Toddler and Baby Eczema

Eczema (or atopic dermatitis) is a dry skin condition that becomes itchy and flaky. The skin can become inflamed (looks red), and may even get infected (gets weepy) particularly with scratching. It usually begins early in childhood. In babies, the eczema rash often involves the face.

How is eczema different in toddlers compared to babies?

In babies, the eczema rash is often on the face and body while in older children, the skin in the creases around the knees, elbows and ankles is affected. Some children have the skin over the entire body affected.

At times your child's skin will look good and at other times it gets worse. This is part of the disease and not caused by bad care.

These photos show a baby with eczema - the face and trunk are affected.

Note the redness and the dryness of the skin. This is an itchy rash and children will tend to scratch.

The photo on the left shows baby eczema that is crusted and weeping - this is infected eczema and this child will require a course of antibiotics. I usually treat with an antibiotic by mouth for at least 2 weeks.

The photo on the right below shows an older child with typical eczema in the elbow crease. It has the characteristic thickened skin we see in eczema. Lots of moisturizers are needed to soften this skin and get it back to a more normal appearance.

Who gets eczema?

Toddler and baby eczema occurs in about 15-20% of children and occurs in children with an allergic tendency. It runs in families and goes hand in hand with asthma and hayfever.

Is there a cure for toddler and baby eczema?

No, but there is a good chance that your baby's eczema will disappear as she gets older - most children grow out of eczema by six years of age. There is plenty you can do in the meantime to make the eczema better.

How do I treat my toddler or baby's eczema?

The aim for toddler and baby eczema is to keep the skin soft and moist.

• Daily bathing is good practice, but use a bath oil and a soap substitute to stop the skin getting dry (see below for information on bath oils and soap substitutes). An antiseptic should be added to the bath twice a week to reduce the skin becoming colonized with bacteria (Staph) - see below for information on antiseptics.
• The bath water should be warm, not hot, as heat makes the skin itch. The bath can become slippery so use a bath mat to avoid accidents. Cover your child in the soap substitute (eg. Aqueous Cream) before getting in the bath and then limit the bath time to the time it takes to wash off the aqueous cream. Pat the skin dry with a soft towel as rubbing may irritate the skin.
• Use emollients or moisturizers to keep your toddler or baby eczema skin soft and moist. Moisturisers should be applied at least once a day, usually after bathing, but I often suggest to also apply the moisturizers at least four times a day. If the skin is very dry, you can apply every hour. If you are using a steroid cream as well, wait at least 20 minutes after applying the steroid cream before applying the emollient / moisturizer. You can keep the emollient / moisturizer in the fridge to keep it cool - this is especially useful for the creams you apply before bedtime.
  Examples of bath oils are Oilatum, AlphaKeri, Oilatum, QV, Aveeno or dissolve a teaspoon of Emulsifying Ointment under the hot tap. Oilatum Plus, QV Flare Up have antiseptic as well so only use if there is infection or twice a week as antiseptic - they are too strong for everyday use.

  Examples of soap substitutes are Aqueous Cream, Emulsifying Ointment, or Soap-free washes that contain no fragrance/perfume (eg. Cetaphil, Dermasoft, Johnsons pH 5.5). Cover your child in the soap substitute before getting in the bath and then limit the bath time to the time it takes to wash off the soap substitute.

  Examples of antiseptics are Oilatum Plus or QV Flare Up but these are expensive. An inexpensive option is to add bleach (Janola) 50ml to a 10cm deep bath. Just do this twice a week

  Examples of emollients or moisturizers are Lemnis Fatty Cream, Alpha Keri Lotion, Aqueous Cream, BK Lotion, E45 Cream, Emulsifying Ointment, and 50/50 Liquid Paraffin/White Soft Paraffin. It is sometimes helpful to change emollients after a few months and use another one for a while.

  If you want, you could use one treatment, such as Emulsifying Ointment, as bath oil, soap substitute and moisturizer. Hold some in a teaspoon under the hot tap while running the bath to make the bath water oily, lather your child with the emulsifying ointment before the bath to act as a soap substitute and then apply to the skin after the bath as an emollient.

Lotions, creams and ointments are all moisturizers (also called emollients). However, they have different water content. Lotions have the most water so absorb easily into the skin; however, lotions don't provide enough moisture to the skin to be used in toddler or baby eczema. Ointments have the most moisturizing quality but can be greasy on the skin and can clog up washing machines - if clothing has lots of ointment on it, soak in hot water before washing.

• Creams: Aqueous Cream, Sorbolene, Cetamacrogel, E45
• Oily Creams : Lemnis Fatty Cream, Lipobase
• Ointments: Emulsifying Ointment, Duoleum

It is vitally important that you keep your child's skin moist if you are to control toddler and baby eczema. Follow these steps:

• Take a good dollop of moisturizer out of the tub using a spoon - put on a paper towel or small tray. It's important that you don't put your hands into the tub of moisturizer to keep it free from bugs
• Apply the moisturizer in a downward motion (in the same direction as the hair growth)
• Don't rub the moisturizer in but leave it in a thick layer on the skin - it should naturally absorb into the skin within 10 minutes or so
• Apply as often as necessary to keep the skin moist - hourly if necessary

Stinging in toddler and baby eczema usually occurs because the skin is dry and so you need to apply more moisturizer, not less. Try changing the moisturizer brand and apply a thick layer to the skin - don't rub in, let the moisturizer/emollient absorb into the skin.

• Aqueous cream can be used as a shampoo
• 2% ketaconazole shampoo (Nizoral, Dandrozol)
• 20% cetrimide shampoo
• Normal shampoo can be used if you wash hair in sink (so the shampoo doesn't touch the body)

Will I need to use steroid cream on my toddler or baby's eczema?

Most toddler and baby eczema will need a steroid cream to calm the inflammation in the skin, where it looks red and angry, some of the time. Children get flare-ups of their eczema (when the skin looks worse) and steroids will help calm these flare-ups.

Are steroid creams safe in toddler and baby eczema?

There are different strengths of steroids, and if used as directed, they are safe. Strong (potent) steroids should not be used continuously without any breaks. The strength of steroid used will depend on your child's age, the severity of the eczema, previous use of steroids and whether the eczema is acute or chronic.

Only 1% hydrocortisone (mild steroid) should be used on the face at any age.

Potency of Steroid Preparations:

Steroid creams only need to be used once a day for toddler and baby eczema.

When should I use the steroid cream on my toddler or baby eczema?

Keep the steroid cream in reserve for when the skin is inflamed - looking red and angry. Don't apply to broken skin.

If you have a baby, a mild moisturizer like 1% Hydrocortisone cream will usually be tried first. For older children, a potent (strong) steroid may be started first

The steroid should be applied to red, inflamed areas usually after the daily bath. Start using the steroid cream on your the toddler or baby eczema as soon as the red inflamed areas appear and continue using until the skin is clear. Once the skin is clear of red, inflamed areas, you can stop using the steroid but start using it again as soon as the skin flares up again. Over time, you will find that you are using the steroid for less days in a row and that there are longer periods between steroid use.

If your child has very problematic eczema, some dermatologists advise that you use the steroid on weekends even when the skin is looking clear - the aim is to keep the skin as free of redness and inflammation for as long as possible.

For best results leave at least 20 minutes between applying the moisturizer and the steroid cream (steroid cream first).

How much steroid cream should I use on my toddler's or baby eczema?

As a guide, for baby eczema, use the last joint of an adult index finger and squeeze out a thin line of cream (this is called a finger-tip unit or a FTU). This amount (one FTU) is enough for the face and neck, or the hands and feet, or one arm. Double this amount for one leg, and four times the amount for back and front of the body. A toddler will need slightly more cream.

There should be enough steroid on the skin to make it look shiny.

The table below gives the number of Finger Tip Units (FTU) for different parts of the body at different ages.

Are there other treatments for toddler or baby eczema?

• Probiotics given orally, like lactobacillus, have been tried with some success in some toddler and baby eczema
• Oils, such as Evening Primrose Oil and Flaxseed Oil, have not been shown conclusively to improve eczema but they are relatively safe
• There is a cream called Pimecrolimus (ProTopic, Elidel) which is not a steroid. Elidel 1% can be used in children for short-term treatment of mild to moderate eczema and for intermittent long-term treatment (up to 12 months). It is not as powerful as strong steroids like Betamethasone valerate (Betnovate) and has similar strength to 1% hydrocortisone. It still needs to be used with emollients/moisturizers. Elidel can cause burning and redness when it is applied. This is generally mild and improves over the first 5 days. Pimecrolimus is good for facial and flexural eczema. The Food and Drug Administration (FDA) has issued a warning that pimecrolimus use may lead to cancer and so should be used with caution for toddler or baby eczema.
• Tacrolimus is similar to Pimecrolimus but slightly stronger. It has not been shown to be superior to strong steroids but is equivalent in potency. It is not available in New Zealand. The Food and Drug Administration (FDA) has issued a warning that tacrolimus use may lead to cancer and so should be used with caution for toddler or baby eczema.
• Very occasionally, strong medications taken by mouth (such as Prednisone, Cyclosporin A) or UV light therapy are necessary to control toddler or baby eczema but your child will need to be under a specialist for this.

Will changing the diet help my toddler or baby's eczema?

Most children with eczema do not have a food allergy that is causing the skin rash and so changing the diet will not help. However, if you have a young baby with severe eczema, there may be an associated food allergy (the younger the child and the more severe the eczema, the more likely a food allergy).

In those children with allergy causing the eczema, they will usually get rashes or more extensive eczema soon after eating a particular food or drinking milk (in the case of babies). If you notice this, remove that food from your child's diet (if you have a baby, this will need to be done under supervision with an appropriate other formula). If there is a marked improvement on removal of the suspected food, then the food may have been the cause - cautious reintroduction of the food after 3-4 weeks will enable you to be sure. If on reintroduction of the food, the skin remains clear, the food can continue in the diet. If the skin flares up again, that food needs to be removed from the diet. A trial of reintroduction could be made in 6 - 12 months time as many children will grow out of these allergies.

Extensively hydrolysed cow's milk formula or an amino acid based formula have been shown to improve baby eczema (infants less than 6 months of age). However, only change your baby's milk permanently if there is a clear improvement. If there is no improvement after 4 weeks, go back to your normal feed as food allergy will not be a factor.

In infants over 6 months with milk allergy, a soya based milk could be tried first. If the reaction continues, then a trial of an extensively hydrolysed formula or even an amino acid formula could be tried. No improvement over 4 weeks on an amino acid formula means the food is not causative in the eczema and your baby or child can go back on a normal diet for their age.

Can my child have all the usual immunizations?

Virtually all children with eczema can have their normal immunizations (including measles). This includes children who have not eaten egg and those with an egg allergy.

Can my child go swimming?

Yes. Your child should shower after swimming if the chlorine or the swimming seems to worsen the eczema. Apply moisturizer after swimming and if necessary, before swimming as well.

What else can I do?

• Try and control scratching as this makes the eczema worse. Wet wraps may help
• Keep you child's nails short and clean
• Encourage rubbing rather than scratching
• Consider cotton mittens at night to stop scratching
• Use a moisturizing cream which is kept cool in the fridge before going to bed
• Try and distract your child when she is scratching
• Loose cotton clothing will keep your child cool and comfortable
• Avoid excessive exposure to sun - wear a sunblock (at least SPF 20)
• Avoid skin products that have perfume in them - buy unscented products
• Some children benefit when house dust mites are reduced - for example, using a dust-mite proof mattress
• Some children benefit from an antihistamine (anti-itch medicine) at night
• Some people find non-biological washing powder better for the skin than normal washing powder
• Some children benefit from "wet wraps" - this is a technique where wet bandages are applied to moisturized skin and then covered in bandages. They are very good at softening hard eczema skin and they stop scratching.
• If your child's eczema becomes weepy, it may be infected and you need to see your doctor in case antibiotics are needed.

Why is my child's skin paler when the eczema heals?

In children with darker skins, the skin can look pale once the eczema heals and this can make the skin look patchy. Don't worry, the normal skin tone will return. This is not a permanent change.

What can I do to help prevent allergic conditions like eczema?

Breast feed your baby for at least 6 months. For high risk infants, so those with a family history of eczema, who are not breast fed, a partially hydrolysed formula (eg. NAN HA, Karicare HA) can be used. If your baby has a confirmed cow's milk allergy, then these formulas are not appropriate.

Delay the introduction of solids until after 6 months of age. A recent study suggests there is no benefit delaying introduction of solids, (including eggs, dairy and wheat), until after 12 months of age but they should not be introduced before 6 months of age. So eggs, wheat and dairy can be introduced after 6 months.

Taking probiotics for 2-4 weeks before delivery has shown a reduced incidence in eczema in infants, so you could take probiotics (like Lactobacillus acidophilus) during the last weeks of pregnancy.

Preliminary studies looking at giving probiotics (Lactobacillus acidophilus) to infants at high risk (those with an allergic mother) during the first six months of life have not shown conclusively any benefit in reducing eczema (atopic dermatitis) in those babies so there is no evidence to support giving probiotics to your baby at this time.

It is recommended that babies and toddlers are protected from tobacco exposure to help prevent allergic conditions.

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