DRY SKIN (ECZEMA) (1-12 months)
What is going on in my baby’s body?
Most babies have dry skin – or at least patches – at some point in time. When your baby is born, the skin that has been wet in water for nine months suddenly gets a sudden awakening … air! The baby’s skin dries quickly and easily. So every time you bathe it, the skin dries out a little more. Eventually some parts of the skin become scaly.
Air is not the only source of dry and cracked skin. If your baby is sensitive to the scents of detergents, the colors of the lotions, the clothing material (such as wool) or some components of the breast milk or the formula he is drinking, then his skin will often react by drying out too. More.
The medical term for dry skin is eczema or atopic dermatitis. Depending on the cause, eczema can have many forms. Classic eczema appears for the first time on the cheeks as two perfectly round, slightly red circles. It also occurs as dry patches behind the ears and sometimes as crusts on the scalp (called the cradle cap). In the first few weeks, it moves to the wrists and ankles and sometimes to the arms, thighs or abdomen. Eczema can appear as white flakes on the baby’s skin, colorless pointed bumps or red spots of fire-engine.
When dry skin is caused by an allergy, it is called irritating dermatitis. This can be confused with eczema. The rash of irritating dermatitis typically appears wherever the irritant contacts the skin. If the irritant is cleanser, the rash will only appear where the clothes washed in that cleanser touch the baby’s skin. If it is a lotion or soap, the rash will only appear where the lotion or soap is applied. If it is a food, however, including a formula component or something you have eaten on a breastfeeding morning, then the rash may be around the mouth and anus or it can spread from head to toe.
What can I do?
When something irritates the skin, remove the irritant. You should only use colorless, fragrance-free cleaners, soaps and lotions. Hypoallergenic moisturizers will help bring water back to dry skin. Minimizing the frequency of the bath reduces the drying effect of the constant washing.
When should my doctor be involved?
Skin that bleeds because it is so dry must be treated by a doctor. If the skin opens, it can become infected. If the eczema continues to spread despite attempts to reduce it, you need to get your doctor involved. A child who is clearly uncomfortable with eczema should be evaluated.
What tests need to be done and what do the results mean?
Eczema rarely requires any type of test unless it is severe enough to suspect an underlying allergy. Unfortunately, allergy tests are not very precise in children under the age of two. In fact, even when the test is performed, the source of the eczema is not always identified. Therefore it is often easier to use trial and error, removing the suspected allergens and then reintroducing them one at a time to see what happens. In the case of suspected food allergy, the trial and error method is called the food challenge.
Food believed to be the cause of the allergy can be stopped for several weeks; a rash or diarrhea at the time of reintroduction usually suggests food allergy. In the case of breastfeeding, the mother must stop eating the food that is believed to cause the problem and then, when she starts again, evaluate the baby for signs of allergy.
In the case of formula feeding, you can change the type of formula (eg cow’s milk versus soy) to see if the skin improves. Again, if the rash returns when the original formula is reintroduced, then that type of formula is the cause.
The two main types of allergy tests are skin tests and RAST (blood) tests. Neither test is perfectly reliable in children under the age of two, but both deserve a brief mention because they can be considered for babies and young children with severe allergies.
The skin test involves puncturing a child’s skin with small needles, each coated with a specific allergen – cat hair, mold, egg, etc. If the area around a specific needle puncture becomes red and irritated, the test is positive. This test works well on children over the age of two, provided that someone can convince them to participate. In children younger than two years, negative results do not mean much: only a positive test shows an allergy.
For example, if the skin in the area around the cat hair needle does not react, the child may still have an allergy to cat hair and the test may appear falsely normal.
The RAST test is the most common blood test used to check for allergies. Blood tests are useful if your skin is so severely irritated that it cannot be done or if you are afraid that a skin test will cause a serious reaction. Blood tests are also sometimes used in young children when skin tests don’t give results. Like skin tests, RAST tests are not always definitive in children.
It is important to remember that antihistamines – such as Benadryl, Claritin and Zyrtec – can interfere with the results of allergy tests. If your child is taking medicines, discuss them with your doctor several days before the allergy test. It may be necessary to stop treatment before the test.
What are the treatments?
The best treatments for eczema are (1) moisturizers and (2) remove the irritant. Skin that is simply dry responds well to thick moisturizers. Remember, these must be colorless and fragrance free or they could make the problem worse. If an allergy is suspected, remove the irritant. Sometimes this is a matter of trial and error – when the cause of the allergy is not obvious, any irritating potential should be removed one at a time to seek improvement. (The reverse is also true: all potential irritants can be removed simultaneously and can then be added again, one at a time, to determine the cause.)
Severe cases of eczema can be treated with a steroid cream or a non-steroidal anti-inflammatory cream. These are used in addition to moisturizers. Steroid creams are available in many strengths. Some are over the counter and some require a prescription. These creams can have side effects if they are used too often or on too large an area.
Over time they can make the skin thinner, changing the pigmentation. The body absorbs steroid creams, so when applied to a large area of the skin or when used too often, the body can absorb a high dose of steroids, causing changes in mood or appetite. Nonsteroidal anti-inflammatory creams are now available. These work well for calming inflamed skin and have fewer side effects than steroids.
What are the possible complications?
The most common complication of eczema is skin infection. This occurs when the skin becomes dry enough to crack or when a the child pulls and scratches in the irritated area. Skin infection may require antibiotic treatment.
There are also many conditions associated with eczema, each of which can cause its own problems or complicate eczema flares. These include anaphylaxis (shock), asthma, rashes other than eczema (such as urticaria) and infection of the ears, sinuses and even blood flow. All of these conditions tend to be associated with eczema because they share the common problem of inflammation.
In each of these scenarios, inflammation exists somewhere in the body – the skin, nasal sinuses, lungs, and so on – and inflammation makes it difficult for that part of the body to function properly. In the case of the lungs, inflammation makes breathing difficult because it obstructs the respiratory tract. In the case of the skin, inflammation causes swelling, irritation and itching. In the sinuses it causes congestion, creating a mature environment for bacterial infection. The coexistence of the triad of eczema, asthma and allergy is so common that it has a name: atopy.