SEAN came to see me the other day, after an absence of some years. Now a developing teenager, he is one of those patients that doctors always remember, like the worst asthmatic you have ever treated or the person whose life you saved in some unusual circumstance.
No matter how much he grows, Sean will always be the young child with the most severe case of eczema I had ever seen. I first met him when he was about two years old, sitting in his mother's arms with nothing but a sheet covering him. His shining, red, scaling face peered out at me, liquid brown eyes quietly assessing his new family doctor.
Eczema is a term used to describe inflammation of the skin. There are several types of eczema, the most common being atopic eczema. The term atopic refers to an inherent tendency for the skin to become inflamed or "eczematous". Atopy is a genetic trait, which leads to asthma and hayfever as well as eczema.
Research has shown that 22 per cent of people with atopic eczema will have the other allergic conditions as well. The incidence of eczema has risen fivefold in the past few years, with a particularly high incidence noted in more affluent families.
Eczema often starts in infancy and is commonest at two years of age. Many children with "baby eczema" will grow out of it, although the tendency will always be there, given the right trigger factors, for the condition to recur in later life. The natural history is for eczema to wax and wane with some good and some not-so-good periods.
How will you know if your child has eczema? You may notice that their skin is dry. The creases of the elbows and knees are the most common sites, as well as the face in babies. Red, inflamed areas of skin will follow next and, if left untreated, these can become blistered and weepy. The child will be pulling at his skin, which may become thickened. Younger children are usually fractious because of the intense itching, and sleep will be an early casualty. Indeed, this is often the reason parents seek medical assistance, driven to distraction by a very demanding and insomniac baby.
There are three key principles in the management of eczema: 1) Avoid irritants to the skin wherever possible.
2) Use moisturising creams frequently to help prevent eczema patches developing.
3) Use steroid creams when the eczema flares up.
When I first saw Sean, his mother knew not to wrap him in woollen clothes. Soap and bubble baths were non-runners in their household. Moisturisers are available as bath additives and should replace all other irritant chemicals in the bathroom. They are the mainstay of treatment. The cream versions of moisturisers are often extremely greasy - however, there is a direct relationship between the thickness of the cream and its effectivness.
Steroid preparations are essential in the treatment of the inevitable "flare-ups" of the skin. In general, a preparation of the lowest strength should be used. It is sometimes necessary to use potent steroids, but this is best done under medical supervision. Occasionally, your doctor will add an antibiotic component to the steroid cream if he suspects infection is present on the eczema patch.
The role of diet in eczema is controversial. According to Dr Joe Fitzgibbon, a medically qualified allergy specialist, it is not usually a factor in mild cases. "It is worth carrying out dietary investigations in more severe cases of eczema - in particular, a skin patch test for allergy to milk or egg white," he says. "If this is positive, then I recommend a trial period of excluding the allergen." It is important not to indulge in broad-based exclusion diets without expert advice, he adds. In general, these are best reserved for cases of really severe eczema which show no response to intensive conventional treatment, according to Dr Fitzgibbon.
Many adults with a childhood history of atopic eczema will notice they are prone to occasional episodes of dry skin when they come into contact with trigger factors in the workplace. Rubber gloves, glues, plastics and resins are likely culprits. Increased humidity can be a problem in the modern workplace, and this too may lead to the return of dry, itchy skin.
Mothers and fathers are the key players in managing a child with eczema. Once they become familiar with the condition, they will be able to treat their child with minimal medical input. Parents will be especially aware of individual trigger factors, from the house dust mite to certain foods which seem to cause the eczema to flare.
Sean's mother taught me many things about eczema. She is a stoic and unflappable woman, and as he left the room last week, I could see that he is cast in the same mould. "Any skin trouble recently," I asked. "No, doc, that has not bothered me since I was a child," he replied. For parents worried about eczema, Sean's story shows that there is light at the end of the tunnel.
Dr Muiris Houston can be contacted by email at mhouston@irish-times.ie
