Eczema

Eczema (also called atopic eczema or atopic dermatitis) is a very common dry skin condition. It affects about 1in 5 babies and children in the UK. Eczema often appears in the first few months of life. Eczema usually improves in most children as they get older, but some children with more severe eczema may continue to have eczema into adult life.

Eczema can cause the skin to become itchy, dry, cracked and sore. Sometimes, children with eczema make may have periods where the eczema becomes more severe (flare ups).

Many things, called “trigger factors” can make the eczema worse. These include:

Irritants such as soap, clothing (wool, polyester), cigarette smoke, chlorine in swimming pools
Changes in the climate such as drier air or temperature (too cold or too hot)
Environmental allergens such as house dust mite and moulds
Viral illnesses
Hormone changes
Stress and anxiety
Rarely foods:
- Immediate reactions (less than 1 hour) after eating
- Delayed reactions (4 to 6 hours) after eating with a flare of eczema

The National Eczema Society has more information about household triggers and how to manage them

There is currently no cure for eczema, however avoiding trigger factors and using of moisturisers 3 to 4 times a day can help keep it under control. Your local community pharmacist or GP can advice you if other treatment for eczema is needed.

The exact cause of eczema is unknown. It is not down to one thing. Atopic eczema often occurs in people who get allergies. “Atopic” means sensitivity to allergens. This type of eczema can run in families, and often develops with other conditions like asthma and hay fever.

If you are worried that the eczema rash looks different to normal please see our page on rashes for advice on where to seek help.

Eczema in babies often appears at between 3-6 months of age. It can develop anytime after birth or in childhood.

The main features of eczema are:

● Intense itch

● Dry skin

● Rash

● Redness

The main symptom is itchiness. Scratching in response to an itch may cause many of the changes seen on the skin. The itch can be severe enough to interfere with sleep, causing tiredness and irritability. Typically, atopic eczema goes through phases of being severe, less severe, and then gets worse again. Sometimes a flare-up can be due to the 'trigger factors' as above, but often no cause can be identified.

In infants and babies, eczema affects the face, scalp and body. It does not usually affect the nappy area. As your child grows older the pattern of eczema changes. It affects the skin behind the elbow and the knee. In some children it affects the whole body.

In children of Asian, black Caribbean or black African ethnic groups, eczema can affect different places including the front surface of the knee or wrist. It can also look different with the skin being bumpy and slightly darker instead of red

It is important to be aware of and look for signs of worsening eczema:

Recognise a flare: A ‘flare’ is a worsening of the eczema. Skin may become red, sore, (more)itchy, crack or bleed
Recognise infected eczema: If skin suddenly worsens, weeps fluid or crusts it could be infected and your child may need antibiotics. Seek urgent advice if your child is unwell or the infection is widespread.
Blisters or cold sores need urgent antiviral treatment. See your GP or seek medical advice the same day.
Food allergy: this is rare. Consider food allergy if eczema started as a baby. It is not usually the cause of eczema in older children

Atopic eczema can affect any part of the skin, including the face, but the areas that are most commonly affected are the creases of the joints at the elbows and knees, as well as the wrists and neck. The affected skin is usually red and dry, and scratch marks (sometimes accompanied by bleeding) are common. When atopic eczema is very active, it may become moist and weep during a flare-up and small water blisters may develop, especially on the hands and feet. In areas that are repeatedly scratched, the skin may thicken (a process known as lichenification) and this may cause the skin to itch more. Sometimes affected areas of the skin may become darker or lighter in colour compared to the surrounding, unaffected skin.

Picture credit: Skin Deep is a project developed by two groups in the UK who aim to produce resources that educate professionals and the public about skin presentations in children with different skin colours.

The features of atopic eczema are usually easily recognized by health visitors, practice nurses and doctors, when they assess the skin. Blood tests and skin tests are usually not necessary or helpful.

Your healthcare professional should:

1. Recognize that your child has eczema or an eczema flare

2. Find out whether anything seems to make the eczema worse or better? You may be asked about irritants (e.g. washing products, toiletries, bathing) and triggers (e.g. foods, toiletries, pets, heat and cold) and what creams or lotions you are using

3. Help you to manage symptoms by providing a management plan or refer you to someone who can provide you with a management plan

4. In rare cases if your child has severe eczema or is not improving despite treatment, your GP surgery may refer your child to a specialist clinic e.g. dermatologist (skin doctor), allergy specialist or pediatrician (children's doctor).

A child with eczema has a slightly faulty skin barrier, which lets water out and allows dust, irritants and bacteria in. Moisturiser (emollient) helps repair and protect the skin barrier. Redness caused by inflammation is treated with steroid creams (topical corticosteroids).

Treatment for your child's atopic eczema should be 'stepped up' or 'stepped down' depending on how severe the eczema is. For instance, if the eczema gets worse, your doctor may advise using a different treatment.

Different areas of skin may need to be treated differently if the eczema is more severe in some places than others.

Flare treatment should be started as soon as symptoms appear, and carried on for at least 48 hours after the flare has stopped.

Bathing & Showering

● Avoid Bubble baths and perfumed products (some of the eczema bath products can provide bubbles if put in running water)

● Use your moisturiser (emollient) or a soap free wash to cleanse skin. Soap or soap based products can dry the skin.

● Bath water should be tepid or lukewarm as heat is a common eczema trigger

Skin should be patted dry after bath

See your doctor if:

You need advice on recognising 'flares' of atopic eczema - this is when the skin becomes more dry, itchy, red or swollen. They should discuss this with you and make sure you have all the information and treatments you need to manage the atopic eczema when there is a flare.
Eczema is infected. It may be pustules, blisters, painful, weeping fluid. Antibiotics may be needed
Eczema is not going away with regular daily use of topical steroids for 2 weeks
Eczema is causing waking at night, missing school or mood problems

● Emollients are moisturisers that soften the skin. It is okay to try different emollients. Talk to your GP or nurse if you do not like one you have been given

● Expect to use large amounts. A large tub (250 to 500 g) per week

● Use everyday, all over

● You may need to change emollient type if one does not work

● Emollients form a protective barrier on the skin

● Emollients are best used few minutes after a warm bath, while the skin is still slightly damp

● Emollients are safe so they can be used as many times a day as needed

● Use at least 2 times a day when skin clear but increase to 4 to 6 times a day during flare ups or when the skin looks dry

● Do not put hands in tubs of emollients as these can introduce “bugs” easily. This is a common reason for repeated skin infections in eczema. Use a clean spoon or spatula to get emollients out of the tub

● For school and for older children and young people emollients with pumps may be better

● Apply in direction of hair growth. This reduces the chance of infection

● Fire hazard. Most eczema treatments contain paraffin and are flammable

Visit our Healthier Together page for more information on how to apply eczema treatments

How do emollients work?

Emollients provide a coating on the skin which help the broken skin barrier and improve the level of moisture. A variety of different types can be used at different times of the day depending on the condition of your skin e.g. a cream may be preferred during the day with an ointment at night.

The vast majority of emollients can be used as a soap substitute. Regular soaps can be drying for skin and cause irritation.

How much emollient is enough?

A thin shiny layer to the skin should be sufficient to all the affected areas. If treating the whole body approximately:

600g per week for an adult
250-500g per week for a child.

Top tips for emollients

As a moisturiser

Smooth onto clean skin and apply as often as needed to prevent the skin becoming dry. Ideally it should be applied 2-4 times per day.

As a cleanser

Apply liberally to the skin and wipe off with single layer of paper tissue, taking care not to damage fragile skin.

As a soap substitute

Mix emollient with water in palm to form lather. Apply to the skin in a downwards direction. Gently rinse lather off skin leaving a thin layer of the ointment on the skin. Pat dry.

In the bath

Ointments can be dissolved in water. Add a spoon full of ointment to a small amount of hot water in a jug. Then add to the bath water. Take care of the temperature of the water and when getting out of the bath, as it will be slippy.

How should emollients be applied?

Step 1

Always wash your hands for 20 seconds before applying a topical corticosteroid.

Step 2

Do not put your fingers into the tub as this can introduce bacteria and cause infection. Use a clean spoon or a spatula to take your emollient out of the tub.

If your emollient is in a pump this can be done straight on to your clean hands.

Step 3

Apply to the affected area in a downwards motion following the hair growth.

Do not rub in as this can block the follicles and cause infection.

● Steroid creams and ointments are treatments for flare ups of eczema and help heal the skin. Steroids come in different strength from mild to strong steroids.

● Steroids are safe when used in short courses as advised by your doctor. When applying it is important to apply sparingly to the skin so that skin glistens.

● Use topical steroids once a day to eczema that is red and itchy. Stop when no longer red and itchy and restart if eczema comes back

● Leave a gap of 20 mins between applying your emollient and steroid. This is so that the topical steroid is not made less effective by the emollient.

Visit our Healthier Together page for more information on how to apply eczema treatments

What are topical corticosteroids?

Topical corticosteroids are a form of medicine applied directly to the skin which helps reduce inflammation, redness and irritation. The type of steroid is similar to those produced naturally in the body.

What are the different strengths of topical steroids?

Your doctor or specialist nurse will identify the correct strength of steroid for different parts of the body and discuss how to increase or decrease treatment appropriately using the steroid ladder.

TCS ladder 2023

Topical corticosteroids are used on adults, children and young people. More potent steroids are typically in adults used on the affected areas on the body and mild/moderate steroids on the face and skin folds (under arms, breast folds, groin and genitals).

Children and young people will be guided by their doctor or specialist nurse with the use of mild and moderate steroids however when required potent steroids will be used when treating severe skin conditions.

How long should I use topical corticosteroids?

It is important that you follow the treatment plan given by your doctor or specialist nurse in order for your skin to avoid a flare of your skin condition. If used correctly topical corticosteroids should not cause side effects. Thinning of the skin and stretch marks will occur only if a strong steroid is used incorrectly or over a prolonged time.

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