Eczema in babies, moisturisers, steroid creams and food allergy

Eczema (atopic dermatitis) is dry, itchy, red skin that comes and goes. It is very common in babies and usually improves as children grow. The two pillars of treatment are generous daily moisturiser and short courses of steroid cream for flares. Used the right way, steroid creams are safe. Removing foods from a baby's diet rarely helps and can cause harm.

What does baby eczema look like?

In babies, eczema usually shows as dry, rough, red patches on the cheeks, forehead and scalp, and on the outer sides of the arms and legs. The nappy area is often spared.

Patches can ooze or crust when they flare. As children get older, eczema moves to the skin creases, such as the elbows, behind the knees, wrists and ankles. Itch is the main feature: babies rub their face on the sheet or on your shoulder and sleep badly. On brown skin, redness can look dark brown, purple or grey rather than red. Doctors diagnose eczema from its look and history, not with a blood test.¹

What causes eczema?

Eczema happens when the skin barrier is weak, letting moisture out and irritants in. Genes play a big part, and it often runs in families with eczema, asthma or hay fever.

A leaky skin barrier gets dry and sensitive, so the immune system in the skin overreacts and causes itch and redness. Scratching damages the barrier further, which keeps the cycle going. Eczema is not caused by poor hygiene, is not contagious, and is not caused by the mother's diet in most cases.

What triggers eczema flares?

Common triggers are soap, heat and sweat, rough or woollen clothes, dust and infections. Each child is a little different.

In Kolkata, the sticky summer heat and sweat often cause flares, and so do dry winter months. Perfumed soaps, bubble baths, detergents left in clothes and strong-smelling oils can irritate the skin. A cold or a skin infection can also set off a flare. Keeping a simple diary for a few weeks can help you spot your child's triggers.

Which moisturiser is best for baby eczema?

The best moisturiser is a plain, unperfumed one that your child likes and that you will use every day. Expensive brands are not better.

Guidelines advise offering a choice of unperfumed emollients (moisturisers) and using them every day, even when the skin looks clear.¹ Thicker ointments and creams hold moisture best. Lotions are thin and need more frequent use. Avoid products with fragrance, and test any new product on a small area first. Smooth it gently onto the skin rather than rubbing it in.¹

How much moisturiser should I use?

Much more than most parents expect. For a child with eczema, guidelines suggest 250 to 500 grams of moisturiser every week.¹

That usually means applying it at least 2 to 3 times a day, all over, and every time after a bath or nappy change when the skin feels dry. Moisturiser should be used in larger amounts and more often than any other treatment, both during flares and when skin is clear.¹ If a tub lasts you a month, you are probably using too little. Keep some at the creche or with the grandparents.

Are steroid creams safe for babies?

Yes, when used as directed. Mild steroid creams used for short courses during flares are safe and are the main treatment for eczema flares.

A review of 38 systematic reviews found no evidence of harm when steroid creams were used as needed for flares, or twice a week to prevent flares.² Skin thinning was rare, and mostly seen with stronger creams.² The fear of steroids is common in India and often leads to undertreatment, which keeps a baby itchy and miserable. The real risks come from using strong creams for months without supervision, or from unlabelled mixed creams bought over the counter.

How should I use steroid cream on my baby?

Apply a thin layer once or twice a day only to the red, itchy patches, start at the first sign of a flare, and continue for about 48 hours after the skin settles.¹

• On the face and neck, use only mild creams, unless your doctor advises a stronger one for a few days.¹
• Apply moisturiser and steroid cream at different times, a few minutes apart.
• Do not use very strong steroid creams on children without specialist advice.¹
• Avoid "fairness" or mixed creams with hidden steroids and antifungals.

Does food allergy cause eczema?

In most babies, food does not cause eczema. Eczema comes from the skin barrier. But babies with early, severe eczema are more likely to develop food allergies.

A food may be worth checking only if your baby reacts soon after eating it, with hives, lip swelling or vomiting, or if severe eczema does not settle with good skin care.¹ Most children with mild eczema do not need allergy tests, and shop or online allergy tests are of no value.¹ Testing should be guided by a doctor.

Should I remove milk, egg or other foods from my baby's diet?

Usually not. Cutting out foods without a proven allergy rarely helps eczema and can harm growth.

A Cochrane review found no benefit from removing egg and milk in children with eczema who were not proven to be allergic. There may be some benefit from avoiding egg in babies with a suspected egg allergy who also have a positive blood test (specific IgE) to egg.³ Removing foods can also make allergy more likely. In the LEAP trial, babies with severe eczema, egg allergy or both who ate peanut regularly from infancy had much less peanut allergy at age 5. Among babies whose skin test to peanut was negative at the start, allergy developed in about 2 percent of eaters and 14 percent of avoiders. Among babies with a mildly positive skin test, the figures were about 11 percent and 35 percent.⁴ If your baby has severe eczema, speak to your paediatrician before starting solids about introducing peanut and egg safely.

Does early moisturising prevent eczema?

No. Good trials show that putting moisturiser on healthy newborns every day does not prevent eczema.

In the BEEP trial of 1,394 babies with a family history of allergy, daily moisturiser for the first year did not reduce eczema at age 2 (23 percent compared with 25 percent), and skin infections were a little more common.⁵ A Norwegian and Swedish trial found the same.⁶ A Cochrane review of many trials concluded that skin care in infancy probably does not change eczema risk and may raise the risk of skin infection.⁷ So moisturise when your baby's skin is dry or has eczema, not as a preventive routine.

How should I bathe a baby with eczema?

A short, lukewarm bath every day or every other day is fine. Use a soap-free wash or a plain moisturiser as a soap substitute, then pat dry and moisturise within a few minutes.

Bath oils and additives are not needed. A UK trial of 482 children aged 1 to 11 found that adding emollient to bath water gave no extra benefit over standard care.⁸ Keep baths short and avoid hot water. Oil massage with strong mustard oil can irritate eczema; if you do massage, choose a plain unperfumed emollient and skip broken skin. Moisturisers on the bathroom floor make it slippery, so take care.

What clothing and bedding help eczema?

Soft, loose cotton clothes and a cool room help most. Wool and rough synthetic fabrics often worsen itch.

• Dress your baby in light cotton layers, and avoid overheating.
• Wash clothes with a mild detergent and rinse well.
• Keep nails short, and use cotton mittens at night for young babies.
• Use a fan or AC to keep the bedroom cool in summer.

How do I know if eczema is infected?

Infected eczema gets worse quickly, weeps, and forms yellow crusts or pus spots. Your child may have a fever or seem unwell.

Bacterial infection is treated with antibiotics. A more serious infection called eczema herpeticum is caused by the cold sore virus. It shows as painful, rapidly worsening eczema with clusters of small blisters or punched-out sores, sometimes with fever. This needs antiviral treatment the same day.¹ Keep anyone with a cold sore from kissing your baby.

Will my baby grow out of eczema?

Many children improve a lot as they grow, and eczema often becomes milder by school age. Some children carry dry, sensitive skin into later life.

Children with eczema are more likely to develop asthma or hay fever. Good control now, with moisturiser and prompt treatment of flares, improves sleep and comfort for the whole family.

When should I see a doctor?

See a doctor the same day, or go to hospital urgently, if:

• Eczema suddenly worsens with painful blisters or punched-out sores.
• Blisters or sores appear near the eyes.
• Your child has fever and looks unwell with a flare.
• There is yellow crusting, pus or spreading redness.
• Your baby has hives, lip swelling or vomiting after a food.
• Eczema is not controlled after 1 to 2 weeks of proper treatment.
• Itch is ruining sleep, or your baby is not gaining weight.