Transcription:
How to Manage the Itchy, Painful Effects of Infantile Eczema

Melanie Cole (Host):  Welcome. Today we’re talking about infantile eczema is Dr. Beth Nieman. She’s a Washington University Pediatric Dermatologist at St. Louis Children’s Hospital. Dr. Nieman, I know we’re speaking to other providers but as a mother, whose baby had this, I’m really interested in this topic. It’s a great topic. So, thank you for joining us. Tell us what is infantile eczema or atopic dermatitis?

Elizabeth Nieman, MD (Guest):  I’m actually excited to hear that you are also a mother of a child who had eczema. My second child had atopic dermatitis or infantile eczema. And I think that living it and kind of experiencing it firsthand really changes how you think about it and kind of your understanding of how it impacts the whole family and how it really changes the mood in the home when your child is uncomfortable, they are itchy, and they are not sleeping. So, this is an important topic to discuss.

So, infantile eczema or atopic dermatitis is incredibly common. It is the most common inflammatory skin disease in the United States. And it’s a really complex process that’s driven both by underlying genetics that are risk factors plus the immune system and inflammation and then the environment and also the microbiome. So, it’s very complicated and we’ve been learning a lot about it and we actually declared this the decade of eczema and so we have a lot of exciting news that we get to share and learn over the next few years.

Host:  So, as a complicated inflammatory skin process, do we know what causes it? Is there a genetic component? Tell us a little bit about what we do know.

Dr. Nieman:  What we do know is that it’s what we call multifactorial so meaning there’s many different things that lead to the development of atopic dermatitis. There’s definitely a genetic component to it. And some of the genetics is still being worked out but some of it is well-known and clear. So, for example, one of the biggest risk factors for developing atopic dermatitis is having a variant or a mutation in filaggrin and that presents in these children as having hyperlinear palms, hyperlinear soles and often they will have this kind of dry plate like scale.

So, when you have that variant in filaggrin we call it ichthyosis vulgaris and the root of that word ichthyosis means scale and vulgaris means common. So, the common scale or the common dry skin. And this often will present before eczema does so sometimes in clinic when I see babies who come in, and they are very dry, they have hyperlinear palms and soles; I know that they are going to be high risk to develop eczema and we start working right away on moisturizing those children to try to decrease that risk.

The other question you asked is well what else is there? We know that these children are shifted in their immune system. They are driven more to what we call a TH2 process and often this is inherited and having a family history of mom having a history of eczema is the highest risk factor for getting eczema and then having either parent with a history of other atopic diseases also increases your risk but a history of both parents with atopic disease actually can increase your risk of getting eczema three to five fold.

So, knowing that that’s there, that genetics behind it are definitely strong. And then the other thing we know is that there is also a shift in the microbiome of these children. They carry different colonization of bacteria on their skin and have a much higher rate of being colonized with staph aureus and this drives the eczema and makes it worse, drives that immune system activation and actually makes our treatments less responsive. So, it’s important to kind of think about all of those different factors when you are managing the eczema.

And then we also know environment weighs in as well. Kids who live in urban environment have a much higher risk of eczema than kids who live in a rural environment. And it’s not entirely clear why all that is right now. But it helps us to stratify and know who is going to be more at risk for developing eczema.

Host:  Wow, that was so interesting. So, Dr. Nieman how does it present? Tell us a little bit about the clinical presentation as it turns into eczema and what would send a child even to their doctor because they can get it on their knuckles and on their hands or on their legs, their face. It can happen anywhere. Tell us what it looks like and how is it different than a rash we might see?

Dr. Nieman:  For atopic dermatitis, or eczema, the actually the age of the patient can effect the way that the eczema presents. So, in dermatology, we kind of break eczema down into a few categories. So, we have infantile eczema which I know is what we are focusing the most one today. And that usually presents somewhere in the first few months of life and we kind of keep it in that category until they are about two years of age. And the distribution of eczema when they are younger is different than the distribution of eczema as people get older.

So, in kids, when it first starts; it’s really acute meaning that it’s very weepy. They have these big red angry plaques. They get crusted from them and that’s different then when kids are older, and it becomes those kind of chronic thick what we call lichenified or recurrently rubbed kind of thickening of the skin. It’s a much more of a inflammatory process when kids are younger. And it’s really high on the cheeks and on the face in kids and it also tends to involve what we call the extensor extremities so kind of that outer part of the arm running down as opposed to as kids get older, in what we call childhood eczema; it tends to be more focused into the creases. So, those arm creases or that antecubital fossa and then the back of the leg creases or what we call the popliteal fossa.

And then what’s really important for eczema is recognizing that it tends to spare the diaper area. So, if you have a rash that’s heavy in the diaper area; then we know that we should be thinking about other diagnoses. The other clue for eczema is that it’s just exquisitely itchy. So, these kids are itching. They are uncomfortable. They are having trouble sleeping at night. And when we think about diagnosing eczema, we have the things we call the essential features. So, it’s that typical pattern of rash, in addition for them being itchy and then we also have what we call the important features which is thinking about how old is the kid, did it start before the age of five, is there family history of eczema or other atopic disorders, does this child have other history of atypia as well.

Host:  So, if a parent brings their baby to their pediatrician; what are some ways pediatricians can treat the condition before referring to a specialist? What do you recommend whether it’s Aquaphor or probiotics or what do you tell pediatricians they can try first before referring to the specialist?

Dr. Nieman:  We know that early moisturization and use of emollients can be helpful in decreasing severity of eczema and there’s some research that shows it may have the potential to decrease the development of eczema. It’s very low level evidence in that research but it’s very easy to moisturize your child consistently. So, if it may help, I do recommend people doing it. So, if you know mom has a history of eczema, or there’s other risk factors; starting out early with frequent moisturization.

When we think about moisturizers there are ointments, and then oils and then creams and then lotions. And ointments and oils are really the best as far as a moisturizer goes so examples of an ointment would be something like 100% Petrolatum or plain Vaseline, Aquaphor as you mentioned and then oils are things like 100% virgin coconut oil, or jojoba oil or sunflower or safflower oil and I really like the ointments and oils more than I like the creams and lotions because creams and lotions have inherently had water or alcohol added to them. They have more preservatives in them and things that sometimes can irritate the skin.  

And so in my kind of hierarchy of where I like to start, I really like to start with the ointments or the oils and moisturizing children at least two or three times a day especially if they are dry or at risk for having eczema. The studies have shown that when you are picking your ointments, that Vaseline or 100% Petrolatum is actually the most cost effective moisturizer and it actually has the least – it doesn’t have any additives to it so it doesn’t have any preservatives, it doesn’t have any fragrance so the least risk of developing any irritant or allergic contact reaction from it.

And so I use plain Petrolatum as the basis for a lot of my patients especially the little babies who have eczema. The other thing that’s important to recognize is that there aren’t any good studies that talk about the frequency of bathing children. So, I know historically, with eczema, it’s gone all different directions that you only want to bathe them once a week because you don’t want to dry out their skin or you want to bathe them every day to try to get off the irritating allergens from the environment, from their skin. And what the studies have shown is that the frequency is less important but what’s more important is consistently getting that moisturizer on their skin.

And then the other thing I always like to recommend is avoiding the use of soap or really limiting the use of soap as much as possible. Small infants and children are usually not very odorous, and they are not very “dirty” and they don’t need a lot of soap and I tell families to avoid it because even the best eczema soaps are going to pull moisture out of the skin and our goal is to continue to replace that moisture.

Host:  So, at what point should a pediatrician refer to a specialist? And tell us as a specialist, what is your approach to treatment and what can a referring pediatrician expect from you and your dermatology team?

Dr. Nieman:  When I think about referring to Pediatric Dermatology for eczema; it’s really those children who have eczema when you are starting to do all of that baseline gentle skincare guidelines and then they are using the low potency topical steroids like the hydrocortisone and their skin is not clearing or not responding or when the families are using it and as soon as they stop; the eczema comes right back. And those children really need kind of more help and more influence from the Pediatric Dermatologist.

Also, there is a nice article that was published through the British Journal of Dermatology just this year. And it’s called The Disease Trajectories in Childhood Atopic Dermatitis an updated and practitioner’s guide. And it’s a really nice article that goes over the risk factors for eczema, kind of talks about how – eczema is not the same in every child. And there’s certain things that you can recognize as risk factors of having more severe persistent disease.

So, for example, when the child comes into clinic, and you rate their eczema as moderate to severe; they are very young when it starts kind of in those early months of life, they have a family history of a parent or two parents having eczema. There’s multiple other atopic disorders going on. You look at them and they have that ichthyosis vulgaris or that filaggrin mutation in their skin and then they live in an urban environment. All of those would be triggers to think about referring those children for further workup for their eczema.

And I think the other question you asked me is what can they expect from me and kind of what is my approach to treating eczema. And so, when I talk to families about eczema, I kind of try to simplify that complex reason why kids have eczema into kind of the three fundamental things I think about. So, one is that we know kids who have eczema tend to be drier and they tend to have more sensitive skin. So, really creating a sensitive fragrant free environment for the child, try to reduce fragrance as far as a lot of families will do the Glade plugins or the Febreze room sprays or the essential oil diffusers. So, anything that’s imparting a lot of fragrance into the environment; we want to back off on that.

Also talking with the families about stopping bubble baths, limiting the soaps on the child, as soon as they get out of the bath, getting the moisturizer on and then moisturizing them multiple times throughout the day. And so, when the kids are little, and they start with that pretty severe eczema; I tell families it’s almost every diaper change that you need to get that layer of moisture replaced and back into their skin.

The next thing we talk about is the inflammation that we know kids who have eczema, are shifted genetically in their immune system to be more inflamed and more autoreactive and we talk about the other things we see that are part of the atopic march that show this. So, we talk about food allergies, we talk about asthma, we talk about seasonal allergies and when to anticipate that those may present if they are going to present, knowing that not every child who gets eczema has all of those different atopic conditions.

And then I spend a lot of time talking about food. Because I know that’s something that parents are worried about int his age group. So, we talk about how children who have severe eczema at higher risk of having food allergies. Maybe about 12-25% of them will. But that those food allergies are not driving the eczema. That they are two separate processes. And that it’s very rare for foods to make the eczema worse. Because what we don’t want to do is limit the nutrition that’s available to these children. And the American Academy of Allergy and Immunology recently released a statement guideline stating that it has not proven to be beneficial to change these children over to hydrolyzed formulas or more kind of broken down formulas and it’s better to kind of continue with a full diet and as we’ve learned from recent studies about early introduction of peanuts; that actually introducing highly allergenic foods earlier in life can actually decrease the risk of them developing food allergies later on. And then depending on the child’s severity of eczema, making sure we are doing that in a safe and controlled manner.

And then we talk about when their skin is inflamed; that we need to use the medicines to get that inflammation under control and depending on the severity of eczema, the age of the child, where the eczema is located; I go through the many different strengths of topical steroids that are available. So, there are actually seven different classes of topical steroids with one being the strongest and seven being the gentlest. And hydrocortisone including both the prescription 2.5% and the over-the-counter 1%; are in class seven. So, they are down in that gentlest strength of hydrocortisone. And I talk about studies that have been shown that with low potency topical steroids; the risk of internal side effects are very low and the risk of thinning the skin when the medications are used properly is very low to give them the empowerment to use the medicines twice a day until the eczema is clear.

And I think that’s the most important thing. I think a lot of times as parents, especially as you’ve had a child who has had eczema; we don’t want to overuse the medicines and we are afraid to overuse them. So, often we wait until the eczema is really flared and really bad and then we start the medicine and then we stop as soon as things kind of start to look better. And what studies have shown, is that if you actually start the medicines right away at the fist sign of eczema flare; we can get the flares under control faster and end up needing to use less medicine, long-term.

And also, if we use the medicines twice a day, until the eczema is clear; and clear in my mind means that when you feel it, you can no longer feel that roughness of the eczema on the skin; it feels smooth like the other skin and until the child is no longer itchy. So, when undress those babies and immediately they start scratching all over. So, when that has stopped; that means the eczema is clear. I don’t use skin color change as a marker because we know that eczema leaves behind color change in it’s wake. We call that post inflammatory hyper or hypopigmentation depending if it’s darker or lighter in that area. And that is not actually a side effect of the medicine; that’s a side effect of the eczema.

So, I really work hard with the parents to make sure that they start the medicines right away at first sign of flare and they use the medicines twice a day until the child is clear and then they get back on their gentle skincare routine while they were continuing that in the background the whole time. And then if I have a patient who presents to clinic and they’ve got a lot of those overlying erosions or sores on their eczema; that’s a sign that they are over colonized with bacteria. And those are patients where we really need to get the bacteria under control before we can get the eczema better.

And one way that we do that is by using dilute bleach baths. So, swimming pool baths. The same chlorination as a swimming pool and we just teach them how to make it at home. And that helps to get the bacteria under control and help to get the flare under control. So, the recipe for that is in a standard bathtub, it’s one fourth cup of plain regular bleach to a half tub of water. And then when the babies are still in the infant tub, the recipe is one to two teaspoons of regular bleach to one gallon of water. And they just do that twice a week. They soak in there for about ten minutes, rinse them off when you are done and immediately get either the medicines or the moisturizers on to their skin. And that can make a big difference for getting the eczema under control.

Host:  Thank you so much Dr. Nieman for joining us today and giving us such great information about eczema and the research going on today and treatments. Thank you again. That wraps up this episode of Radio Rounds with St. Louis Children’s Hospital. To consult with a specialist or to learn more about services and resources available at St. Louis Children’s Hospital; please call Children’s Direct Physician Access Line at 1-800-678-HELP. Or you can head on over to our website at www.stlouischildrens.org for more information and to get connected with one of our providers. If you as a provider, found this podcast informative, please share with other providers, share with your patients or on social media. And be sure to check out all the other interesting podcast in our library. Until next time, I’m Melanie Cole.