Atopic eczema
What is atopic eczema?
Atopic eczema is mainly a condition of childhood. Studies vary concerning how much eczema persists into adult life. More than 70 per cent of children improve considerably, but probably around 50 per cent will still have some eczema in adolescence and possibly later.
The diagnosis of eczema usually becomes obvious within the first year of life, although parents often say that their child’s skin was not quite right from birth. Areas of gentle rubbing look sore, the skin becomes red and blotchy for little reason, and creases or patches on the face may look angry.
The diagnosis is not easy to make straight away, however, because many babies have a range of non-specific rashes that are difficult to interpret without seeing how they develop over time. If your child has any persistent skin problems, even in the first year, you may want to ask your doctor for an opinion, bearing in mind that the doctor may have difficulty being precise.
Recognising atopic eczema
A patchy dry rash on the face is a common sign of atopic eczema in the first six months of life. Although the area beneath the nappy may be spared, atopic eczema can also contribute to soreness around the anus. Pointers to the diagnosis of atopic eczema in your baby’s first year include:
• generally dry skin
• problems in skin creases
• worsening of symptoms when near pets
• worsening of symptoms when using soap or bubble bath
• restless rubbing and scratching activity.
Later, your child may get a more typical skin rash, allowing a clearer diagnosis. The fact that the rash has persisted makes the diagnosis of atopic eczema more likely, especially if there is a family history of atopy (asthma, hay fever and eczema).
Often a parent or grandparent recognises the problem because he or she or another child has had it, although the character of atopic eczema may vary in different family members, particularly at different ages.
The condition can vary in severity from a little dryness behind the knees in winter to a troublesome all-over rash that seems to go on for years. Milder cases may just cause a few dry patches in the early years, which get worse if other factors, such as swimming in chlorinated water or wearing woollen clothes, are involved.
Why has my child got eczema?
Atopic eczema is largely determined by a mix of factors. These include your environment, habits, age and the genetic make-up you have inherited from your parents.
If both parents have eczema, the chance of any child inheriting the same problem is about 50 per cent. This drops to 25 per cent if only one parent has eczema.
Is eczema caused by an allergy?
In general, eczema is thought to result from an inherited tendency of the immune system to over-react. Several typical things can set this reaction off, such as contact with dogs, cats, horses and hay, and it is reasonable to say that there is an allergy to these specific things.
However, allergy is not the underlying cause of the eczema, which usually remains even if you avoid these things completely. The skin continues to be red and angry, with no obvious cause other than the background family history of eczema or related conditions.
Sometimes the concern is about allergy to foods. In the first year or two of life, cows’ milk products may sometimes make eczema worse, but the data on this are conflicting.
Is eczema caused by loss of barrier function of the skin?
Recent evidence suggests that it is common for people with atopic eczema to have a mutation in a gene that controls the production of a protein called filaggrin. Filaggrin is important in holding together skin cells called keratinocytes.
If it is defective, the skin may be more vulnerable to breaks and the damaging effects of irritants on the surface, such as water and washing materials. The overall effect is that the skin has a reduced barrier function, which normally protects the body from the outside world.
Will my child grow out of atopic eczema?
Atopic eczema usually improves significantly after the first few years of childhood and has often gone almost completely by adolescence. Figures vary, but suggest that 50 to 90 per cent of children grow out of it by their teens. Those who continue to have eczema usually improve greatly, even though they may have some residue of eczema that continues to affect their lives.
As children get older and become adolescents, they tend to develop a more fixed pattern of skin trouble related to their eczema. This may be fixed patches of dry skin, a tendency to rub in certain areas or soreness when clothing rubs in certain patterns, such as wet swimming costumes on holidays.
What if eczema persists?
Some adolescents may continue to have active eczema, but again it usually takes on a more fixed pattern than in infancy. This pattern can evolve, such that there might be periods when the eczema is active on the face, for no apparent reason, or starts to become more widespread.
What causes the pattern to change?
When these patterns change, the child and parents will naturally seek a factor that may be responsible for this. Typical points will be the change in season, possibly connected with central heating, new washing habits, new hobbies or sports, or any of the factors that we know may alter eczema at any stage in life. However, in spite of searching, new factors may not be found and, after a period of more intensive treatment, the eczema will usually return to the more settled pattern.
What if bad eczema persists?
A small percentage of adolescents (less than 10 per cent) will continue to have difficult eczema affecting a large part of their skin. These children may continue to have shared medical supervision between the GP and hospital, and may at times need tablet treatments to suppress their immune system.
Can tests determine whether the eczema is caused by allergy?
There is no consistently good way of testing a child with atopic eczema for allergy. Tests can be misleading and your observations are usually more reliable than any test in telling whether you or your child has an allergy.
Most doctors believe tests are not helpful in the diagnosis of atopic eczema in babies. However, in some situations where the diagnosis is unclear in older children and adults, a test may be performed. Possible tests include:
• blood test to measure immunoglobulin E (IgE)
• prick test
• radioallergosorbent test (RAST)
• patch test.
Testing for IgE
The immunoglobulin IgE is one of a family of antibodies. Antibodies are proteins carried in the blood that are capable of sticking to cells and bacteria as part of the process of clearing infection from the body (antibodies are the ‘foot soldiers’ of the immune system).
IgE sticks to specific substances and triggers a reaction that causes the redness seen in atopic eczema. The substances attacked may be proteins from animal dander, house-dust mite or grass pollen. IgE is present in everyone, but is high in most people with atopic eczema.
Prick testing
Prick tests are another form of test for IgE and are only rarely thought to be necessary or helpful in atopic eczema. A range of proteins commonly thought to cause problems in atopic people is tested against the skin of the arm. Common examples are proteins from dogs, cats, horses, donkeys, rabbits, hay, pollen, feathers and dust. The arm used must be free of eczema.
The arm is held out, palm up, and a drop of dilute protein from each source to be tested is placed on the arm and labelled. A small scratch is then made through each drop, so a minute amount penetrates the skin. If the skin is sensitive to that particular protein, a red reaction may develop.
RAST
Radioallergosorbent tests are rarely performed. They attempt to examine sub-families of IgE which react to specific substances that can make eczema worse, such as certain foods or those examined in prick tests. RAST requires a blood test, and results are usually scored between 0 and 6, where 6 indicates a high level of IgE to a particular substance and 0 means that none is detectable.
Unfortunately, RASTs and prick tests are unpredictable and not as specific as theory would suggest. Some people who know they get worse when exposed to animals such as horses or dogs may find the relevant tests are negative. Or they may know that they have no problems with cats, yet the test is positive for cat protein.
Patch tests
Patch tests are a way of diagnosing allergic contact dermatitis and are rarely performed in atopic children. As people get older, however, they may have both atopic eczema and allergic contact dermatitis, so there is sometimes a reason for undertaking patch tests in adults. Patch tests are described in detail under Allergic contact dermatitis (see www.truetest.com for information on the internet).
Coping with atopic eczema
As a parent many different worries will pass through your mind when you have a child with eczema. From the psychological point of view, there are many important things you can do to help both you and your child cope with eczema.
Be positive
Your child may need encouragement through difficult episodes if his or her eczema is bad. People at school may ask questions, and make unpleasant comments. Affected children may have questions themselves such as ‘When will my skin be normal?’ and ‘Will I ever stop itching?’.
Throughout this you need to keep a level head and remember that the condition is likely to get better. Encourage a positive attitude and show children how to treat themselves so they are involved with their ointments and creams.
Get them to play with moisturiser in the bath and rub creams on you so your skin can also become smooth. Find books about other children with eczema so that they can hear their stories.
Give yourself enough time
Make sure that treatment is not hurried or only half done. Treatment that is always rushed is unpleasant for you and for your child. Try telling a story or singing while applying therapy.
Become obsessional
This is a difficult one to get right. If you go too far, life gets out of perspective and small failings in routine treatment cause you unnecessary worry and your child feels overwhelmed.
However, a failure to be adequately obsessional is probably one of the more common reasons why skin treatment does not work as well as it should. Being obsessional means making sure that:
• there is plenty of treatment available at all times, with back-up of stronger treatments if there is a sudden deterioration
• treatment always goes on, in the right amount, in the right places at the right times
• the clothing, bedroom, bedding and household environment are right for a child with eczema.
Think about other family members
Other children in the family can easily become left out if much of your time is given to caring for one child more than others. You may be able to include other children in putting on treatments, or arrange to have some time alone with them.
Share things with your partner
Don’t neglect your relationship with your partner, or things will only get worse because you will not have the reserves to deal with bad nights and family upsets. Take time to talk about your difficulties with your partner and other close family members, and find some time to get away and be refreshed.
Your partner should also become involved in caring for the child. This will give you a break, help your partner understand things better and contribute to your partner’s relationship with the child.
Managing the skin in atopic eczema
There are many aspects to managing atopic eczema, some of which are common to the treatment of all forms of eczema. You will need to learn how to respond to fluctuations in symptoms with variations in treatment.
The most important aspects of treatment are:
• Avoid things that make eczema worse
• General skin care and use of skin treatments
• Psychological treatment.
