Interview with Doris Day, MD
When you feel an itch, your first instinct is to scratch it for relief. Sometimes a simple scratch will help right away, and sometimes that itch continues to drive you crazy. For people with eczema, a chronic inflammatory skin condition, scratching won't make the itch go away. In fact, it will only perpetuate the red, itchy, flaky skin caused by eczema.
But try telling that to a kid. Since eczema commonly strikes in young children, it's important to find ways to prevent it from spreading to different parts of the body and to curb the scratching. A number of factors can trigger an eczema flare-up, only some of which can be controlled. If a flare-up occurs, there are two types of medications, steroidal and non-steroidal, that can be applied to help relieve the symptoms of eczema. While the word "steroid" may carry the stigma of dangerous body-building steroids, the steroids used for eczema are a different type of drug.
Doris Day, MD, is a clinical assistant professor of dermatology at the New York University Medical Center. She often treats children with eczema, and has helpful advice on how to approach their treatment, including the advantages and disadvantages of steroidal and non-steroidal treatments.
When do parents seek help for their child's eczema?
I tend to see children after about the age one or two, though sometimes they are as old as five, six or seven. These are children whose parents may have been unable to manage it with their pediatrician. Now they're finding that they need some help.
What triggers eczema in children?
There are so many factors that can precipitate an attack of eczema in a child. It can be change of weather, a cold or viral infection, or it can be clothing that's put on them, which they may not be able to express is uncomfortable.
If children have an itch, they're going to scratch it. That scratching itself will exacerbate the eczema. With a grownup, they're going to have a little bit more control. But with a child, if something is itching them, they are going to go after it, and that creates a whole itch-scratch cycle that has to be stopped in order to help get control of the eczema.
Is there a cure for eczema?
Right now, there is no cure for eczema. As we do more research and we understand it better, we're hoping to find a cure. Fortunately, with a lot of the treatments we have, we're able to control it, and that's where we are right now.
What can you teach an older child to help them control their eczema?
With a child, I think one of the most important things I do is explain that this is not their fault. I don't have something to necessarily cure their eczema, but I can help them control it, and that's what I'm here for. But we have to work together, which means that they have to be involved, too. I find that dealing directly with children and helping them understand the condition has been really helpful in making them better.
What is the role of steroids?
There are lots of different hormones that our bodies make, and the topical steroids that we use to treat things like eczema, allergic dermatitis and poison ivy are called general corticosteroids. These are the ones you can even buy over-the-counter such as hydrocortisone, which is actually the same substance that your own body makes. And this reduces inflammation and reduces the immune response locally. There is a small subset of patients who do require oral prednisolone or oral steroids for a short period of time to get control.
There are other steroids, called anabolic steroids, which athletes have used to help pump up their muscles, and those steroids are very different. They have a whole different set of effects and belong to a whole different category and would have no effect here. They are two completely separate things, but a lot of parents with little children worry that when you give them steroids they're going to have those anabolic effects.
What are the pros and cons of using steroid treatments for eczema?
They happen to be excellent for short-term treatment of eczema because they will knock it out for most people. But then there's the problem of maintaining that clearance. Eczema is a chronic condition, and steroidals are never really great for treating chronic conditions because there are a lot of problems with them over time.
While I think that steroids have a huge role to play in the treatment of eczema, you have to use them appropriately and have very close control over the patient and how they're using the steroids.
Are there specific concerns about using steroids in children?
Children are smaller than grownups, so they have a different body surface area to weight ratio. If you put a steroidal cream or ointment or gel on a child, they'll have relatively more absorption than somebody who's bigger. So the concerns that we have with grownups for steroids are the same but even more in children. We worry about growth issues and adrenal suppression. We worry about cataracts and glaucoma, thinning of the skin, stretch marks, broken blood vessels. We also worry that the skin becomes used to having the steroid there, so that when it's gone you can have a worsening of the skin rash and the skin can become very uncomfortable, and then you have to wean them off.
I'm very concerned about side effects of steroids, and I find that when I have somebody on a topical steroid, I have to monitor them much more closely. I do this in one of two ways. One, I have office visits more frequently, so that I can make sure that I come across very clearly on my concerns. Two, I give only specific amounts of the medication that I feel comfortable they'll be able to use up without actually harming themselves.
I happen to think steroids are absolutely incredible in making certain things better. It's great for the short term for eczema. It's great for allergic skin reactions such as allergic dermatitis. It's great for poison ivy in the short run. But you have to respect it. It's a pretty serious drug, so you have to use the steroid appropriately and then stop.
What is a good treatment strategy for children? In moderate-to-severe cases, I usually discuss using a steroid cream to start off. I might start with a mid-potency steroid, and do that in the morning and do one of the non-steroidals at night. I try and get them off the steroid as quickly as possible. I usually use an antihistamine in conjunction with the steroid to help control the itching, and just to help the child sleep, so the parent can also sleep at night.
Now we have this new category of drugs that are called non-steroidals, which come in creams and ointments. They're used once a day when people are also using steroids, then it moves up to twice a day as people move away from using steroids. I find that any more than that doesn't seem to make any difference. If children are motivated to do something more often, I'll have them moisturize two or three times a day.
I expect to see results within a few days. So I expect the child not necessarily to have the rash completely gone but to be more comfortable. I want to hear that after one or two days they're sleeping better, they're eating better, they're feeling more comfortable and playing better. As soon as children feel better, they're off playing again like nothing ever happened to them, and that's what you want to see. And then the rash will slowly clear over the next week to two weeks.
Can children outgrow eczema?
There are some children who outgrow their eczema, and that's always very rewarding and exciting when that happens. There are a subset of children who will just stay the same, and they'll tend to have some exacerbations and times when they're better. And that's fine; we manage those. Then there are children who will have eczema that will be persistent and difficult to treat over years to come. It's very difficult to know which child will fall into which category. You just have to treat it as you go and see what happens.
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