It looks like a rash and your baby is scratching furiously and feeling miserable. So, you bring him to a doctor, only to be told “ah, eczema, it’s quite common here” and you’re given some cream. But what exactly is eczema and why do we get it?
1) Dry, red, itchy rashes
From ancient Greek, “eczema” meant “boil”, explains Dr Tan Siew Kiang a dermatological specialist at Raffles Skin & Aesthetics, “It is used to describe red, dry, itchy skin which can sometimes become weeping, blistered, crusted, scaling and thickened.”
Adds dermatologist Dr Neoh Ching Yin, of Specialist Skin Clinic & Associates, “An inflammation of the skin is sometimes referred to as dermatitis. It affects one in five school-going children; one in 10 persons get it at some point in their lives. It is the most common chronic inflammatory skin condition here.”
2) It runs in the family
Dr Tan says, “Eczema tends to run in families, especially in those who have strong family history of atopy.” “Atopy” refers to the inherited tendency to develop allergic reactions such as asthma, sinusitis, rhinitis and eczema. These involve an over-active component of the patient’s immune system ― for instance, a defect in the skin’s barrier allows allergy-causing substances to enter the skin, causing itch and inflammation.
“Atopic eczema usually starts in the first few months of life but it may also develop for the first time in adulthood. There are a few sub-types — such as discoid eczema, which usually affects young adults, and old-age eczema, which affects middle-aged or elderly patients,” she says.
Above all, you cannot just “catch” it.
"Eczema affects one in five school-going children; one in 10 persons get it at some point in their lives."
3) It looks bad and did we mention? It ITCHES.
“The main symptom is itch,” says Dr Tan. In fact, your child is probably constantly scratching and rubbing at the itchy areas, leading to the redness and even swelling in the area, darkening of the skin and causing the body to react by itching more. “Itch can be severe enough to interfere with sleep, causing tiredness and irritability. This can have an enormous impact on the whole family.”
She adds, “Frequent moisturising is the mainstay of treatment as well as the most important treatment for all patients with eczema.” Wash with a gentle soap or bath oil and apply moisturiser several times daily to help the outer layer of the skin function better as a barrier against the environment.
Doctors can also prescribe antihistamines to ease itching.
4) It’s in my baby’s wrists, and the backs of her knees…
Eczema can affect any part of the skin, but the most commonly affected are the neck, wrists, elbows and back of the knees ― in other words, areas where you sweat. In some adults it can spread out along the arms and legs, the face, and the whole body — we saw that in the case of Eu Huiling, reported in the news.
Dr Tan says, “In babies, cheeks, chin and neck are commonly affected because of the milk and saliva from drooling that irritate the skin.”
Other subtypes of eczema presented differently. She describes discoid eczema as “coin-sized rashes on the arms and legs”; follicular eczema (“small, red bumps around the hair follicles”).
“When the eczema is very active, the skin may become moist and weepy. Small water blisters may develop especially on the fingers, hands and feet,” she says.
If you don’t treat a “flare up” (when you aggravate the eczema by things you are allergic to and/or scratching it), your scratching can break your skin, letting in infections that could lead to the development of pus-filled wounds.
5) Is it a Chinese “condition”?
Eczema isn’t restricted to one race, although a local study of 492 patients who visited National Skin Centre from January to June 1994 found that some 83 per cent were Chinese, 7.9 per cent Malays, 5.1 per cent Indians and 4.2 per cent others, notes Dr Tan.
“If we compare to the racial composition of Singapore in the 1990s (77.8 per cent Chinese, 14 per cent Malays, 9.1 per cent Indians, 1.1 per cent Others), eczema is slightly more prevalent in the Chinese population.” But basically, anybody could have eczema.
6) Is there a cure?
No, there isn’t a miracle cure.
Dr Neoh explains, “The cornerstone of treatment involves repairing the skin barrier using skin moisturisers. Acute flare-ups are treated with topical corticosteroid cream of the appropriate potency. Any skin infections must be treated, if not, the recovery of the skin will be delayed.”
Dr Tan notes, “Your doctor will advise you on which type needs to be used where, and for how long.” Weaker steroid creams/lotions are usually prescribed for use on the face, breasts, genitals, eyelids and armpits. They should not be applied more than twice daily — when used appropriately, topical steroids are very effective and safe to use, even in babies. “However if used inappropriately (too strong or for too long), topical steroids may cause side effects, including thinning of the skin,” she warns.
“In children, the use of strong steroid creams must be avoided. The use of non-steroid creams such as topical calcineurin inhibitors or physiological moisturisers are useful for maintenance and prevention of flares.”
“The cornerstone of treatment involves repairing the skin barrier using skin moisturisers. Acute flare-ups are treated with topical corticosteroid cream of the appropriate potency.”
For very severe cases, patients can be treated with phototherapy or oral medications to suppress the inflammatory response of the skin, she says. “In view of the side effects and need for patient cooperation, these are more suitable for adults.”
Some oral medications used include: oral steroids (prednisolone), azathioprine, cyclosporine, methotrexate and mycophenolate mofetil. Dr Tan says: “As these medications may affect the bone marrow, liver or kidney, regular blood monitoring is required.”
She explains that if the eczema becomes wet, weepy and crusted, it may be infected. Your doctor may prescribe topical antibiotics or a course of antibiotics in such instances.
7) Aren’t steroids dangerous?
Topical steroids are safe, very effective therapy for eczema in babies and children, Dr Tan insists. “Although there are many side effects that are reported with the inappropriate use of topical steroids, when used in the proper dosage, frequency, duration with close monitoring by a physician, topical steroids have a very low risk of causing skin thinning or systemic side effects.”
She notes that some parents, in an attempt to stop their children’s itching, do buy topical steroids from countries like Malaysia or Thailand. “These are usually strong or ultra-strong topical steroids. When they are used inappropriately in children (with their larger surface-area-to-body-weight ratio) and poorer skin-barrier function, they can be absorbed well enough to cause systemic side effects like glaucoma, cataract, diabetes, high blood pressure and hormone suppression.”
On the other extreme, children whose parents who are terrified of administering topical steroids on them, suffer poor outcomes.
Dr Neoh asserts, “To ensure compliance with treatment, myths and misconceptions about medications must be dispelled.”
8) What about a condition known as steroid withdrawal?
Dr Tan says topical steroid-withdrawal syndrome occurs when moderate- to high-strength topical steroids are used inappropriately over a prolonged period. “Patients are usually adult females who apply topical steroids daily for more than 12 months, especially on the face and genitals. Burning, stinging and bright red skin occurs within days to weeks after discontinuation of topical steroids.”
9) Are there alternatives to steroids?
Dr Neoh says, “Patients often try alternative treatments such as homeopathic treatments and Traditional Chinese Medications. However, they have not gone through rigorous clinical trials to prove their efficacy. In the real world, their effects vary with patients and are not consistently effective.”
10) Do food allergies affect eczema?
“Food is seldom the cause of eczema,” Dr Neoh says. Although some patients do find their symptoms “get worse with certain foods”. “Indiscriminate avoidance of foods especially in growing child is not recommended.”
“When used in the proper dosage, frequency, duration with close monitoring by a physician, topical steroids have a very low risk of causing skin thinning or systemic side effects.”
11) What about dust and heat?
Many environmental factors ― heat, sweat, dust, wool, pets and irritants such as soap and detergents ― may worsen your itchy condition. Says Dr Tan, “We should not stop children from exercising; but make sure your kid changes his clothing after exercise. Use a towel to clean the sweaty skin-fold areas. Apply plenty of moisturiser after drying the skin.”
She adds that chlorinated water can irritate and dry up the skin, so swimmers need to rinse well right after swimming. And moisturise.
“Stress and lack of sleep definitely aggravates eczema. More children would present to us with eczema flare during the exam period. Stress management would be helpful for sure.”
If necessary, says Dr Neoh, children with acute flare-ups can be excused from PE lessons. She suggests that you help your child choose CCAs that are based indoors or those that don’t involve heavy perspiration. “Empower and educate your children to know about their condition and be responsible about applying their creams.”
In general, adult or child, the idea is to keep cool. Wipe away sweat and wear clothes made of breathable materials such as cotton. Wool, unfortunately, can be quite an irritant. And, of course, moisturise to build a stronger skin barrier to the environment.
12) Does relief from stress (including meditation and relaxation techniques) help?
Says Dr Tan, “Stress and lack of sleep definitely aggravates eczema. More children would present to us with eczema flare during the exam period. Stress management would be helpful for sure.”
Dr Tan Siew Kiang, is a specialist in Dermatology and a consultant with Raffles Skin & Aesthetics.
Dr Neoh Ching Yin is a dermatologist with Specialist Skin Clinic & Associates.
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