TVO 304 July 2021

Managing eczema in winter

Words: Lane Cove's Dr Carl Wong

Every winter, eczema tends to be a big problem. But it doesn’t have to be, if a few things are kept in mind, and on the skin.

Talia’s mother was at her wits’ end, “I can’t seem to get (my daughter’s) eczema under control no matter what I do.”

Occurring in 60 per cent of children during the first year of life, and tending to improve by adulthood, childhood atopic eczema (or dermatitis) is a chronic common itchy inflammatory condition of the skin. It can be a distressing condition – for both child and parent and is associated with disrupted sleep and poor school performance.

There are many misconceptions about eczema and many traps fallen into when managing it. Parents of affected children often say it is difficult to get a consistent clear message on treatment.

it more susceptible to allergens and irritants. The skin then becomes itchy which leads to scratching. Scratching gives temporary relief, but the skin counterintuitively becomes more itchy!

Part of the problem is that the damaged skin does not retain moisture very well, causing it to dry out easily, making

This self-perpetuating ‘itch-scratch’ cycle is even more frustrating because eczema has no clear cause and unfortunately no cure. Therefore the management goal is to get the best control possible, and to not aim for a ‘cure’ finish-line that will never come.

One cure attempt parents often try is by way of food-elimination diets. Unfortunately this won’t work and strong evidence in studies have consistently shown this. Furthermore eliminating food groups completely from the diet can ironically lead to the severe allergies one was trying to avoid in the first place, as the growing body does not get acclimatised to that same food from a young age. Up to 30 per cent will develop food allergies, but like also with asthma and hay fever, these are associative but not causative relationships.

Instead, the most important treatment is to moisturise – at least twice daily on the whole body (not just the affected areas). A minimum total of 125 grams (infant), 250 grams (child), and 500 grams (adult) is needed weekly. The moisturiser brand does not significantly matter, though Sorbolene products can cause stinging. Jar moisturiser preparations are preferred over pump packs which are weaker (contain more water). Use a clean spatula or spoon to scoop out the total required amount at each use to prevent bacterial hand contamination.

Management also includes controlling triggers. Showers should be kept under three minutes(a big ask at this time of year!). Baths can be longer if oils (eg QV, Alpha-Keri) are added. Use liquid non-soap cleansers only. Avoid multiple layers of clothing due to the trapped heat. Wool should not be worn (or ideally not directly on the skin) as it is too abrasive. Once weekly hot water washing of bed linen, and carpet vacuuming/floor-board mopping is needed to combat dust. Grass, sand (particularly sandpits) and chlorinated pools are also common irritants. Picnic rugs, wearing long sleeve loose clothing, showering immediately after the pool and even embalming the skin with a greasy moisturiser prior to pool use will help. Other common triggers are weather changes (cold snaps or stuffy overheated rooms), acute illnesses (eg common colds), mould and household pets.

Despite good moisturising and trigger avoidance, acute eczema flares will still occur. The primary and best management is with corticosteroid creams and ointments. Under good medical supervision, they are perfectly

safe and will not cause common concerns such as skin pigmentation changes or skin-thinning. In fact, loss of pigment is due to the severe inflammation of the eczema itself which resolves over time once treated but may take months. Ointments are more moisturising, penetrate deeper and are less stinging compared to creams. Ointments are thicker and feel heavier on the skin, and therefore creams are often more suitable in summer and better tolerated for the face. Don’t use sparingly (another common myth) – use enough to cover the area adequately. I recommend first applying steroids onto the skin before the moisturiser.

When applying the steroid, think of the eczema flare as a raging bushfire. It would be futile to use a garden hose (ie weak steroid) to control it. Instead, bring out the big fire truck (potent steroid) – it will put out the eczema fire usually within a week, and you’re done. This intensive treatment will result in quicker results and overall less topical steroid used. Keep the milder steroids (hydrocortisone) for delicate areas (face, neck folds, armpits, genitals) and also sometimes use twice weekly as maintenance if flares reoccur quickly after the stronger steroid treatment has been ceased (ie putting out any bushfire embers). If after two weeks of this you are not winning, seek medical help; often there is something (commonly an associated bacterial skin infection which requires an antibiotic) that is holding back recovery.

Childhood eczema can be challenging to control but is made easier if these basic treatment principles are followed.