Hard-to-Control Eczema

Many parents of children with eczema know the basic treatments to control and prevent eczema flares.

If your child has frequent eczema flares, you are likely already:

• controlling eczema flares with the short-term use of a low- or- medium-potency steroid ointment or nonsteroidal eczema medicine, such as Elidel or Protopic
• applying moisturizers on top of your child's other topical medications during eczema flares or applying them at other times of the day. A steroid cream or ointment isn't going to work if you put it on top of a moisturizer.
• using a moisturizer every day and within 3 minutes of getting out of the bath or shower
• not using hot water in the bath or shower and using a mild soap, such as Dove or Oil of Olay, or a soap substitute, such as Cetaphil Gentle Skin Cleanser
• giving your child an antihistamine, such as Benadryl or Atarax (a prescription strength antihistamine), to help control itching, especially at bedtime
• avoiding known triggers, such as harsh soaps, bubble baths, dust mites, food allergies, overheating and sweating, wool and polyester clothing, etc.
• trying a nonsteroidal prescription cream or lotion instead of an over-the-counter moisturizer, such as Hylira, Mimyx, or Atopiclair
• using wet dressings or wet-to-dry dressings during hard-to-control flares
• washing your child's clothes with Dreft or other speciality "baby" laundry detergent, such as Tide Free (Ultra Tide Free, Tide Powder Free), All Small & Mighty Free Clear or Ivory Snow
• keeping your child's fingernails short, so that he doesn't damage his skin if he gets itchy and scratches

After all of the above, though, why can't you still get your child's eczema under control?

Although poor eczema control sometimes has to do with not following, understanding or having an eczema treatment plan, some kids simply have hard-to-control eczema.

Sometimes by trying new treatments a pediatric dermatologist may help these children get their eczema under control, but often, more education may prevent and treat eczema flares.

Staph Infections and Eczema

If your child has hard-to-control eczema, you might also consider that he could have a secondary skin infection. Your pediatrician will especially suspect a bacterial infection if your child's skin is red and has honey-colored crusts over it, pus-filled blisters or appears wet and weepy.

Many eczema experts believe that the Staph. aureus (MRSA) bacteria infects many children who already have eczema and can cause eczema flares. In fact, one study showed that more than 90% of patients with atopic dermatitis were colonized with the MRSA bacteria.

That is why many doctors, in addition to traditional treatments for eczema flares, will also prescribe an antibiotic.

If your child is already on antibiotics and his skin still looks infected, then he could have the MRSA bacteria on his skin, and he may need a different antibiotic, such as Bactrim or Clindamycin, to get the infection under control.

A skin culture can also help to determine if your child's eczema is complicated by a bacterial infection and which antibiotic will help to treat it.

Hard-to-Control Eczema

In addition to the eczema treatments above, a pediatric dermatologist may recommend:

• using a stepped-down approach to therapy, in which instead of simply stopping a steroid cream or ointment when a flare is under control, you switch to a lower strength of steroid for a few days or weeks. For example, you might go from a prescription-strength steroid cream, such as Cutivate or Elocon, to an OTC hydrocortizone cream, before you stop using a steroid all together. Or your pediatric may go from prescribing your steroid every day to every other day before stopping. This may help your child's skin from flaring up again as soon as you stop using a steroid treatment.
  
  
• trying a higher-strength topical steroid in small areas that aren't responding to treatment with a moderate-strength steroid. Higher-strength steroids can include Cutivate ointment, Diprolene AF cream and Lidex cream. Keep in mind that these higher-potency steroids are usually only used for short periods of time, like three or four days, and never on the face.
  
  
• a prescription for a compounded mixture of a steroid with a moisturizer, such as triamcinolone acetonide 0.1% ointment and Aquaphor
  
  
• weekly diluted bleach baths to help prevent staph infections. Using this technique, a 1/4 cup of household bleach is added to a bath tub that is then filled with lukewarm water. Your child can then soak in this bath, which will be like a chlorinated swimming pool, for 10 to 20 minutes. Rinse him off after the bath and as usual, pat your child dry and cover him with a moisturizer within 3 minutes to trap in the moisture from the bath. Keep in mind that diluted bleach baths are usually restricted to just once a week, since they can be irritating and should usually be done under the guidance of your pediatrician or a pediatric dermatologist.
  
  
• coal tar lotions and shampoos
  
  
• treatment with cyclosporine, which suppresses the immune system
  
  
• ultraviolet (UV) light phototherapy treatment
  
  

Keep in mind that using coal tar, cyclosporine and phototherapy are typically reserved for the most-severe cases of eczema.

_Sources:

Atopic Dermatitis. Simpson EL - Med Clin North Am - 2006 Jan, 90(1), 149-167

Atopic dermatitis: An update and review of the literature Lipozencic J - Dermatol Clin - 01-OCT-2007; 25(4): 605-12