You’re not alone! Here’s how to tackle one of the most common—and least understood—skin conditions for babies, kids, and adults.
“Your child 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 nine kids has eczema), and often the first flare up is in infancy. Troublingly, cases of adult eczema are on the rise too. That’s why we gathered up the most frequently asked eczema questions and brought them to Peter Lio, MD, 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 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. In infants, the cheeks are typically involved, 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, but the common elements are the scaling, the redness, and the itch.”
Q: How does eczema show up differently in older children and adults?
A: “Atopic dermatitis has different characteristic patterns for different ages. Toddlers generally develop the rash in the folds behind the knees and elbows. Adults often have the head and neck areas involved, as well as the hands and feet. However, it’s important to know that it can be different in different people, and even different in the same person at times.”
Q: Why do people get eczema?
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 children 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. 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.
Q: What are the most common eczema triggers?
A: “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: Why are certain body parts more prone to eczema?
A: “This is an important question that we don't fully know the answer to yet. We do know that some areas of the skin, like the nose, develop a natural moisturizing factor (an important compound that helps strengthen the skin barrier and keep water in the skin) very early, and that may explain why the nose is usually spared. The skin on the cheeks, on the other hand, matures more slowly, so that may help explain why they often have significant eczema lesions. We also think that the microbiome, the humidity, and friction in different areas of the body may also alter the risk of developing atopic dermatitis lesions there. Some people, however, are what we call "erythrodermic": meaning just about all of their skin is affected by the eczematous rash.”
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: What should parents not use on their babies’ skin when they’re dealing with 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 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 eczema lotion 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 fragrance-free 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.
“[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 an 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: Do males and females get eczema in equal numbers?
A: “There seems to be a slight preponderance of females, but it’s fairly close to 50-50.”
Q: Are there certain seasons of the year when eczema is worse?
A: “Winter is probably the most common time for eczema flare ups: the cold dry air outside is made worse by the forced hot air inside, and these two factors team up possibly with the relative vitamin D deficiency in the winter months to make a lot of people miserable. However, hot, sweaty summer months can trigger flares as well for some patients. For others, any weather changes can cause things to act up, and for others still, they are just bad year-round.”
Q: Are there certain parts of the country where people suffer more from eczema?
A: “More urban areas with more pollution seem to have higher rates than more rural parts of the country, and it does seem like colder climate areas with less sunlight (like Chicago, sadly, where I live... sigh...) have more eczema. In a large Australian study done recently, there was also less eczema in warmer areas that were closer to the equator, but it's not a super-strong predictor.”
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. Food allergies are indeed associated with AD—one third of patients with moderate to severe AD also have true food allergies. 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 eczema.
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 patched up in the hopes of minimizing food allergies, rather than the other way around.
Sometimes families want to try an avoidance diet. 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: Are there any other common conditions patients with eczema may experience?
A: “Asthma, hay fever (allergic rhinitis), allergic conjunctivitis, and eosinophilic esophagitis are also commonly seen in patients with AD. Beyond that, we get into more rare associations, but there are neuropsychiatric associations like ADHD and even heart disease seen in some studies.”
Q: Any words of wisdom you’d share with worried parents whose child 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!”