Eczema in infancy and how to recognise it

Allergy parent and author, Alexa Baracaia, details the diagnosis and treatments while sharing practical tips for fellow caregivers and parents.

Our son was just five or six weeks old when he began to show signs of eczema. What seemed at first a standard bout of cradle cap crept gradually down from his scalp and forehead: a red, bumpy rash blooming across his cheeks, neck and torso.

The GP struggled to treat it with petroleum creams and mild steroids, as well as antibiotics as it became periodically infected. None of the lotions were working. Some seemed to make his skin worse. Ridiculous overreaction though it may seem, it was hugely distressing to see him with such inflamed and scaly skin. Soft as a baby’s bum? Rosy cheeks? Peachy? All those descriptors of babyhood just didn’t tally with our little one. Plus, he smelled variously of paraffin (those petroleum creams) or smelly socks.

What we didn’t realise at that point was that allergies were also linked to his poor old skin. Atopic eczema is what he had.

If someone is ‘atopic’ it means they are genetically predisposed to allergic disease – whether that’s hay fever, asthma, eczema or food allergy, or a bumper combination of the lot. There is a strong link between eczema and food allergy, with more than half of infants with ‘moderately severe early onset eczema’ (that’s onset before three months and requiring treatment with topical steroids) developing a proven food allergy by the age of one. This doesn’t mean that food allergy causes eczema, but that the conditions are linked – and that an allergic reaction to food can cause flare-ups.

That was us. And it was only after subsequent diagnosis of our son’s multiple food allergies, in conjunction with the strict new routine of steroid creams for flare-ups and twice or thrice-daily moisturising, that we finally got fully on top of the outbreaks.

These days, his eczema is thankfully well under control, with patches triggered only now and then by chlorine, hot sun and salt water, the dry air thrown off by central heating and if he’s feeling under the weather. We slather on the cream, apply a thin layer of his steroid rarely, if needed, and generally his skin stays pretty clear.

When I came to write my book, My Family and Food Allergies: The All You Need to Know Guide, the key thing I wanted to do was to help other parents going through the same rollercoaster journey we had faced. It took a lot of false starts to get properly diagnosed, and for many weeks our son’s eczema went unrecognised and untreated. If your child develops any sort of rash, always seek medical advice. But here’s a starter guide on the condition, and how to manage it:

What does eczema look like?

Eczema usually presents as dry and bumpy patches, pink or red in light-skinned babies and darker brown, purple or ashen grey in children of colour. There are different types of eczema, but atopic eczema – the one associated with allergies – generally develops in babyhood. In infants, it may begin on the scalp and cheeks. A sign that it may be linked to food allergy is whether it is early onset, and persistent.

It can affect the insides of the elbows, backs of knees and face. In older babies, it may break out in chubby folds, such as the nappy area or neck. It can also occur on the front of the knees, the ankles and back of elbows, as well as in the creases. It may look like roundish patches of inflamed skin, or fine bumps or ‘dots’ across the chest and tummy.

The biggest clue is whether it is itchy. Babies may be seen to squirm or try to reach the offending area. I remember my son, too tiny even to sit unaided, trying to bat at his face with his hands – a sign, we later realised, of his itchy discomfort.

If it becomes infected, it may look red and weepy or crusty, or there may be small blisters. You will need to see your GP as this may require antibiotics.

There are different types of eczema, but atopic eczema – the one associated with allergies – generally develops in babyhood.

How to treat it

While there is no cure, treating the skin and avoiding triggers where possible can see dramatic improvements and keep the condition well under control. In many cases the worst is outgrown as children get older.

The first step is to see your GP, who will be able to prescribe emollients and, where necessary to reduce inflammation, topical steroids. Finding an emollient that works for you is vital, as regular use (at least two or three times daily) will stop the skin from becoming too dry and soothe the itch.

Advice from the British Association for Dermatologists (BAD) is that “the best one to use is the greasiest one you are prepared to apply”. You may find a lighter emollient works by day, or in hotter temperatures, and a thicker one by night. We had to switch out the oiliest ointment when we took our son swimming as he had a tendency to slip from our hands like a wet fish.

When using an emollient, wash your hands beforehand and smooth the cream on to the skin in a downward motion rather than rubbing. If you have a tub or pot, use a clean spoon or spatula to avoid contamination.

And don’t just moisturise when the skin looks ‘bad’ – moisturising the whole body, even when it appears clear, can keep eczema well controlled.

Some children may require more complex creams and treatments, so you may also be referred to a dermatologist specialising in skin conditions. National Institute for Health and Care Excellence (NICE) guidelines recommend referral where management has not controlled the eczema satisfactorily, or it is significantly affecting the child’s sleep or behaviour.

You may also be prescribed a topical steroid, which is a treatment to keep swelling, redness and inflammation in check. These are creams, gels or ointments that come in varying strengths, with hydrocortisone being the mildest. They should be used under the guidance of your doctor because the best treatment needs to be tailored in terms of strength and duration.

You may have heard concerns around topical steroids ‘thinning’ the skin, but the National Eczema Society notes: “The likelihood of side effects occurring is related to the potency of the preparation, where it is used, the condition of the skin on which it is used and the age of the person using it. All these factors will be taken into consideration when a prescription is given to treat eczema.”

They add: “Fear of side effects can make people under-treat their eczema by stopping a treatment too soon or not using enough of it. This can be detrimental to the overall management of the condition and may mean that a stronger topical steroid has to be used to bring the eczema under control again.”

Official BAD guidance also notes: “Used appropriately, topical steroids are very effective and safe to use.”

Sometimes, non-steroid anti-inflammation creams, called ‘calcineurin inhibitors’, are useful to control eczema when steroids are not working or on the thinner skin of the eyelids and face. Other treatments include ‘wet wrapping’ – a way of cooling the skin and providing relief. Both should only be used after assessment by a specialist.

How to wash

Too much water can be drying, but a short daily bathe using tepid or warm water and a special bath emollient – ask your doctor to prescribe one or advise you – can be very helpful and soothing.

Avoid bubble baths and regular soaps, as these will aggravate the skin. If you don’t have a bath emollient, you could apply your child’s medical moisturiser all over their body and let them soak and rinse off in the bath. Just beware that these creams can make them very slippery!

Pat rather than rub your child dry afterwards and reapply their usual emollient.

Beware ‘natural’ creams

There are many ‘natural’ dry skin creams on the market, but these may not be suitable for your child – and may even exacerbate their eczema.

If your child has food allergies, there is also a risk of sensitisation when using products containing common allergens, for example nut or sesame oils. This means the body may become reactive to an allergen if it is first absorbed via broken skin.

Olive oil is also not recommended as it has been found to disrupt the skin’s natural barrier. And certain creams marketed as ‘herbal’ may even illegally contain undeclared powerful steroids, or potentially harmful levels of bacteria.

More top tips:

• Try to keep their bedroom cool
• Stick to light cotton clothes and bedsheets where possible
• Sleepsuits with mitts can help to stop babies scratching, and for older children a pair of soft gloves or socks on the hands can also help at nighttime.
• Keep fingernails short