Childhood eczema can be a concern for parents and upsetting for children. Our expert answers your questions on this tricky topic.
Dr Carsten Flohr Senior Lecturer & Consultant in Paediatric Dermatology St John’s Institute of Dermatology Guy’s & St Thomas’ Hospitals NHS Foundation Trust
Q What dose and duration of topical steroids should we use with children, and how does this differ with age?
A As a quick reminder, the common topical corticosteroid (TCS) preparations are: 1% hydrocortisone (mild), 0.05% clobetasone butyrate (Eumovate, moderately potent), 0.1% betamethasone valerate (Betnovate, potent), and 0.05% clobetasol proprionate (Dermovate, very potent).
Q What topical steroids are safe to use on the face? And are there any areas which require stronger steroids?
A In infants, mild TCSs are safe to use on the face, where the skin is thinner. In older children this can be increased to moderate strength TCSs without concern. An exception are the eyelids, where only mild TCS should be used. The arms, the trunk and the legs should, in my view, only be treated with moderate-to-potent steroids, as under-treatment of the skin inflammation is more likely to lead to more frequent flares and disease chronicity. However, it is not only the strength of the steroid that matters but also the length of treatment. Generally speaking, applying topical steroids for only one or two days does not settle the skin inflammation sufficiently, meaning the eczema often rebounds quickly upon stopping treatment.
Q Can we ever instigate topical pimecrolimus or tacrolimus in primary care if steroids are not tolerated or if there is parental objection to their use? What special precautions are needed?
A Topical calcineurin inhibitors (TCIs) were introduced to the UK market more than 10 years ago and are approved for use in moderate to severe eczema in immunocompetent patients over the age of 2 years; tacrolimus 0.1% only from 16 years of age. There was concern about their use based on animal studies in association with oral ingestion, suggesting a higher risk of malignancy. However, this has not been confirmed with topical use in humans, and there is nothing to stop a GP from prescribing pimecrolimus or tacrolimus, provided they have experience in their use, as many GPs with a special interest in dermatology have.
Q Any good tips which can be shared with parents?
A Parental eczema education, especially with regard to the use of topical treatments, is an important part of disease management. This includes reassuring parents that adequate use of TCSs will not thin their child’s skin (see above for guidance on steroid strength in the face and on the body at different ages). Unfortunately, GPs working under tight time constraints in their clinics may find it difficult to spend too long on eczema education. However, experienced practice or community nurses are often an excellent additional source of information for parents and patients.
- The application of moisturiser and TCSs should be separated by 20-30 minutes to avoid diluting the steroid. The moisturiser should be applied ﬁrst
- The greasier the moisturiser the better the emollient effect
- Soaps should be avoided, as they dry out the skin and are a potential skin irritant.Most moisturisers can be used instead
- There is little evidence that bath emollients provide additional help in controlling eczema
- It is important that an emollient is used directly after a bath or shower. If applied several times daily to the whole body, children will require at least 250g per week and adults 500g per week
- Sports are not contraindicated and improve quality of life
- With regard to swimming, showering directly after coming out of the water followed by ample application of a greasy moisturiser helps to prevent chloride-induced skin irritation
- There is no good evidence that exclusive breastfeeding beyond three months of age protects against the development of eczema
- Non-biological washing powder is not better than biological ones.
Q Are there any complementary therapies available, and is there any evidence to support their use?
A A long list of complementary therapies and dietary supplements are being used in the treatment of eczema. There is limited evidence from a small number of randomised control trials that systemic traditional Chinese medicine compared with placebo might improve eczema both in children and in adults. Evening primrose oil taken orally might also have an effect in some cases of moderate to severe eczema, but again the evidence for this is weak. It should be given in doses of 160-320mg daily in children age 1-12 years and 320-480mg in older children and adults for three months. If no improvement is noted after that period, it is unlikely to be helpful. Clinical trials on other complementary therapies, such as homeopathic remedies, multivitamin supplements, acupuncture, hypnotherapy, massage, or aromatherapy have not shown any clear benefit.
Q Is there any difference between the efficacy of the different moisturisers available?
A The choice of moisturisers is staggering. Unfortunately, there is little research evidence available to help us choose between different preparations. Even in a specialist setting, we encourage patients to try different emollients to see what suits their skin type and dryness best. As a rough guide, creams are used for mild-to-moderate skin dryness, with greasier preparations being used for more stubborn skin dryness. Lighter creams are more suitable for frequent daytime application, as they sink in quicker, while a once daily ointment used at night time might be enough for some. There are now also emollient sprays on the market, which many teenagers prefer, as they can be applied quickly. Again, it is best to give the patient a choice, as this is likely to enhance adherence to treatment. Please see Emollients for eczema below.
Q What is the role of antihistamines?
A Histamine is not a main mediator involved in the itch pathway in eczema. This is probably why non-sedating antihistamines rarely make a difference. We occasionally use sedating antihistamines, such as chlorpheniramine, to help a child fall asleep. I only use non-sedating antihistamines during the day in children who have immediate-type allergies (eg, hay fever), in particular with known sensitisation to grass and tree pollen. In such cases, eczema is often strikingly focused on the face, neck and arms.
Q When should eczema be referred?
A NICE guidelines for childhood eczema are quite clear and suggest referral to secondary care where:
- The diagnosis is uncertain
- There is inadequate disease control based on subjective assessment by the child or parent/carer (eg, one-two weeks of flares/month or reacting adversely to topical Rx) There is need for advice on specialist treatments (eg, wet wraps)
- Contact allergy is suspected
- There is significant quality of life impairment
- A child experiences recurrent skin infections, and
- Where food allergy is suspected as a main trigger factor.
Q When should we consider an underlying food allergy if a child presents with eczema and what are the next steps of management?
A Food allergy should be suspected in all children with moderate-to-severe eczema, and which does not respond to adequate strength topical treatments, especially if the child is under six months old and skin infection has been ruled out as a trigger factor.
Emollients for eczema (MIMS)
• Aquadrate (Urea)
• Aquamax Cream (Paraffin, liquid, Paraffin, yellow soft)
• Aquamol (Liquid paraffin, Paraffin, white soft)
• AquaSoothe (Aqueous cream, Menthol)
• Aqueous cream
• Aripro (Glycerol, Propylene glycol)
• Aveeno (Oatmeal)
• Balneum (Soya oil)
• Calmurid (Lactic acid, Urea)
• Cetraben (Paraffin, light liquid, Paraffin, white soft)
• ClearZal Hard Skin Remover (Salicylic acid, Trichloroacetic acid, Urea)
• Decubal Clinic
• Dermacool (Aqueous cream, Menthol)
• Dermalo (Lanolin, Paraffin, liquid)
• Dermatonics Once Heel Balm (Urea)
• Dermol (Benzalkonium chloride, Chlorhexidine, Isopropyl myristate, Paraffin, liquid)
• Diprobase (Paraffin, liquid, Paraffin, white soft)
• Doublebase (Isopropyl myristate, Paraffin, liquid)
• E45 (Lanolin, Paraffin, light liquid, Paraffin, white soft)
• Eczmol (Chlorhexidine gluconate)
• Emulsiderm (Benzalkonium chloride, Isopropyl myristate, Paraffin, liquid)
• Emulsifying Ointment
• Enopen (Liquid paraffin, White soft paraffin)
• Epaderm Cream (Emulsifying wax, Paraffin, liquid, Paraffin, yellow soft)
• Epimax (Paraffin, liquid, Paraffin, white soft)
• Eucerin (Urea)
• Fifty:50 (Paraffin, liquid, Paraffin, white soft)
• Flexitol Hand Balm (Dimeticone, Urea)
• Hydromol Ointment (Emulsifying wax, Paraffin, liquid, Paraffin, yellow soft)
• Infaderm Therapeutic Oil (Almond oil, Paraffin, liquid)
• Kamillosan (Chamomile)
• Lipobase (Paraffin, liquid, Paraffin, white soft)
• Liquid Paraffin/White Soft Paraffin
• LPL 63.4 (Light liquid paraffin)
• Nutraplus (Urea)
• Oilatum Cream (Paraffin, light liquid, Paraffin, white soft)
• QV Cream (Glycerol, Paraffin, light liquid, Paraffin, white soft)
• R1 Gel
• Sudocrem (Lanolin, Zinc oxide)
• Thirty:30 (Emulsifying wax, Parrafin, yellow soft)
• Ultrabase (Paraffin, liquid, Paraffin, white soft)
• Unguentum M (Paraffin, liquid, Paraffin, white soft, Silica)
• ZeroAQS (Macrogol cetostearyl ether)
• Zerobase (Paraffin, liquid)
• ZeroCream (Liquid paraffin, Paraffin, white soft)
• Zeroderm (Paraffin, liquid, Paraffin, white soft)
• Zerodouble Gel (Isopropyl myristate, Liquid paraffin)
• Zeroguent (Paraffin, light liquid, Paraffin, white soft)
• Zerolatum (Liquid paraffin)
• Zeroneum (Soya oil)
1. http://www.nice.org.uk/guidance/cg57/ resources/guidance-atopic-eczema-in-children-pdf