For one in five children in the UK, itchy skin is more than just an occasional irritation. Despite eczema being one of the most chronic skin conditions in early childhood, it is often dismissed as ‘just a bit of dry skin’. But for affected children and their families, the lived experience can be distressing, disruptive and at times overwhelming.
‘Society as a whole can often overlook eczema because it's often seen as just a patch of itchy skin, but for those who have it in its severest form, it can be hugely impacting on their quality of life,’ says Moira Clark, head of services at Eczema Outreach Support. ‘Children can have eczema from birth and it can be widespread all over their body and head. They often have to endure quite gruelling treatment regimes with regular application of emollients because their skin can't hold moisture, so that moisture has to be regularly replenished throughout the day.’
Clark says children often miss nursery and school because of their symptoms, and she knows of parents who have been forced to stop work in order to care for their child's condition.
CAUSES AND SYMPTOMS
Eczema is thought to be caused by a combination of genetic and environmental factors. At its core, eczema involves a problem with the skin's natural barrier – it doesn't retain moisture well, allowing irritants and allergens to penetrate more easily and trigger an immune response. External factors include soaps, allergens such as dust mites, changes in temperature and even emotional stress.
The appearance of eczema can vary depending on skin tone and the affected area, but key characteristics include:
- Intense itching that can lead to scratching and further irritation.
- Dry skin, which may be cracked, scaly or even crusty.
- Redness, swelling and inflammation.
- Skin appearing bumpy or leathery.
TREATMENT
A combination of strategies are used to treat eczema, aimed at reducing inflammation, relieving itching, preventing a ‘Thare-up’ and restoring the skin's natural barrier. They depend on the severity of eczema and the child's individual triggers but typically include:
- Emollients (moisturisers) that help keep the skin hydrated and form a protective barrier to reduce water loss. These are applied several times a day, even when the skin appears fine.
- Topical steroids to reduce inflammation during a ‘flare-up’. These are used for a short period of time only on the inflamed area, not all over the body.
- Antihistamines are sometimes prescribed to reduce itching.
- Phototherapy, or light therapy, involves using ultraviolet light to reduce inflammation and itchiness in severe eczema.
Another important strategy is to identify the child's individual ‘triggers’ and to avoid these wherever possible.
Eczema is highly individual – what affects or helps one child can have no influence on another – which means personalised care is essential. ‘There is a huge amount of trial and error and lots of visit to the clinician,’ says Clark. ‘It's not like an antibiotic that will definitely work and clear an ear infection in seven days. It's hard for clinicians to find the right treatment that will match that child.’ However, the impact of eczema is shared by all – the affected area is very itchy and the urge to scratch it is almost impossible to resist. This can lead to skin becoming increasingly sore, and it may bleed or become infected.
Beyond the physical symptoms, eczema can affect children's emotional wellbeing and their ability to fully engage in activities. Irritability, poor concentration, anxiety and social withdrawal are not uncommon in children who are coping with severe symptoms.
‘Children are massively impacted by their sleep and the intense itch can often lead to children having huge amounts of broken sleep,’ says Clark. ‘The itch can be far worse at night as children lie under covers and they can be scratching and clawing at their skin for hours. In some families, a parent will literally lie on the floor to soothe their child and try to prevent them from scratching. A child who hasn't had a good sleep is not going to be in a good space mentally when they go to nursery or school. Children who are tired or experiencing a constant itch can experience fluctuating moods, which can affect their behaviour and concentration.’
Some children have long periods without a ‘flare-up’, but for others there is no respite.
IN THE NURSERY
By taking time to understand the child's individual condition and making a few practical changes to the nursery day, early years practitioners can make a big difference to the lives of children with eczema (see box). ‘Nurseries need to take eczema seriously, be fully aware of the child's condition and know how to apply the emollients,’ advises Clark. ‘Some parents will say that their child returns from nursery with bone-dry, irritated skin because staff are not applying emollients.’
Along with raising awareness among staff, she adds that it is also important to explain eczema to children so they understand the condition. ‘Eczema can also impact peer relationships,’ says Clark. ‘Children will report their peers not wanting to hold their hand because they think it's contagious. Children can also ask what is wrong with their skin and be unintentionally cruel.’
The practitioner's role: know the condition
Ensure the whole staff team understands what eczema is and that it can vary widely from child to child. Consider accessing training to understand the importance of consistent skincare routines. ‘Eczema is a condition that needs to be taken seriously, as you would with a severe nut allergy or asthma,’ says Clark.
Work with parents – Remember they are the experts in their child, so ask them when and how treatments should be applied. Ask them to provide sufficient quantities of the emollient, labelled with the child's name, and consider using a communication diary to ensure consistency.
Make adaptations – Some activities can irritate eczema, such as messy play, getting too hot while running around, helping with pets or going out in cold weather. Ask parents what triggers their child's eczema and discuss how to minimise this. For example:
- Provide nitrile gloves with a cotton insert for wearing during sand, water and messy play. Ensure hands are washed with an emollient afterwards.
- Have a special cushion or mat for the child to sit on if carpet fibres irritate their skin.
- Check cleaning products – including hand soap, what towels are washed in and surface disinfectants.
- Ensure fibres in uniforms and dressing-up clothes do not irritate the child's skin.
- In summer, cool down children who have become hot and ensure sun cream is suitable. In winter, take care children do not sit next to radiators that may excessively dry their skin.
- Provide a quiet place for a child to rest after a disrupted night.
Model empathy – Give support to the child if they are having a ‘flare-up’ – be sympathetic and also try to distract them from the itching (giving them a fidget toy to play with). Answer any questions children have about the eczema with respect and honesty, and emphasise that they can't ‘catch’ it.
FURTHER INFORMATION
- Eczema Outreach Support provides training for staff working with nursery-/school-aged children: https://tinyurl.com/5dyj9yfs
- National Eczema Society: https://eczema.org
- The Itchy-saurus by Rosie Wellesley
