Friday Feature – Eczema Q&A with Dr. B

Dr. Christopher Bridgett is Hon. Clinical Senior Lecturer Imperial College at Chelsea & Westminster Hospital London. He is a psychiatrist with a special interest of using behavioural interventions to help people with atopic eczema, co-author of The Combined Approach at AtopicSkinDisease.com

Q&A with Dr Christopher Bridgett on Childhood Eczema and Habitual Scratching

This was originally a series of Friday Q&As in 2012 which had since been combined into one informative post.

Bedtime Routine for Eczema Kids

Marcie Mom: I set up a bedtime routine of reading books, singing songs, turning off all the lights and playing baby christian songs. We also pray for good night’s sleep! How does routine help a child’s behaviour and how can it help the child’s eczema?

Dr B: Your routine enables learning the desired consequence – a good nights sleep – if all the pieces of the sequence follow each other frequently enough, including the consequence of falling asleep. It’s best to move on from reading, and singing songs, to turning off the lights and saying prayers only when the signs of sleep arriving soon are quite clear!

When you think the child will sleep OK without the routine, it may be tempting to make some short cuts. I suggest that this would be a mistake! If on the other hand, a child is especially fraught, and therefore wakeful, it is best to go slowly along the routine, reading more stories, singing more songs, before the lights are turned off, and good night kisses are given.

Routine usually enables most of us to cope with everyday life. Generally following an established and happy routine means less stress, and changes in routine are usually stressful. And less stress means calmer skin, and less scratching… sounds good for eczema, I think!

Stress Control for Eczema Family

MarcieMom: Parents taking care of eczema children experience high stress levels, apparently as high as parents taking care of children with kidney illness. I’ve also read that stress can be passed onto babies, is there a chance that the stress that parents of newborn feel may worsen the eczema of the baby?

Without making parents even more stressed (that they are passing on the stress!), are there any tips for them to manage their own stress or to prevent stressing their child inadvertently?

Dr B: The causation of atopic eczema is multifactorial – there is no one factor, there are many, and they can be divided up into those that we have to accept, and those that we can do something about. First we need to draw up the list that applies in a particular case – stress is usually there on the list, and stress is usually a factor we can do something about!

Stress and frustration directly affects the skin – the skin is very sensitive to our emotions, and we all tend to scratch more when stressed and frustrated, and scratching soon becomes habitual – which is the cause of chronic eczema. There is no doubt that stress can be part of family life; kids become how they are through their parents, don’t they?

Marcie Mom: Most parents of eczema children have no time for themselves, let alone exercise. Obviously, we know exercise is good for us but how does exercise affect our psychological well-bring?

Dr B: Great question! We seem to live in stressful times. Under stress the body releases hormones like adrenaline, that facilitate fighting, or fleeing! In modern times we can’t do either usually, so it’s important to have a regular physical outlet. A healthy mind in a healthy body.

Marcie Mom: Also, parents of eczema child tend to have less couple time and higher stress in marriage. What simple and practical advice would you give them?

Dr B: The first step is the one you have already taken: recognize the problem. Coping always begins with confronting reality. Next how it leaves you feeling needs expression – don’t bottle it up, let it out, talk about it, understand it and think it through.

Then consider getting and accepting help – problems shared are problems halved. Experiment with new ways of doing things. Don’t take the situation for granted – there is usually a way of changing arrangements for the better. 

Steroid Side Effects

Marcie Mom: Some child’s skin turn brown where it frequently itches, being scratched and steroid creams have been applied. Some parents think it’s the steroid cream that causes the change in skin colour but I’ve read that the brown patch is caused by cells in skin (‘melanocytes’) releasing extra pigments from scratching. Which is true? Particularly it’s important to dispel any misperception of steroid when the risk of under-treatment due to steroid phobia is real.

Dr BBoth are true!

In the first case, yes steroid creams will change the colour of skin – they very slowly reduce the pigmentation, lightening the colour of the skin. The anti-inflammatory effect of the steroid reduces the activity of all skin cells, including the pigment cells – the “melanocytes”.

In the second case, cellular activity in skin is stimulated by habitual scratching, and this affects all cells, including the pigment cells – the “melanocytes”. So habitual scratching causes the skin to thicken up – lichenification – and colour up – hyperpigmentation. Both are characteristic of chronic atopic eczema.

Cradle Cap

MarcieMom: Some eczema babies also get cradle cap, and the cradle cap shampoo has to be used to massage the scalp and wash off the cradle cap. What’s the difference between cradle cap shampoo and normal baby shampoo?

Dr B: Aha! I think I can answer this… Yes, they are different. Cradle cap is seborrheic dermatitis of the new born and infants – it is usually harmless, and can clear on its own, without any special treatment. The regular baby shampoo will help reduce the rash, but specially formulated cradle cap shampoo is stronger – it may have salicylic acid in it for example. If the special shampoo is used, please make sure it is suitable for the age of the child!

Marcie Mom: I’ve also read that brushing a newborn hair helps to keep cradle cap away. Is that true? What does brushing hair do to the scalp?

Dr B: Yes, brushing the hair helps tidy things up, until the cradle capclears. With cradle cap there is excess sebum being produced. Sebum is the natural oil of the skin. Sebum is good for the skin and hair, in moderation – for example, it gives insulation against water loss. When birds preen they are spreading oil over their feathers, and that is what brushing the hair does – see how it shines! 

Swimming for Eczema Children

Marcie Mom: Some parents are very skeptical of bring their eczema child to swimming but my baby’s doctor recommended it. Just 10-15 minutes 3 times a week and wash off pool water and moisturize immediately. Will that also be your recommendation? Swimming is so fun and I hate to see eczema children being kept off it!

Dr BSwimming is fun and good exercise – it also saves lives! So it’s good to say that swimming and atopic eczema usually go together just fine. The problem is caused by the water – it washes off a layer of the skin’s protection and leaves it very porous to water loss afterwards: a thin application of moisturizer before swimming protects against this. Make sure the application is thin though – no need to prepare for cross-channel swimming – see http://www.atopicskindisease.com/articles/TopTip1

Otherwise, the chemicals in the water of a swimming pool are disinfectants – chlorine, & bromine for example – they can be good for the skin, as their antibacterial effect is anti-inflammatory. However these additives can irritate too, so your procedure is a good one!

Moisturizing

MarcieMom: Moisturizing is important to maintain the skin barrier, particularly when eczema child has a weaker skin barrier that allows for more allergens to penetrate. The recommended guideline is about 500ml per week, that’s a lot and some children simply squirm when parents try to apply the moisturizer. What do you suggest parents can do to get their children to like being moisturized? Or even better, moisturize themselves!

Dr B: The use of a moisturizer – also called an emollient – is central to the care of atopic eczema.  The way it is used is very important – much more important than which one is used. Sometimes the better ones are the cheapest – and the best one is the one that is liked and used properly!

With children, as with adults, there are four key words to remember:

Thinly, Gently, Quickly and Often

and with the child it is very important to get it done quickly, and on afterwards to do something fun together, so that fun becomes the focus, not the moisturizing!

Getting the child to do their own moisturizing needs careful consideration: left to their own devices there is a good chance it will not get done properly – perhaps age and temperament come into it. 

Reactive Skin Reactive Mind?

Marcie Mom: It is mentioned in this article a comment by Sophie Worobec MD at University of Illinois that eczema children are “very bright” as the skin and the brain develop at the same time, so “very reactive skin and very reactive mind”. What do you think of this statement?

There seems to be an association between ADHD and eczema children. And have you seen more cases of ADHD for eczema patients?

Dr B: That there seems to be a close relationship between the skin and the mind is often referred to, and the development of the skin and the brain from the ectoderm of the early embryo is seen as relevant to this relationship – I sometimes say the brain can be called a specialized part of the skin!

But in reality the whole body is closely integrated. All the separate parts are interdependent through shared characteristics, and the overall function is enabled by circulating hormones and by the nervous system links between brain and body.

Both ADHD and atopic eczema are relatively common conditions. The recent reports of an association need to be treated with caution. I have no personal clinical experience of this reported association.

Tensed Baby

Marcie Mom: My baby has taken to tensing her stomach and legs in positions such as doing leg raisers or push-ups. My husband and I think it’s related to her being swaddled too much when young (we had to swaddle her due to scratching, sometimes looping a cloth around her limps cos the scratching was so bad). Do you think it is possible that she has learnt to use tensing to ease her itch and will this impact her psychologically? We certainly hope we haven’t made her gone bonkers!

Dr B: No, I do not think so! Probably what your baby is doing is “within normal limits” and is not due to swaddling, or to itching – and will have no psychological significance at all.

Marcie Mom: That’s comforting to know. Here’s another ‘crazy’ question from me. I frequently use finger food like biscuits (but only vitamin fortified, non-sugary, suitable for babies) to distract from my baby from scratching. My husband thinks I’m turning her into a glutton and soon she’ll have compulsive behaviour to keep eating. Is that true? 

Dr B: The importance of neutral/helpful alternative behaviours to scratching is fundamental to habit reversal – the new behaviour should not risk substituting a new problem for the old problem. I do not think what you describe is likely to lead to compulsive behaviour, but using eating as a habit reversal tactic does seem to encourage habitual snacking, and that may not be what you want to do?

Parental Guilt

Marcie Mom: Some parents have feedback that they feel guilty that they have either passed on the ‘bad gene’ or haven’t noticed their child scratching. What advice would you give to parents to cope with the guilt, which of course, isn’t justified!

Dr B: Both awareness of genetic inheritance, and coping with achild’s scratching are common human experiences and, as “facts of life”, need keeping in proportion. Some of us are more prone to self-blame than others. I think self-blame regarding genetic predisposition is quite unjustified. Failing to supervise a child’s scratching behaviour may be something to review. Sharing experiences in real time with others, and over the internet should be really helpful: great that you have this site!

Stop Scratching Eczema

Marcie Mom: Eczema babies seem to form a habit of scratching, mine even scratches my spouse or I when we’re beside her. How do you suggest parents can help to break the habit for your children (who can’t understand not to scratch nor appreciate the full negative effect of scratching)?

Dr B: Follow The Combined Approach to atopic eczema …. usehabit reversal behaviour modification to treat habitual scratching, together with optimal conventional treatment. To rescue a young child from chronic eczema please refer to Chapter 5 of our book“Atopic Skin Disease” – available to consult at www.atopicskindisease.com

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