoid using too much air conditioning or heating as this is designed to remove humidity. A humdifier might be useful in your child's room.
Moisturise regularly: If your child is finding their eczema very itchy, you can try applying a soft, damp towel to cool their skin, before applying moisturisers. Wet dressings of cool bandages may also be used (see section on Wet Dressings).
Avoid scratching: Keeping your child’s fingernails cut short is important to stop them hurting their skin when they scratch their itchy eczema.
Medical therapies
Eczema requires regular treatment, which can be difficult for many busy families. Your GP and dermatologist will help to create a treatment plan to care for your child’s eczema, which will vary depending on the severity of your child’s eczema. But ultimately you as the parent will be the ones that need to invest the time to carry out the treatments.
The treatment plan may include:
Moisturising creams: Emollients are thick moisturisers that help to restore the skin’s barrier, which is disrupted in atopic dermatitis. These will need to be applied regularly, ideally at least 3 times per day. Sometimes they may also need to be applied with dressings to help the skin stay moist (see section of Wet Dressings).
Other creams: In most circumstances, prescription creams, such as steroids to reduce inflammation, will be necessary. These are used to control flares of eczema, but do not replace moisturisers. Your dermatolgist will advise the right strength of cream for your child's eczema and also to match the area of the body being treated. There is a lot of fear about the use of steroid creams amongst parents (and even amongst some doctors and phamacists!). However, these are absolutely essential in the day to day management of most children's eczema. Your specialist will reassure you about the very low risk of side effects with these treatments if used correctly.
Immune medications: tablet immune medications are reserved for more severe eczema in children.
Biologic treatments: These treatments are now the cutting edge of managing eczema but due to their recent introduction via medicare they are usually only reserved for teenagers or adults. Your dermatologist may be able to prescribe this for your child if they qualify.
What happens after treatment?
Atopic dermatitis should improve and resolve with treatment and age. However, if your child has had dermatitis, it likely indicates that they have sensitive skin even if the rash has resolved. Therefore your child may need to use gentle products and avoid irritating chemicals throughout their life. As previously mentioned, your child may be more likely to develop asthma and hay fever in the future too. If this happens, you should tell your doctor that your child previously had dermatitis, even if the rash has resolved.
What support is available?
Your GP and dermatologist will work together to look after your child and improve their dermatitis.
Eczema Australia is a patient support group that provides information about eczema and treatments for patients and their families, and can be found here: https://www.eczema.org.au
The Eczema Support Australia network https://www.eczemasupport.org.au/support-for-you/ is a useful website that may provide you and your family with support/information.
Authors/Reviewers:
Author: Dr Imogen Kate Thompson
Paediatric Reviewer: Dr Mayuri Sivagnanam
Editor in Chief: Dr Tevi Wain
