Atopic Dermatitis & Eczema

The Itch That Rashes ...

There are many good resources on this topic, so I won't reinvent this particular wheel, but since it comes up so often in our office, let me share my favorite sensitive skin and eczema tips. As to why this this is SO COMMON in our adoptees, particularly those from China, I suppose it's a combination of ethnic predisposition, climate, harsh orphanage soaps and detergents, institutional disinfectants, malnutrition, chronic stress, poor skin care, and lack of appropriate treatment. While atopic dermatitis is a chronic tendency towards sensitive, dry, rash-prone skin, it tends to eventually improve when children come home, especially with the techniques below ...

Everyday Prevention 

• Avoid triggers, like perfumed products, non-cotton clothes, dust mites, heat/sweat, bleach, disinfectants, and chemical/fragranced soaps and laundry detergents (try Charlie's Soap ...)
  
• Do bathe your child 1-2 times per day in tepid-warm water for 10-15 minutes. You can add oatmeal-in-a-stocking or Aveeno to the bath, but oils just make things very slippery. Minimal, if any, soap ... use unscented Dove, Cetaphil cleanser, or similar. Don't use Ivory, scented soaps, or bubble bath.
  
• Alternately, bathe 1-2 times per week. The "wet" and "dry" approaches to atopic dermatitis both work - it's the hot, soapy baths that aren't followed by moisturizer application that are trouble, as they remove protective skin oils and leave the skin dry and itchy.
• Immediately after the bath, pat your child somewhat dry, apply any necessary topical medication, and then dip your child into a big vat of thick, greasy moisturizer. Seriously, you need to be applying a greasy, scoop-it-out-with-your-hand moisturizing ointment at least once a day, to seal in moisture and provide a protective barrier for the skin. No pump lotions ... you need a TUB, like Cetaphil-in-a-tub, Eucerin, Vaseline, or similar products. Most contain petrolatum - it's been used for centuries and has a good track record. If you must avoid the petroleum products, vegetable shortening, shea butter, or other balms might be an option. Happy to hear feedback on these. Daily, religious moisturizing is the key to this chronic condition, especially in winter.
• Some newer "active" moisturizers are coming onto the market that are touted to be better at retaining moisture in the skin, and restoring the skin barrier. Some are also mildly anti-inflammatory, equivalent to hydrocortisone cream. They may be useful for children with moderate-severe eczema as a way to need topical steroids less often. Some of the ceramide products (CeraVe, Triceram) are over-the-counter; others, like MimyX and Atopiclair are by prescription.
  
• If you're in a hot climate, creams might be preferable to ointment mositurizers. Lotions still not recommended, since they can actually be drying to the skin.
  
• All-cotton clothes, ideally. No wool or short-fiber synthetics - they itch. Do thoroughly prewash new clothes to remove sizing and other itchy products.
  
• Keep nails trimmed and itchy areas covered by clothing.

Treatment Strategies

• For face, neck folds, armpit folds, and groin area, don't use anything stronger than Hydrocortisone 1% ointment (OTC) without discussing the pros and cons with your provider.
  
• For the rest of the body, prescription ointments like Desonide 0.05% (a low-potency topical steroid) or Triamcinolone 0.025-0.1% (a mid-potency steroid) twice a day will help itchy, inflamed areas that don't respond to hydrocortisone. Apply a thin layer underneath the moisturizer, and use only long enough to control the itchy flare. Not for daily longterm use - if it doesn't help by 1-2 weeks, see your provider.
  
• For those of you scared by the word "steroid", remember that chronic skin inflammation and itching is miserable, can cause infections, growth failure, sleep & behavioral problems, and overall irritability. Untreated eczema can cause longterm changes to the skin, just like overuse of potent topical steroids.
  
• I don't use Elidel or Protopic so much these days ... waiting for more safety data.
  
• For itch relief, an ice cube can substitute for scratching. Benadryl (OTC) or Atarax (Rx) at night (Allegra, Claritin, or Zyrtec during the day) are antihistamines that can help with miserable itching. Sometimes we need to use higher doses for severe itching - ask your provider what would be safe.
  
• Check behind the ears ... eczema likes that spot too.
• If an area is especially weepy, red, painful, or crusted consider using Bactroban cream for antibacterial help. If this is widespread, ask your provider about using an oral antibiotic to cover staph bacteria.
• Don't forget scabies ... very very itchy bumps on hands, feet, abdomen, or any really prominent, itchy, chronic-looking rash in a child residing in orphanage care could be scabies. Have it checked, and have a low threshold to treat with Elimite.

Complementary Approaches

• Probiotic supplements or daily active-culture yogurt or kefir seem promising for folks with eczema.
  
• Some studies suggest benefit from Evening Primrose Oil (EPO), which contains GLA, an omega-6 essential fatty acid. Some recent studies don't. Probably safe to try, in moderate-severe eczema, at 3g/day in divided doses. May take 1-2 months to work.
• Don't use tea tree oil - it may be antibacterial, but it can trigger eczema flares (and may have hormonal effects in boys).
• Consider dust mite control measures, like mattress/pillowcase covers, high-filtration vacuuming, and removing frilly dust mite traps in the room. May be more effective for asthma and nasal allergies, but kids with eczema often have those too.
• As for diet, perhaps 10-20% of kids with eczema have associated food triggers; this percentage is higher for infants or children with severe eczema. Generally, unless the eczema is chronic and more than a mild nuisance, I don't go chasing food allergies, since the only reliable test for food allergies is a strict elimination trial, with reintroduction of the suspicious food. Blood tests (RAST) and skin-prick tests can rule out certain allergens, but positive results may not indicate a true food sensitivity, so they are of limited use. Stay alert for quackery when it comes to this issue, consult your provider and an allergist if need be, and please involve a nutritionist if you are considering prolonged eliminations of major food groups, especially in young children.
  

Atopic Dermatitis Links

• Atopic dermatitis: Taming "the itch that rashes" - Contemporary Pediatrics
• Article about the newer "active" moisturizers
  
• Diet and Eczema

  Overview from the (British) National Eczema Society

Café-au-lait Spots and Neurofibromatosis

There is a group of genetic neurologic conditions called neurocutaneous syndromes where skin findings can be the first clue to a broader syndrome. One of the most common is neurofibromatosis type 1 (NF1), which occurs in up to 1 in 3000 individuals. This is a condition where benign tumors grow on nerve tissue, causing skin, bone, and sometimes brain issues.

One of the first signs of NF1 can be "café-au-lait spots", which are typically light to dark-brown flat, discrete, round or oval skin patches. These spots become more common with age, and can be more common in African-Americans, but most of us have 3 or less. If more than 5 café-au-lait spots (>5mm each) are seen, this should be considered NF1 until proven otherwise. Other findings like freckling in the armpits or groin, or firm, rubbery neurofibromas typically show up later, in preadolescence. Many with NF1 only develop a few fibromas, but they can be quite cosmetically significant for some.

Mental retardation is rare with NF1, but attentional and specific learning issues are common in this disorder. While fibromas are benign, there is a somewhat increased risk of malignancy (3-5%), and brain fibromas can be associated with epilepsy. Short stature and large head are common in NF1.

The majority of folks with NF1 have mild disease, and complications are often correctable to some degree. Treatment focusses on surgery for painful or cosmetically significant fibromas, and addressing learning issues through early intervention and school supports.

Here are the diagnostic criteria for NF1 (2 or more are required for the diagnosis), from GeneReviews:

• Six or more café au lait macules over 5 mm in greatest diameter in prepubertal individuals and over 15 mm in greatest diameter in postpubertal individuals
• Two or more neurofibromas of any type or one plexiform neurofibroma
• Freckling in the axillary or inguinal regions
• Optic glioma (tumor of the optic pathway)
• Two or more Lisch nodules (iris hamartomas)
• A distinctive osseous lesion such as sphenoid dysplasia or thinning of long bone cortex with or without pseudarthrosis (related orthopedic issues)
• A first-degree relative (parent, sib, or offspring) with NF1 as defined by the above criteria

Additional Resources:

• Understanding NF1 - a great resource from Harvard, with consultation video discussions
• The Children's Tumor Foundation, another NF resource for families
• The National Neurofibromatosis Foundation
• NF1 information from KidsHealth
• NF1 on MedLinePlus
• NF1 on DrGreene
• Article about neurocutaneous syndromes in general
  

Diaper Rashes

Want an advanced degree in diaper rash management? This excellent article from Pediatric Nursing takes you deep into the world of diaper pastes, for when Desitin just isn't cutting it anymore:

•  "Diaper Rash Care and Management"

Me, I'm a big fan of the descriptively named Boudreaux's Butt Paste for your basic diaper rashes and irritations. It works well, smells good, and, well, it's called Boudreaux's Butt Paste.

Another good option is Triple Paste. I use this on raw diaper rashes that need a really tenacious barrier paste.