Q: My 3-year-old has eczema on her elbows and legs, and itching keeps her awake most nights. She really has a hard time falling asleep. What can I do?
Chitra Dinakar, MD: Watching a child struggle to fall asleep when eczema (or atopic dermatitis) is flaring up is really hard and frustrating for parents. The important thing to remember is that when children with eczema scratch, it’s because their itch threshold is low.
I recommend approaching this tendency in four ways:
Moisturize the skin. It’s okay to bathe the child but I recommend wetting the skin with lukewarm water – just enough for the moisture to soak into the skin. Let the moisture get in so that the skin traps it. Then, pat the skin dry – don’t wipe it dry.
For moisturizers, I recommend hypoallergenic products because sometimes fragrance-based products can actually irritate the skin.
You should think of your child as having skin like a prince or a princess. Treat it very delicately – and moisturize!
Control the itch. Antihistamines, such as diphenhydramine, can help decrease the itch threshold and reduce the amount of time it takes to fall asleep. It helps the child get a longer and better night’s sleep – which is also beneficial for the immune system.
Treat with anti-inflammatories such as topical corticosteroids. Eczema is an inflammatory condition so the more the child scratches, the worse the inflammation. The goal is to break that itch-scratch cycle.
Topical corticosteroids are a very common eczema treatment. There is a range of strengths (or potency); you can start with a mild-strength topical corticosteroid available over-the-counter and then switch to a stronger one if mild is not working well.
Mild topical corticosteroids are available over-the-counter while higher-strength topical corticosteroids such as topical calcineurin inhibitors (TCIs) require a prescription from a doctor, such as a primary care physician, an allergist or a dermatologist.
Anti-inflammatories are typically used in conjunction with moisturizers. They control the inflammation when the skin is moisturized.
Identify what is causing the itching. The triggers can be physical, such as getting hot and sweaty; contact with a fabric such as wool or polyester, or metal such as nickel, that irritates the skin; soaps or household cleaners; and even emotional stress.
The triggers could also be related to environmental allergies (such as seasonal pollen, mold, dust mites or pet dander) or food allergies. Skin testing can help identify which allergens are causing flare-ups.
I recommend working with an allergist to identify triggers and develop strategies to manage the condition.
Chitra Dinakar, MD, FACAAI, is a board-certified allergist and immunologist, Clinical Chief of Allergy, Asthma & Immunodeficiency at Stanford Health Care and Clinical Professor of Medicine at Stanford University.
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