DRY SKIN (ECZEMA) (1-12 Months)
What is happening inside my baby’s body?
Most babies have dry skin – or at least patches of it – at some point in time. When your baby is born, skin that has been bathed in water for nine months suddenly gets a rude awakening… air! The baby’s skin dries out quickly and easily. Then, each time you bathe her, the skin is air-dried a little more. Eventually parts of the skin become scaly.
Air is not the only source of dry, flaky skin. If your baby is sensitive to the perfumes in detergents, to the colours in lotions, to clothing material (such as wool), or to some component of the breast milk or formula she is drinking, then her skin will often react by drying out even more.
The medical term for dry skin is eczema or atopic dermatitils. Depending on the cause, eczema can have many forms. Classic eczema first appears on the cheeks as two perfectly round, slightly red circles. It also shows up as dry patches behind the ears and sometimes as crusting on the scalp (called cradle cap). Over the first few weeks, it moves to the wrists and ankles, and sometimes to the arms, thighs, or abdomen. Eczema can look like white flakes on the baby’s skin, colourless pinpoint bumps, or fire-engine-red patches.
When dry skin is caused by an allergy, it is called irritant dermatitis. This can be confused with eczema. The rash of irritant dermatitis typically appears wherever the irritant contacts the skin. If the irritant is detergent, then the rash will appear only where clothes washed in that detergent touch the baby’s skin. If it is a lotion or soap, then the rash will appear only where the lotion or soap is applied. If it is a food, however – including a component of formula or something a breast-feeding morn has eaten – then the rash may be around the mouth and anus, or it may spread from head to toe.
What can I do?
When something irritates the skin, remove the irritant. You should use only colour-free, perfume-free detergents, soaps, and lotions. Hypoallergenic moisturizers will help return water to the dry skin. Minimizing bath frequency cuts down on the drying effect of constant washing.
When does my doctor need to be involved?
Skin that bleeds because it is so dry needs to be treated by a doctor. If the skin breaks open, then it can become infected. If eczema continues to spread despite attempts to reduce it, then your doctor should be involved. A baby who is clearly uncomfortable because of eczema should be evaluated.
What tests need to be done, and what do the results mean?
Eczema rarely requires any sort of testing, unless it is so severe that an underlying allergy is suspected. Unfortunately allergy testing is not very accurate in children younger than two years of age. In fact, even when testing is done, the source of the eczema is not always identified. Therefore it is often easiest to use trial and error, removing 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 a food challenge.
The food that is thought to be the cause of the allergy can be stopped for several weeks; a rash or diarrhoea upon reintroduction usually suggests food allergy. In the case of breast-feeding, the mother must stop eating the food that is thought to be causing the problem and then, when she begins again, assess her baby for signs of allergy.
In the case of formula-feeding, you can change the type of formula (i.e., 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 testing are skin testing and RAST (blood) testing. Neither test is perfectly reliable in children younger than two years, but both deserve a brief mention because they may be considered for infants and young children with severe allergies.
Skin testing involves pricking a baby’s skin with tiny needles, each coated with a specific allergen – cat dander, mold, egg, etc. If the area around a specific needle prick becomes red and irritated, then the test is positive. This test works well on children older than two years, as long as someone can convince them to participate. In children younger than two years, negative results do not mean much – only a positive test proves an allergy.
For example, if the skin in the area around the cat-dander needle does not react, the child may still have an allergy to cat dander and the test can appear falsely normal.
RAST testing is the most common blood test used to check for allergies. Blood testing is helpful if the skin is so severely irritated that skin testing cannot be done or if there is concern that a skin test will cause a severe reaction. Blood tests are also sometimes used in small babies when skin tests do not yield any results. Like skin tests, RAST tests are not always definitive in babies.
It is important to remember that antihistamines – such as Benadryl, Claritin, and Zyrtec – can interfere with allergy test results. If your child is taking any medicines, then discuss this with your doctor several days before allergy testing. The medicine may need to be stopped prior to the testing.
What are the treatments?
The best treatments for eczema are (1) moisturizing and (2) removing the irritant. Skin that is simply dry responds well to thick moisturizers. Remember, these need to be colour-free and perfume-free or they may worsen the problem. If an allergy is suspected, then remove the irritant. Sometimes this is a matter of trial and error – when the cause of the allergy is not obvious, each potential irritant should be removed one at a time to look for improvement. (The opposite is also true: all potential irritants can be removed at once and then they can be added back, one at a time, to determine the cause.)
Severe cases of eczema may be treated with a steroid cream or a nonsteroid anti-inflammatory cream. These are used in addition to moisturizers. Steroid creams come in many strengths. Some are over the counter and some require a prescription. These creams may have side effects if they are used too often or over too big an area.
Over time they can cause the skin to thin, changing the pigmentation. The body absorbs steroid creams, so when they are applied over a large area of skin or when they are used too often, the body may absorb a high dose of steroid, causing mood or appetite changes. Nonsteroid anti-inflammatory creams are now available. These work well to calm 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 so dry that it cracks, or when a baby pulls and scratches at the irritated area. Skin infection can require antibiotic treatment.
There are also many conditions associated with eczema, each of which may cause problems of its own or may complicate eczema flares. These include anaphylaxis (shock), asthma, rashes other than eczema (such as hives), and infection of the ears, sinuses, and even bloodstream. All these conditions tend to be associated with eczema because they share the common problem of inflammation.
In each of these scenarios, inflammation exist somewhere in the body – the skin, sinuses, lungs, and so on – and the inflammation makes it difficult for that part of the body to work effectively. In the case of the lungs, inflammation makes breathing difficult because it clogs the airways. In the case of the skin, inflammation causes swelling, irritation, and itchiness. In the sinuses, it causes congestion, creating an environment ripe for bacterial infection. The coexistence of the triad of eczema, asthma, and allergy is so common that it has a name: atopy.