Most children with WAS have eczema at some time in their lives. They are also prone to infections with bacteria such as with streptococcus and staphylococcus, viral skin infections such as molluscum, warts and recurrent herpes. These infections can be severe and difficult to treat. Chicken pox can be severe in these children. Many of these children are prone to autoimmune disorders which affect the skin such as vasculitis and recurrent hives. This section just focuses on eczema.
Eczema is a chronic recurring skin disorder that results in dry, easily irritated, itchy skin. The skin is dry because the outer layer is unable to retain water. Unfortunately there is no cure for eczema and it has to be controlled with good skin care. The skin is the largest organ in the body. It provides a barrier against infection and anything that affects the skin can affect the rest of your body. It is therefore important to take good care of the skin. The goals of controlling eczema are three fold:
1. Avoid triggers that cause flare ups of eczema. Some food, and several chemicals can irritate the skin. Find products that do not irritate the skin and stick with them. These irritants could be harsh soaps, detergents, household cleaners, lotions etc In general keep away from perfumed products as they tend to irritate the skin. Using half the recommended amount of a hypoallergenic detergent and double rinsing the clothes can help reduce eczema. Wash all new clothes before wearing them. Avoid the use of fabric softeners. Wear cotton clothes. It breathes, absorbs moisture, feels better and irritates the skin less. Wool can very often irritate the skin of these children. Cold temperatures, especially when combined with low humidity during winters in a heated home, wind, heat, sweat, and excessive bathing can worsen eczema. Stress can cause flare ups. It is important to help children find effective ways of coping with and managing stress.
2. Moisturize the skin by means of baths and retain the moisture by frequently applying moisturizers.
3. Use of medications to control the eczema and the itching.
- Bathe every day. Take 5-10 minute baths or showers in warm water. Avoid long, hot showers. Pat dry after the shower and avoid vigorous toweling. Bathing regularly helps moisturize the skin and reduces skin infections. Here are some suggested mild soaps.
- Swimming helps patients with eczema. The chlorine in the pool kills some of the bacteria on the skin and seems to reduce the flares and control infections. Take a quick shower after the swim to wash off the chlorine and moisturize. Try one of the following baths suggested by the National Eczema Association
- Bleach Baths: Bleach baths make the tub into a swimming pool! Soak for about 10 minutes and rinse off. Use 2-3 times per week. Bleach baths decrease the bacteria on the skin and decrease bacterial skin infections. Use 1/2 cup household bleach for a full bathtub, 1/4 for a half bath.
- Vinegar Baths: Referred to as the “pickle the patient” treatment. Add one cup to one pint of vinegar to the bath. Can be used as a wet dressing too as it kills bacteria.
- Salt Baths: When there is a significant flare the bath water may sting or be uncomfortable. Add one cup of table salt to the bath water to decrease this side effect.
- Baking Soda Baths: Added to a bath or made into a paste it can be used to relieve the itching.
- Tar Baths: Tar baths can soothe inflammation and itch. Tar bath oil or tar shampoo can be used. Warning: if the skin is open or excoriated tar baths can sting.
- Oatmeal baths: Added to a bath or made into a paste it can be used to relieve the itching.
- Liberally apply moisturizer within 3 minutes after taking a bath in order to lock the moisture into the skin. Moisturizer should be applied all over the body, including unaffected parts of the skin. Moisturizing the skin immediately after a bath locks the moisture from the bath into the skin and can help reduce the itching. Retaining the moisture allows the skin to heal. Moisturize frequently all day long. It is best to take baths at night as the exposure to chemicals etc are minimal at night. This minimizes skin irritation for 9-10 hours , allowing the skin to be moisturized and heal during that time. Lotions and oils are usually inadequate in the treatment of eczema. These are some suggested moisturizers.
Medications to control the eczema and Itching
1. Topical Corticosteroids(Steroids): These medications come in the form of ointments and creams and are often the only medicines that can help eczema. They come in various strengths, from mild to very potent. Steroids are potent medicines and must be used with care. Always use as directed by the physician. A thin layer of medication should be applied to the affected parts only. Applying moisturizer over the medication increases the effectiveness of the medicine, but also increases absorption and should be done under the direction of the physician. A mild steroid such as hydrocortisone 1% which is available over the counter is relatively safe. However, the more potent steroids can cause thinning of the skin, stretch marks, growth retardation or suppression of the adrenal gland if used in the same areas for a long period of time1. Children should be supervised if they use steroids.Listed are the topical steroids that are used and their potency. Use the lowest potency steroid that is effective for your child.
2. Infections can happen more frequently than normal as the skin is not intact and allows bacteria to enter more easily. Routine use of soap and water helps reduce the infection. If there are signs of infection such as redness, pain, swelling, etc. this may require topical or oral antibiotics. Patients with WAS are more susceptible to severe infection with chicken pox, molluscum (a viral infection) and warts. More details on these infections are in the section on infections.
3. Tar creams can help in milder cases of eczema. Once used widely, tar preparations are used less frequently nowadays.
4. Topical Immunomodulators (they alter the immune system): These are newer medications which control the redness and itching associated with eczema. Tacrolimus andPimecrolimus are FDA approved for patients over the age of 2 years. They work by stopping the immune system from producing factors that cause eczema. Some experts(verbal communication- Dr. Buckley) feel that it is best to avoid the use of these medications in children with WAS if possible. It should not be used under the age of 2 years and is not meant for long term use. Patients below age 16 can only use the 0.03% cream and not the 0.1% cream. It is very important to follow the doctors advise exactly when using this medication. A few cases of lymphoma and skin cancer have been reported with the use of these mediccations and patients who are post transplant may be more vulnerable2. When using this medication, please read the instructions and follow them thoroughly. The area where the medication has been applied should be protected from natural and artificial sunlight. Use normal, loose fitting clothing to cover the area to protect it. Use sunscreen on the area only if the doctor advises it.
5. Itching is part of the eczema process and persistent itching worsens the eczema and can cause bleeding. Itching can be disruptive to sleep, school and cause social problems. It also predisposes the patient to infections. Good skin care and the routine use of moisturizers and oatmeal baths can help control the itching. Keep nails short and filed. Encourage routine washing of hands prior to applying topical medications. Medications such as benadryl or atarax, especially at night can help control itching and break the itch-scratch cycle. All topical products should be kept using good hygiene practices to avoid their contamination with agents that can cause skin infections.
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1. National Eczema Association. www.nationaleczema.org
2. Tacrolimus Topical. www.nlm.nih.gov/medlineplus