In any patient with atopic dermatitis, the first step is to moisturize the skin thoroughly. In the past, physicians routinely recommended avoidance of bathing, believing that it caused further drying of the skin. Most experts now believe that daily bathing is very helpful in restoring moisture to the skin. To help accomplish this, I encourage parents to have their children lie in a tub of tepid water for at least 15 minutes, and if the face is also involved, to place a wet hand towel on the face during that time. I stress the word tepid, as hot water may further irritate dry, itchy skin. While a shower is better than no bathing at all, sitting in a tub is preferable.
After leaving the bath, the skin should be gently patted dry with a soft towel. Immediately after this, a moisturizer should be liberally applied to the entire body, emphasizing areas that are prone to rash. The moisturizer will help seal in the water that has entered the skin during the bath and help prevent future water loss from the skin. The best moisturizer has a high-lipid content, making ointments the best form of moisturizer, followed by creams and then lotions. Beyond moisturizing, there are other tips patients should consider in treating eczema.
In patients living in very dry geographic regions, use of a room humidifier may occasionally be helpful. Irritant avoidance is also very important, which means eliminating heavily per-fumed or scented soaps, limiting soap application to the underarms or genital areas or very dirty areas, and completely rinsing all soaps from the body. Equally important is putting all washed clothes through a double rinse cycle in order to remove any residual detergent that might be left in fabric. As noted above (in Question 95), allergenic foods identified by skin or blood tests and possibly oral challenges should be strictly avoided, and environmental control measures aimed at relevant airborne allergens (mites, animals, molds) should be put into place.
When all of the above measures have been taken and the child continues to have a recurring rash, medications will be necessary. In areas of active rash, topical corticosteroids used for 7 to 10 days are very effective in reducing itching, redness, and scaling and expediting the healing of the rash. For the face and neck, it is best to use a low-potency topical steroid (such as hydrocortisone 1% or 2.5% cream) which will usually be effective without causing thinning of the skin. For the body, a medium-potency topical steroid (such as triamcinolone 0.1% ointment) will usually suffice in eliminating signs of inflammation.
However, in children with moderate to severe dermatitis, the rash will frequently recur after stopping the steroid. In this situation, use of a nonsteroidal topical anti-inflammatory such as Protopic (tacrolimus ointment) and Elidel (pimecrolimus cream), which may cause the rash to improve markedly for a period of weeks to months before the next recurrence. Inflammation in atopic dermatitis may be aggravated by bacterial infection of the skin.
Children with oozing and crusting of their rash over large amounts of their body may benefit from a 2-week trial of an antibiotic, such as cephalosporin (cephalexin). In situations where the area of infection is very small and localized, a topical antibiotic such as Bactroban (mupirocin) may be adequate. Occasionally, children are referred to me who have been treated with recurrent courses of oral steroids, such as prednisone, for control of their atopic dermatitis. While these drugs are extremely effective in clearing the rash, I strongly discourage this approach to therapy due to the high occurrence of systemic complications, such as growth impairment, osteoporosis, and cataracts.