Ask a dermatologist: all your baby eczema questions, answered

You’re not alone! Here’s how to tackle one of the most common—and least understood—baby skin conditions.

“Your baby has eczema.” It’s not a phrase any of us want to hear, but far too many of us have had the experience; childhood eczema is on the rise in the United States (about one in 10 children has eczema), and often the first flare-up is in infancy. That’s why we gathered up all your most frequently asked infant eczema questions and brought them to Peter Lio, M.D., Clinical Assistant Professor of Dermatology and Pediatrics at Northwestern University Feinberg School of Medicine. What you learn from him might surprise you.


Q:  What does baby eczema look like, and where does it usually show up first?

A: “Eczema—which dermatologists refer to as atopic dermatitis, or AD—is characterized by scaly red patches that are itchy. Sometimes they become open and oozing. Typically the cheeks are involved in infants, but the neck, inner parts of the arms, and the areas behind the knees can also be involved. Sometimes it starts on babies’ scalp, almost like cradle cap, and then spreads to more of the body. It’s a little variable between babies, but the common elements are the scaling, the redness, and the itch.”


Q:  When do babies usually have their first eczema flare-ups?

A: “For many babies, it starts in the first few months of life—I’d say in my experience one to three months is a very common time. In other words, very few kids have it in the first couple weeks of life, but many have something going on by the first few months.” 


Q: Why do babies get eczema? And what are the most common triggers?

A: “We honestly don't fully understand it. It remains an important and central mystery in dermatology. Part of it is absolutely genetic: for many babies with AD, there are often other members of their family who have either AD, asthma, or allergies. All of these seem to be genetically related to AD. Skin barrier function (keeping the water in and the bad stuff like allergens, irritants, and microbes out) is also critical, and an impaired skin barrier may be the first cause of eczema for many babies. I refer to this as "leaky skin," and it’s an important concept. Another theory is the hygiene hypothesis: that we're too clean in modern times and that the immune system sort of gets bored and starts picking on the skin. We still have so much to learn here, however.

Common eczema triggers include getting a cold or other viral infection, stress of any kind, poor sleep, irritating products such as harsh soaps or fragranced moisturizers, abrupt weather changes or any weather extreme (hot and humid, cold and dry), or allergic triggers such as foods, pollens in the air, or exposure to cats or dogs. There are so many potential triggers that it can be overwhelming to try to avoid all of these, so we tend to focus on getting the skin better and stronger.”


Q: What should parents not use on their babies’ skin when they’re dealing with baby eczema?

A: “I’m a bit of a minimalist with babies and try to avoid anything unnecessary in their products, since we know that babies’ skin is more permissive and absorbs much more than adult skin—even in the best of times! This is increased many-fold in babies with eczema, since that "leaky skin" is even more permissive. I like to avoid fragrances, harsh detergents and cleansers, and perfumes of any sort—and I absolutely try to minimize exposure to preservatives as well. We ideally want minimalist products with well-tested ingredients for our littlest patients.”


Q: What sorts of products should parents look for to help calm baby eczema, and how
often should they use them?

A: “This is hopefully where we (dermatologists and pediatricians) can come in with advice. In general, we're looking for a good fragrance-free moisturizer that will help protect the skin barrier and ideally help fortify the skin. This should be applied at least twice daily, but in drier skin, three to four times per day can be helpful to really protect and heal. A gentle cleanser can help remove bacteria, allergens, and irritants on the skin, decrease the harshness of plain water, and actually leave the skin better than before a bath. And moisturizing right after a bath can "super-hydrate" the skin by locking in more water, which can be very calming.

If we’re seeing more inflamed skin, we may recommend topical corticosteroids: we pick carefully and use them sparingly for short bursts to minimize side effects while maximizing relief from the vicious cycle of “itch-scratch-itch” that continues to damage the skin, introduce more bacteria, and cause more inflammation. In some cases we might also incorporate anti-bacterial therapies, as we’re learning about the increasing role of staphylococcus aureus (a particular type of bacteria) as a driver of AD.

Putting all of these treatments together sometimes requires a written ‘Eczema Action Plan.’ I try to provide this for all of my patients to outline a safe and hopefully highly effective plan of attack to calm things down and get the skin healed.”

 

“[Look] for a good fragrance-free moisturizer that will help protect the skin barrier and ideally help fortify the skin.”

 

Q: With the right treatment, how long does it usually take a baby’s eczema flare-up to clear up?

A: “With proper treatment, we expect to see patients improving within a few days. If someone is still flaring at one week into therapy, I usually ask them to call me. Ups and downs are normal, but with appropriate treatment the response should be pretty speedy. 

The bigger question is when the entire disease (rather than just a flare-up) will resolve...and we don't really know. We think around half of patients get better and ‘grow out of’ the eczema over time. Usually school age (5-7 years) is the first stage when it might resolve, and then puberty is the second stage. Even so, there are still a lot of kids who are angry that everyone told them they would ‘just grow out of it,’ but they never did. I tend to say that most people get better over time, and we think that keeping it under good control maximizes the chance of improvement over time. Our goal is to get things clear and keep them clear as long as we can.”

 

Q: So if a child has eczema as a baby, what are the chances that they’ll develop it again
later on as an older child or an adult?

A: “It's such a good question. My sense is that it depends on the severity. More severe eczema seems to correlate with a higher chance of having it as an adult, while milder is less likely, in my experience.”


Q: What’s the connection between eczema and diet?

A: “So many families are convinced that food is the root cause of eczema that sometimes it can be hard to talk about anything else at a visit. Part of the issue is that food allergies are indeed associated with AD—one third of moderate to severe patients with AD also have true food allergies that can be life-threatening. But just as the association between fire trucks and fires does not mean that fire trucks actually cause fires, my thinking is increasingly that food allergies are not causing AD either, but are simply associated with it.

It’s been incredibly exciting to see what amounts to a true reversal on this line of thinking just in the past few years: the theory now is that an impaired skin barrier allows food proteins to abnormally enter the body and stimulate food allergies. So we’ve begun to talk about it in terms of getting the eczema and “leaky skin” patched up in the hopes of minimizing food allergies, rather than the other way around. It’s still somewhat speculative, but I think the data is compelling and that the biology makes sense this way. 

Sometimes families want to try an avoidance diet. Historically, we might have said that that’s fine to try as long as overall nutrition isn’t impacted. However, recent work suggests that this may actually increase the risk of developing true food allergies. So I’ve been less supportive of this approach lately, to be sure. And importantly, I’ve seen an awful lot of failure to treat AD from dietary modification. If simply cutting dairy out of the diet worked, well, they wouldn't be in to see me!”


Q: Any words of wisdom you’d share with worried parents whose baby has their first eczema flare-up?

A: “First and foremost: you are not alone. There are a lot of people in exactly the same situation, so take some solace in that. Second: there really are resources out there to help! Check out the National Eczema Association for a great place to start learning more and finding people to help. Third: start with your pediatrician, but if you aren’t happy with the answers and approach, don't stop there. Dermatologists and allergists have devoted their lives to helping patients with AD and even among these specialists, there are many different approaches and focuses. Keep searching until you find someone that you connect with and trust.”


Q: Anything else parents should know about eczema?

A: “I learned long ago from one of my teachers that eczema patients were the most interesting to work with because they tended to be much smarter than average. He thought that it was due to their heightened sensitivity: yes, it works against them when it comes to allergens and irritants, but it also makes them incredibly perceptive about the world and extremely intelligent!”

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