I grew up with terrifically dry skin which, at first handshake, makes people think that I must be 67 years old — that is, unless they are staring me in the face and see I otherwise look about my age. Because of this, throughout my pediatric practice I have made it a point to get good at treating eczema – first through myself, then through recommendations to the many patients with eczema I treated in clinical practice.
Let it be a fitting thing that, just as I gave birth to my picky-eater first child, I should also give birth to a child with skin rougher and drier than my own. And that skin is giving me a run for my money.
Since a month or two of age I could tell that R’s skin was drier than the average infant’s – a bit of scaliness here, some flaking to the scalp there. As a newborn she used to lie in her crib and shake her head back and forth like a miniature Stevie Wonder. This is what I thought, at least, until she turned 4 months old and, with newfound control of her hands and fingers, she began to scratch her head and ears furiously as she shook her head back and forth. All this time she’s been itchy, I realized.
So out came the creams, salves, oils, and ointments. Not just the few that I had on deck, the ones I’d massage into her gingerly every day or every other day after a quick bath. I went from being the one to give advice on skincare to getting advice from every angle – mostly at my own frustrated behest. “Use Aquaphor!” “Give her a massage with [insert name of oil/ointment/cream here]“. Eat this, do that. Unfortunately, no matter what I do, I am not sure that people believe the truth of my predicament (as I constantly advised the same to my patients): no matter what I do, the skin doesn’t get any better.
It came to a head a few weeks ago when, covered with itchy red bumps and her scalp bleeding, my baby saw her to her pediatrician and was prescribed antibiotics and a light topical steroid. At that point, I decided to turn a new, entirely more disciplined leaf regarding my daughter’s skin. But to my dismay, just as we were getting a handle on things and moisturization was working, her skin got much much worse — with a severe viral infection atop the eczema — and we were back on medications. That struggle brought us to the dermatologist and has taken us even further into the realm of understanding regimented eczema care.
Here is what I have learned:
1) Itching really does make the rash worse. I could do all the skin care I wanted for days and days, but within about 5 minutes of finding utility for a particular sharp fingernail, my daughter could destroy weeks of effort. So it’s really important to control the scratching. So I cover her hands with socks, or put a stretchy, light hat on her head, or both, as an effort at damage control.
2) Be vigilant about fingernail length. I cut my daughter’s nails with a clipper exactly every day and a half and “prn” (which means “as needed” in medspeak). I don’t bother using a nail file – it makes her nails short but sharp, so clipper it is. And if I miss a day, she could end up a scratchy mess, so timing is key. Every nail, every other day.
3) Keep ‘em wet.
Ongoing through the eczema debateOne question you may have about eczema treatment is whether to bathe multiple times a day and keep children in wet wraps versus the other end of the spectrum – barely bathe them at all. I’ll admit that this is an individual decision based on what works best in your child, but for us and pervading the more recent literature, a frequent moisture source is helpful. For my daughter, this means bathing at least once a day, and no ordinary bath. I no longer use soap or fragrances of any kind, but I am now about to give the colloidal oatmeal bath industry their biggest client. Every bath is an oatmeal bath with a 10-15 minute soak. (One hint – just get the plain fragrance-free 100% colloidal oatmeal – don’t get a “baby” preparation – if it says “baby” it WILL be more expensive and also comes in smaller quantities – save yourself a few bucks and just use less of the packet for one bath. Save the rest for next time.
ADDENDUM 8-6-2014: (See cross-outs above) and clarification here: As my colleague, an pediatric allergist, has noted, whether to keep kids wet versus dry is not really a debate – physicians are in consensus that regular soaking baths and especially wet wraps can improve eczema a lot. There are other treatments which he discussed – and about which I will not go into more detail here – like bleach baths, which can also really improve eczema. You can discuss alternate treatments with your doctor.
4) Selenium sulfide doesn’t work for everyone. As a public health pediatrician this was one of my most frequent treatments for patients with cradle cap or fungal skin issues, but my daughter’s eczema has a scalp component that is itchy, rough, and flaky. Using selenium didn’t do much for her itching and didn’t change the rash, but it did give her head an unpleasant odor that also affected her washcloths. Odor: just a tiny detail. It also stings her eyes and must be removed carefully. It may get another shot as we move into round two of skin care, but I’m not expecting miracles.
5) Massage two or three or six times a day with the most nourishing ointment or oil that you can find. My current concoction is a homemade preparation of coconut oil, vegetable shortening, olive oil, shea and cocoa butter, and jojoba oil. But to be honest just the plain coconut oil or shortening works fine. It’s important to check the melting temperatures of your products (it’s easier to apply if it melts easily in the hand) and check labels before you buy – a cocoa butter cream typically has a very small percentage of cocoa butter and lots of other additives. Same goes with other preparations that include the ingredients I have listed above. Probably the cheapest and easiest thing is to just buy a tub of vaseline or unflavored vegetable shortening and call it a day, and boy do they both work well! I haven’t tried Aquaphor, but there are also other more expensive creams I have recently tried which contain ceramides, which are a component in skin cells that are generally lacking in skin with eczema. Unfortunately these preparations haven’t helped my daughter much, so I don’t bother with that anymore.
6) Be willing to try steroid creams for the skin, if the doctor recommends them When my daughter’s eczema started to arise I was the last person who wanted to try steroid creams, but with her most recent flare they did wonders to calm down the rash with just a few uses, and now we are willing to have Judicious use of creams as prescribed by the doctor. It is important, however, to use these very sparingly and only as needed because steroid creams can thin the skin and are absorbed by the body – and too many steroids can affect hormones in the body, so still be careful.
7) Diet can be related to eczema As a very young pediatrician this was something that I didn’t buy into before, but now that it’s my own kid – dietary restrictions were some of the first changes that I made in my daily routine. The dermatologist mentioned that in her experience food allergies can be related to eczema, and I will never forget a child who I met in residency who had a terrible infected eczema case and when I met him a few months later, when several food allergies had been identified, he also had much improved skin. There may not be credence to me restricting my dairy and egg intake, but I have been able to manage this change and I do notice a change when I do “cheat” on the diet.
In any case I hope that this was helpful and I welcome questions and commetns. I have had lots of people suggesting various guidance and as I learn more I will try to post. In my new job I am writing a ton, so scratching that itch has made me blog much much less than I normally would, but staying off my computer at home has also meant me enjoying each day with the kdidies. Now time to enjoy a good night’s sleep!