If your child has eczema and has been avoiding a food that he/she has been tested positive in the Skin Prick Test (SPT), it may be time to review if there is indeed a true food allergy. Research indicates, as I understand from various online articles, that the skin prick test is a test of sensitization, and not clinical relevance. Below are some points on the accuracy of skin prick test:
1. Skin Prick Test is more accurate for non-food allergen, such as dust mite and pollen, than for food allergen.
2. Skin Prick Test is More Accurate in predicting when there is NO food allergy and Less Accurate in predicting a Positive food allergy. The implication of this is that children who have been avoiding food (for example more than 50% of those tested positive for milk and eggs, and more than 70% of those tested positive for peanuts) actually didn’t have an allergic reaction to these foods. (There is only a 0.5-10% chance that a child who is allergic to a food will test negative for it.)
3. Follow-up tests are required for skin prick test for children at different age, sometimes about 1-2 years later. The results can be different as children may ‘outgrow’ some allergy or develop new ones? (hopefully not…)
4. An oral food challenge is the most accurate (less than 5% incorrect).
5. For children with eczema, there is an 80% possibility that food that the child is avoiding turn out not to be one he/she is allergic to. Refer to this article for detailed research.
Despite above, Skin Prick Test still remains the most recommended first test for allergy, as it is by comparison simpler, lower cost, faster results, more tolerated (children won’t feel much pain, you can read this post on my baby Marcie’s experience) and more accurate than blood test. If anyone has an experience to share on skin prick test for your child, do comment below this post.
Is your child just irritable with his/her skin condition or has ADHD (attention deficit hyperactivity disorder)? Just came across two studies in 2003 and 2009 that suggest an association between eczema and ADHD in children. 5.2% of 1,436 children with eczema also have ADHD versus 3.4% of children without eczema. Also the younger the child has eczema, the increased likelihood of ADHD. When I read this, I’m thinking “Oh no! Watching TV is already linked to ADHD (and we do let Marcie watch TV to distract her from scratching while we do some housework/eat a quick meal) and now eczema also?!”
The good news is that the studies do not suggest a causal relationship, not definitive and it could also be that eczema children see a doctor more often, thus more chances of detecting ADHD. It could also be that eczema children who suffer from lack of sleep get restless or cranky, and not that they have ADHD. The even better news I read online is 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” according to Sophie Worobec MD at University of Illinois.
In case you are wondering if your eczema child has ADHD, as we sometimes wonder, below are some symptoms of ADHD:
– Can’t focus on the task, easily distracted
– Unable to pay attention
– Fidget when sitting/ climbing all the time
– Talk excessively, can’t play quietly
The ADHD behavior has to continue for 6 months. ADHD, like eczema, is also linked to genetics and immune system. Having a daily schedule, immediate reward system for good behavior, eating high protein food (like meat, beans, eggs) and complex carbohydrates have been reported to help with ADHD (but again nothing conclusive). So.. while I can’t survive without letting Marcie watch TV and can’t do any better than what I’m already doing for her eczema, I will read more books and build more blocks with her.. hopefully, it helps.
2014 update: Read also Dr Cheryl Lee, dermatologist, views on ADHD, eczema and environmental pollutants here.
In my post on “Are you suffering from Steroid-Phobia?”, I have encouraged parents to be open to using steroids under the doctor’s supervision. My baby girl Marcie has taken a one-time 3 weeks oral steroid course and has been applying steroid cream prescribed by her specialist doctor, like the o.1% Elomet Cream.
A recent research study confirmed that there is no major negative effect on the skin of children who have applied topical steroid over approximately 10 months. I couldn’t find the original study, supposedly published in Pediatric Dermatology. You can however find a summary of the report, widely published by numerous online news websites here. Main points reported by the online news are:
– 70 children tested versus a control group of 22 children
– 10 months’ usage with experts checking on skin transparency, flattening, shiny ‘glazed’ appearance or dilated blood vessels
– Result is no evidence of skin thinning, stretch marks or scars
– Do note that there is also comment that the sample size is too small, with information such as their age, doses not provided
For parents fearing the use of too potent steroid, below is a potency ranking chart from National Skin Centre’s website.
You may be fearful of using steroids, as many parents (myself included) are. The fear could partly arise due to the negative news on steroid abuse by athletes and partly due to its side effects. If you have googled steroids, you will find numerous websites ‘promising’ treating eczema without using steroids. When Marcie’s doctor put her on oral steroid, I had a lot of reservations and fear and remembered scaring myself to death googling all the side effects.
But after going through resisting steroid use to using mild steroid lotion & cream and a 3-week oral steroid course for Marcie, I like to encourage you not to fear using steroids but instead use it under the instruction of your doctor, preferably a specialist.
How much steroid is ok?
Where there is no inflammation, just dry skin that’s itchy – I’d recommend using lots of moisturizer. Keeping the skin cool helps to relief the itch, so try turning the air-conditioner colder. (I sometimes give Marcie a cold drink bottle to hold and its works!)
Where there is inflammation and the skin is reddish and itchy – I’d clean the skin with cool liquid chlorhexidine (antiseptic) and apply mild steroid lotion or cream. For areas with delicate skin such as the face, I’d apply a 0.5% hydrocortisone and for other areas like the knees or elbows or hands, I’d apply a 1% elomet cream. Marcie’s doctor’s instructions were not to apply more than twice a day. So far, I have only needed to apply 2 to 3 days in a row, not exceeding twice a day, and the skin will go back to normal.
You can refer to this chart extracted from patient.co.uk for how much to apply, measured using fingertip units (ftu):
For a 3-6 month old child
Entire face and neck – 1 FTU
An entire arm and hand – 1 FTU
An entire leg and foot – 1.5 FTUs
The entire front of chest and abdomen – 1 FTU
The entire back including buttocks – 1.5 FTUs
For a 1-2 year old child
Entire face and neck – 1.5 FTUs
An entire arm and hand – 1.5 FTUs
An entire leg and foot – 2 FTUs
The entire front of chest and abdomen – 2 FTUs
The entire back including buttocks – 3 FTUs
What happened to Marcie after taking oral steroid?
You may be wondering why I’m encouraging parents to be open to using steroids when I initially did not even apply steroid on Marcie. It was very difficult to get the eczema under control and her eczema will suddenly just flare and affect her whole body. However, a one-time 3 weeks reducing dosage of oral steroid, prednisolone, really helped to keep the eczema manageable. Marcie’s rashes disappeared within the first 2 days of the oral steroid, but gradually came back as the dosage is reduced. I worried a lot after reading the side effects of steroids such as thinning of skin, acne and damage of blood vessels. I am very glad that I chose to trust Marcie’s doctor and persisted with the 3 weeks course despite being fearful everyday. After the 3 weeks course, Marcie’s doctor said he will not give Marcie any treatment that is not 100% safe and will not give her another oral steroid course because that will not be safe. I read later that stopping an oral steroid course halfway causes more harm than following through and makes it more difficult for the doctor to decide on the next step.
After the oral steroid course, there are still rashes on and off, triggered by hot weather, sweat but never affecting her whole body with no reason. This makes it a lot easier to manage and Marcie has been a much happier baby since.
Sending a baby or a young child to a skin prick test may be fearful for you or your child.
My baby girl, Marcie, had her skin prick test about 7 months old when I gave up trying to identify what triggered her eczema flares (some days I thought it’s the stage 1 food she was having and some nights I drove myself paranoid researching all sorts of allergies). Prior to the skin prick test taken at Singapore’s National University Hospital, I had some fears of the skin prick test myself; I imagined that Marcie’s skin will be pricked all over with many holes to test for all possible food she will eat in her lifetime and I also imagined the needle to be like a syringe that will inject the possible allergens into her skin.
A Quick Prick that tells a lot
It turned out that the skin prick test is about 20 minutes, starting with the medical staff cleaning Marcie’s inner forearm and applying the possible allergens (egg, dust mite, cat’s hair, dog’s hair, milk, mold) onto her arm. While one staff proceeded to prick Marcie’s skin with a needle to allow the substance to enter her skin, another staff was playing with Marcie. Marcie did not cry or even whine but I think that’s because her usual itch is far more ‘painful’ than that little prick. We had to wait 20 minutes or so before the medical staff examined the size of the wheal, i.e. reddish swelling to determine if Marcie is allergic to any of the substance.
What the Skin Prick Test Results say
All the results tested negative and as mentioned, this takes a lot of stress out – no worries over food allergy (apparently, testing for milk and egg is sufficient for food allergy; no need to prick 100 holes to test for all possible food to be consumed in a lifetime).
Don’t try pricking at home
It was a blessing that Marcie did not show any allergic reaction. However, if there is a reaction to the allergen, there will be swelling that is bigger than the dummy test and also itching. The test is not to be done at home without medical staff in case of severe reactions to the allergen. The skin area to be tested must also be free from rashes, otherwise, the reactions will not be visible. Plus, consumption of anti-histamines should be avoided otherwise the skin may not show a reaction (when there should be one).
I strongly encourage parents to bring their child for the skin prick test, otherwise, you may drive yourself paranoid guessing what causes the eczema..
Scratching. Maybe my baby knows this word better than Daddy or Mommy.
Since about a month old, Marcie started to be able to scratch her head and soon it’s her face, hands, legs and body. Scratching is like a reflex and a relief to itch and studies are still being carried out to understand the science behind it. So far, it seems that by scratching, the nerves trigger the body to release endorphins that makes your baby feels good and block off pain information. Also, scratching damages the itch nerves which take from seconds to hours to be repaired.
BUT Scratching is very bad for your child
1. damages the skin barrier, making it more vulnerable to irritant
2. damages the skin cells, causing the cells to release more itch signals
In my page on eczema tips, one of the most important step is to “know the triggers in order to control them“. I feel that this is very crucial, because it takes a lot of guesswork (and stress out) of managing your child’s eczema. I remembered that at one time when Marcie started on solids, I got soooooo paranoid that everywhere I looked, I saw potential triggers. A skin prick test eliminated a lot of what I thought might be a trigger, thus immediately reducing a lot of anxiety relating to cleaning the house and monitoring food allergy (which both Marcie tested negative to). So what are the common triggers? In order of highest probability (extracted from the book “Eczema Free for Life”):
1. Heat and Perspiration 96%. Heat is the ONE thing that I’m most afraid of. Even in an air-conditioned restaurant where not-so-cold air comes out from only certain air vents, Marcie would scratch her neck out before we even ordered the meal. Don’t be afraid to walk into a restaurant and ‘feel the air’ and ask for the coolest seat. Sweat contains chemicals that may trigger itch, so keep your baby fresh all the time. Sudden changes in temperature or humidity may also be a trigger.
2. Wool 91%. Scratchy fabrics are to be avoided, including nylon and polyester, which may irritate the skin. Wear light cotton for your baby.
3. Stress 81%. Baby gets stressed too, so let your baby have a routine and keep her occupied with toys. I co-sleep with my baby as I feel it reduces her stress too.
4. Spicy food/ hot beverage 49%. I know this is going to be controversial – I give Marcie cold baby fruit juice from fridge. My parents and the infant care teachers freak out at this and blamed a lot of Marcie’s problems on cold drinks. But I know she’s happy and almost immediately stopped scratching and took her mind off the itch. When I’m out, I may buy her a cold drink just so she can hold the cold bottle (it works!). For the record, I read that the only negative impact of cold drinks/food is that the baby takes more energy to digest them, thus reducing the energy left for your baby’s body.
5. Alcohol 44%. Not an issue with children but don’t apply alcohol on your baby’s skin though it’s cooling when the alcohol evaporates. It may dry her skin further. Drinking alcohol is of course a no-no. It expands the blood vessels near the skin, causing the skin to be more sensitive.
6. Cold 36%. I’m not sure about this one – whether the cold triggers the itch or simply a baby with cold feels cranky and scratches.
7. Dust mite droppings 35%. Marcie is tested to be not allergic to dust mite droppings but I still steam her clothes and the bed sheet, pillow cases in hot water to kill the dust mite. (Please buy a good steam washing machine if you like to do this; boiling water yourself and soaking the clothes take too much of the little time you have).
More possible triggers below:
– Soap, perfume, laundry detergent. I use soap-free bath oil for Marcie, nothing she uses is perfumed and the laundry detergent is children-friendly. Plus my washing machine has an allergy function that washes off the chemical in the detergent thoroughly.
– Chlorinated water. Bathe and moisturize after swimming, check out this post.
– Pet fur. Marcie is tested not allergic to dog’s and cat’s hair. Do get your baby tested too. Plus pets bring in lots of allergens from outside the house, do keep them at least out of your baby’s bedroom.
– Mold. Marcie is tested not allergic to mold too. Do get your baby tested.
– Saliva. This is quite a common irritant for even non-eczema children. Baby’s cheeks and areas around the mouth usually get red with rashes due to constant contact with saliva, especially when they start teething and playing with their saliva! I use cool boiled water to wipe Marcie’s face before her bedtime.
– Food. Though food is the most worrying for most parents, it is seldom the trigger. Marcie is not allergic to peanuts nor cow’s milk or egg, but the doctor’s advice is to wait till one year old to try these food. Mango is another fruit that many people balked at me for letting Marcie eat, citing that it is a ‘heaty’ food. I read somewhere later though that the area around the mango skin may cause itch, so just take care to let your baby eat the flesh inside. Mango is a very good fruit with vitamins, don’t ignore it and baby loves them with yoghurt!
Determining if your baby has eczema may not be so straight forward. Being a first time mom, I remembered reading a checklist from the paediatrician on what is normal and not normal in a newborn. Rashes is one of the items listed as normal, no need to see a paediatrician.
My baby Marcie has eczema from 2 weeks old and I only realised that her rashes were not ‘normal’ on her 1st month checkup. The paediatrician diagnosed Marcie with eczema after looking at her rashes and linked it as an allergy to milk (which turned out to be not the cause).
If you are wondering if your baby has eczema, the signs and symptoms listed below can serve as a guideline:
1. Itch – Itch causes scratching (and keeping my baby from scratching really stresses me out!)
2. Inflammation – Damage to skin cells caused by scratching. The redness in skin is caused by increased blood flow and the skin feels warm to touch and swollen.
3. Scaly Skin – More than usual dead cells on skin; can come in various forms, including white/powdery, cracked, thin/transparent sheets that peel off or thick/yellow flakes/chips
4. Lichenification – Thicker, darker and rougher skin from scratching/rubbing
5. Brown skin color – Brown spot where eczema used to be, caused by cells in skin (‘melanocytes’) releasing extra pigments from scratching
6. Scratch marks
7. Crusts – Caused by leaking serum, the liquid part of blood that heals inflammation
9. Small blisters
10. Nails – Thick & rough nails, pitted/ ridged
11. Dry skin
There are more signs and symptoms listed in the book “Eczema Free for Life” by Adnan Nasir, but listing all that here will be information overkill.