Doctor Q&A

Facial Eczema with Dr Lynn Chiam: Rashes, Treatment & around the Mouth and Lips

Facial Eczema Eyelids Mouth Lips with Dr Lynn Chiam Dermatologist

This was an original series combined to a post that focused on facial eczema, with the privilege of having Dr Lynn Chiam, of Children & Adult Skin Hair Laser Clinic, to help explain the type of facial rashes, its treatment options and daily facial care. Dr Lynn is a consultant dermatologist who subspecializes in pediatric skin conditions, adult pigmentary conditions and laser dermatology. 

Types of Facial Rashes

What are these Rashes on my face?

A rash on your face is possibly something you’d notice soon enough and start worrying about whether others would notice too. It can affect across all age groups, from infants to children to teenagers to adults, but are they all the same? And which age group or profile is more likely to suffer from one type of facial rash versus another type?

Below is a list of possible rashes on your face and with the help of Dr Lynn, a brief explanation of each and who is more likely to suffer from it.

Atopic Dermatitis

What it is: Inflammation of the skin, that is often associated with itchiness, redness, dryness and infection. It tends to occur together with rash elsewhere on the body.

What it looks like: Atopic dermatitis on the face typically presents as red patches on both cheeks associated with scaling. It can also affect the forehead and behind the ears. Darkening and skin folds can appear on the skin below the eyes as a result of constant rubbing. Infected eczema on the face can present as an oozing patch with crusting and scabbing.

Who gets these rashes: Infants with eczema commonly present with rash on their cheeks. Facial eczema occurs less commonly in older children and adults.

Infant with face eczema rash on cheeks
Facial eczema on baby’s cheeks (copyright picture)

Seborrhoeic Dermatitis

What it is: Seborrhoeic Dermatitis is a harmless scaling rash that can affect the face and scalp. It tends to occur in oily areas where there is a high concentration of sebaceous glands. It is believed to be an inflammatory reaction to a yeast called malassezia.

What it looks like: Seborrhoeic dermatitis presents as a slightly pinkish rash with white/yellow scales. It can affect the eyebrows, sides of the nose, inside and behind the ears, forehead and scalp. It can be aggravated by stress, illness and fatigue.

Who gets these rashes: Infants with seborrhoeic dermatitis presents with yellowish scales mainly on the scalp (also known as cradle cap). Adults can also get seborrhoeic dermatitis and commonly present with pinkish scaly rash on the face and white flakes on their scalp.

Infant with seborrhoeic dermatitis on scalp (picture credit from Dermnet NZ)
Infant with seborrhoeic dermatitis on scalp (picture credit from Dermnet NZ)
dult with seborrhoeic dermatitis (picture credit: Dermnet NZ)
Adult with seborrhoeic dermatitis (picture credit: Dermnet NZ)

Irritant Contact Dermatitis in Babies

What it is: Irritant contact dermatitis occurs when external chemical or physical agents damage the skin. Common culprits include detergents, solvents, acids, water and friction. The severity of the rash depends on the amount and strength of the irritant, the length of exposure and the individual’s skin susceptibility. People with atopic eczema are more susceptible to irritant contact dermatitis.

What it looks like: Irritant contact dermatitis causes a well demarcated rash which is red and itchy and there can even be swelling and blisters. It can occur anyway in the body where the agent is in contact with the skin. In infants, the rash can occur around the mouth as a result of frequent contact with saliva.

Who gets these rashes: Anybody who gets in contact with an irritating agent can develop rashes. Patients who suffer from atopic eczema are more susceptible to irritant contact dermatitis as their skin’s protective barrier is damaged. People working in certain occupations like dishwashers, metal welders, hairdressers and cleaners are more prone to irritant contact dermatitis as they are often in contact with strong chemical agents. Infants who are teething can also be affected as their saliva is irritating to the skin.

Allergic Contact Dermatitis

What it is: Allergic contact dermatitis occurs because of an immune reaction to a substance which had been in contact with the skin and to which that particular individual is allergic to. Unlike irritant contact dermatitis, a small amount of the substance can lead to development of a rash. Allergic contact dermatitis does not occur in everyone in contact with the particular substance, it only affects people who are allergic to it i.e. those who develop an immune reaction to the substance. Irritant contact dermatitis, on the other hand, may affect anyone provided they have had enough contact with the irritant.

What it looks like: The rash caused by allergic contact dermatitis normally develops a few hours after being in contact with the substance. It is normally confined to the site where the skin had been in contact with the allergen though in severe cases, the rash can extend outside of this area and can even be generalized. The rash is red, itchy, swollen and blistered.

Allergic contact dermatitis on the face is often due to allergens found in skin care products or cosmetics. Other common sites are the ears and the neck secondary to nickel containing costume jewellery.

Who gets these rashes: Anyone can get allergic contact dermatitis as long as they are in contact with substances to which their body mounts an immune reaction to.


What it is: Rosacea is a skin condition that causes redness and acne-like zits on the central face. It can be transient, recurrent or permanent.

What it looks like: A patient with rosacea flushes or blushes easily especially in hot environment, when excited or after ingestion of alcohol. There is obvious redness of the face with prominent blood vessels. There can also be pimples on the face.

Who gets these rashes: Fair-skin females between the ages of 30-60 are more likely to suffer from rosacea.

Rosacea on face (picture credit Dermnet NZ)
Rosacea (picture credit Dermnet NZ)


What it is: Psoriasis is a chronic non-contagious skin condition caused by rapid growth of the outer skin layer. It is one of the more common skin conditions seen in Singapore and genetics is believed to play a part.

What it looks like: Psoriasis usually presents with thick silvery flakes of scales on raised pinkish red skin with well-defined margins. Psoriasis can occur anywhere on the body including the face. On the head, it commonly affects the hairline, scalp, and behind the ears.

Who gets these rashes: People of any age can get psoriasis from infants to the elderly. It commonly starts in the 20-30 age group and the 50-60 age group.

Psoriasis (picture credit Dermnet NZ)
Psoriasis (picture credit Dermnet NZ)

Facial Eczema Treatment

Treatment options for the face may differ slightly from the rest of the body due to the thinner skin and higher concentration of superficial blood vessels found in the face. Before Dr Lynn helps with the treatment specific for facial eczema, let’s run through good skin care routine that’s applicable for the whole body.

1. Moisturizing – Dry skin needs moisturizing and as there is a high concentration of sebaceous glands on the face, it will be good to choose a product that is non-comedogenic. A non-comedogenic product does not lead to the formation of whiteheads or blackheads.  As always, choose one that does not contain an ingredient that you are allergic to and always choose one that has been clinically tested. Read this post for the top allergens and here for a better understanding of product label. For the face, you may also want to use a sunscreen that protects your face and not irritate it, read here for sunscreen selection.

2. Cleaning – As with the body, you will have to clean the face. Choose a facial cleanser that works for you, without abrasive materials. There’s no need to exfoliate your face more than how it is naturally exfoliating on its own. Moisturize after cleaning. Pat dry your face, do not rub and always avoid hot water.

3. Cold Presses – If you have an itchy rash on your face, you can apply a cooling pack on the area to reduce the itch. Dr Lynn advises not to use a hot pack as this may make the rash and itch worse. A cooling pack can be placed to temporarily reduce the itchiness on the face.

4. Avoiding Irritants and Allergens – Avoid harsh soap, common allergens which you are sensitive to.

Question: I have more than one type of eczema on my face! How do I treat both atopic dermatitis and seborrhoeic dermatitis? What if I have both irritant contact and atopic dermatitis?

Dr Lynn: It is not uncommon to see patients with eczema also having seborrhoeic dermatitis. These two conditions can be treated with similar creams. A thin layer of low-to mid potency steroid cream  can be applied to the rash for a limited amount of time. Alternatively, a steroid-sparing cream like calcineurin-inhibitors (Tacrolimus or Pimicrolimus) can also be used. It is important to use moisturizer regularly together with the steroid cream/ Tacrolimus as it will help improve the barrier function of the skin. In order not to over-dry the skin, use a gentle soap and avoid facial scrubs.

Atopic dermatitis makes an individual more susceptible to irritant contact dermatitis. This is because people with atopic dermatitis have a suboptimal skin barrier which makes them more sensitive to chemical and physical agents. It is important to identify which substances/products are responsible for the irritant contact dermatitis. It is advisable to see your dermatologist. Avoidance of the irritant product and application of a suitable steroid cream and moisturizer are needed to treat both the irritant contact dermatitis and atopic dermatitis. Sometimes, if the dermatitis is severe, a course of oral steroids may be required.

Question: I’m told to use only mild steroids but the eczema on my face isn’t getting better! Are there other treatment options?

Dr LynnIn general, only low to mid potency steroids should be used on the face for a limited amount of time (1-2 weeks). There are certain mid-potency steroids with minimum side effects that can be used on the face. I will advise starting with a mid-potency steroid cream if the eczema is persistent then tailing down to a low potency steroid once the rash is better.  Another alternative is to use topical Calcineurin- Inhibitors like Tacrolimus and Pimicrolimus. This is a group of creams that have similar effect as steroids but without the steroidal side effects. They can be used for a longer period of time compared to steroid creams.  It is important to see your dermatologist to decide on which cream is suitable for you. The regular use of a good moisturizer and gentle soap is also important.

Rashes on Eyelids

A particularly tricky part of the face are the eyelids because the eyelid skin is very thin and steroids can be absorbed more readily, leading to problems such as cataract and glaucoma. Dr Lynn’s advice on treatment options include:

1. Do consult a doctor if you have rashes around the eyelid. It is important to determine what is causing the rash. Common causes include eczema and contact dermatitis secondary to eye make-up.

Topical Steroid on Face – Precautions

In general, mild to mid potency steroids can be applied to the face. It should be applied twice a day and for not longer than 1-2 weeks. A mid potency steroid can be used initially then tailing down to a low potency steroid once the rash is better. Alternatively, a steroid-spring cream such as Tacrolimus or Pimicrolimus can used . In a minority of patients,Tacrolimus can cause a stinging sensation. At night, apply the cream just before you go to sleep. To prevent the steroid from dripping into the eyes, you can use a cream or ointment based steroid rather than a lotion based one which is more ‘watery’. Allow 20-30 minutes after application of the cream to the eyelids before doing activities that may cause sweating.

2. Clean the eyelid area, with lukewarm water, including cleaning the ‘mascara’ area of the eyelid. Avoid using water that is too hot. Use a gentle soap and do not rub this area excessively. Avoid using products with ingredients you’re allergic to. A patch test can be taken at the dermatologist, and ingredients that you’re tested sensitive to should be avoided for your face and eyelids as well.

3. Moisturize the eyelid, taking care again to use products that you are not allergic or sensitive to. If you feel that the moisturizing lotion you are using is too “watery“ and runs into your eyes, you can change the moisturizer to a cream or ointment form which is thicker.

4. For those who are using makeup, it is important to wash your brushes  and change them regularly. Do not use make-up past their expiry dates as bacteria will accumulate in make-up which can irritate and infect your skin. Avoid mascara and choose products from large cosmetics and skincare companies that clinically test their products. Also avoid products that are shimmery or glitters as these contain metal particles, mica, which can irritate the skin.

A final note is to avoid rubbing the eyes, as this can lead to neurodermatitis, a thickening (lichenification) of the eyelids due to prolonged scratching. The appearance of the eyelids will be darker and in some instance, lead to skin folds on the eyelid.

Eczema Rash on Mouth and Lips

Apart from being prominent and noticeable as one will look inevitably look at someone’s mouth when he/she is talking, the lips is also an area that comes into contact with the food we eat, lip balm, lip stick and to some extent, toothpaste!

What sort of rash is common around the mouth? And is the same common on the lips? What is allergic contact cheilitis?

Dr Lynn: Some of the common rashes which can occur around the mouth include

  1. Facial eczema. This happens in individuals with eczema and facial eczema is more common in infants.
  2. Perioral dermatitis consists of groups of itchy or tender small red papules (bumps) which appear most often around the mouth. They spare the skin bordering the lips but develop on the sides of the chin, then spreading to include upper lip and cheeks. The surrounding skin may be pink, and the skin surface often becomes dry and flaky. Perioral dermatitis can be caused by the overuse of steroid creams, moisturizers, make-up and sunscreen. It is important to see your doctor as a course of oral antibiotics is needed.
  3. Cheilitis is inflammation of the lips. It can cause deeps cracks at the sides of the lips which can be painful. There are many causes of cheilitis and they include: eczematous cheilitis, contact cheilitis (reaction to substances like make-up etc), medications and nutritional deficiencies. Allergic contact cheilitis is allergic contact dermatitis affecting the lips. It is an immune reaction of the body towards a substance to which the individual is allergic. Lip cosmetics, toothpaste, medication and dental materials are the most common cause of allergic contact cheilitis.

Identifying the Allergen/ Irritant: What can one try to isolate the product or food that is causing the rashes? For instance, should one note if a rash occurs after shaving, brushing teeth or ingesting certain food? What is the appropriate allergy testing?

Dr Lynn: The appropriate test is the patch test. A patch test is a method used to determine if a substance is responsible for causing an allergic inflammation of the skin. Diluted amounts of the substances are placed in contact with the skin on the back. If the individual is truly allergic to the substance, a local reaction will occur on the skin. Testing should include the standard series of test allergens as well as any other materials suggested by the history (like lip cosmetics, toothpaste). If you notice that a particular facial or dental product or food causes a rash around the lips consistently, do inform your doctor and include it into the patch test.

Food versus Contact Allergens: Is there a difference in the time lag between an allergic reaction triggered by contact, say with a musical instrument, or a cosmetic/skincare product versus food?

Dr Lynn: Allergic contact dermatitis triggered by contact with a musical instrument or cosmetic/skincare product is an itchy skin condition caused by an allergic reaction to a substance in the product. It arises some hours after contact with the responsible material, and settles down over some days provided the skin is no longer in contact with the skin. Contact dermatitis should be distinguished from contact urticaria, in which hives appears within minutes of exposure and fades away within minutes to hours.

Likewise, food allergy can present with immediate reactions occurring within minutes after ingestion like swelling of the lips, hives and in more severe cases, difficulty breathing. It can also present few hours later and can cause late reaction like eczematous rash.

Treatment: What is the treatment available for lips? Can steroid be applied?

Dr Lynn: If the lips are involved in contact dermatitis or eczema, a low potency steroid or a topical calcineurin-inhibitor like Pimecrolimus or Tacrolimus can be applied. As the skin on the lips is thinner and absorbs more cream compared to similar sized-skin on other areas on the body, only low potency steroid creams should be used for a limited amount of time.

Doctor Q&A

Teen Eczema – Acne, Sports, Skincare & Shaving

eenage eczema with Dr Lynn Chiam dermatologist Singapore

This blog has covered lots on children with eczema, but as they grow older, eczema may present a different set of challenges and in a different form (for instance, due to puberty). MarcieMom is privileged to have Dr Lynn Chiam of Children & Adult Skin Hair Laser Clinic, a consultant dermatologist who subspecializes in paediatric skin conditions, adult pigmentary conditions and laser dermatology .

Puberty, Skin Changes and Eczema

As children move into pre-teen years and into puberty, what are some of the body changes that may trigger eczema?

Dr Lynn Chiam: As young children move into pre-teen and pubertal years, there are changes in the body’s hormonal profile and maturing of the sexual characteristics of the body. Sex steroids modulate skin thickness as well as immune function. It had been noted that under the age of 10, eczema occurs equally among boys and girls. However, from 10-18 years, eczema becomes more prevalent among girls. During adolescence, more girls develop eczema and more boys outgrow it. This suggests a role for gender-specific pubertal factors.

Are there certain parts of the body that are more prone to eczema at the onset of puberty? And is there any difference noted between eczema in a teenage boy versus a teenage girl?

As children mature, it has been noted that females with eczema had more problems with issues of clothes and shoes than boys. Significant itch and sleep disturbance affected both genders. The areas of the body affected by eczema remain similar between the two genders during puberty. More studies are needed evaluate the effects of hormonal changes on eczema.

In infants and toddlers (0-2 years), eczema tend to affect the face and scalp while in childhood (2-12 years), it affects the flexures (inner aspect of elbows, neck, back of knees), wrist and ankles. In adolescents, eczema tend to affect the eyelids, neck and flexures (inner aspect of elbows, back of knees).

Acne, Oily Skin & Warts

MarcieMom: Apart from eczema, other common skin problems in teens include acne, oily skin and warts. Can you briefly explain each of these conditions? 

Also, can a teenager with eczema (i.e. dry skin) also suffer from acne or oily skin? And if yes, what’s your advice to managing two or more skin conditions?

Acne – Acne can occur in adolescents and adults. It usually starts during the teenage years and is thought to be related to hormonal changes during this period. Most people will suffer from some form of acne during their teenage years.

Acne can be divided into predominantly comedonal (whiteheads) or predominantly inflammatory with papules (zits) and pustules (zits filled with pus). Large and deep zits can result in permanent scarring.

Acne can be triggered by oily skin, oily face creams, smoking and stress. Mild acne can be treated with creams containing benzoyl peroxide, antibiotics and tretinoin. Moderate acne may require oral medications such as antibiotics and oral hormonal tablets. Severe acne can be treated with oral isotretinoin. Oral isotretinoin is usually well tolerated and can result in long term cure. However, it must not be taken in pregnancy.

Oily Skin in Teenagers

Oily skin – Oily skin (seborrhea) is a common cosmetic problem that occurs when oversized sebaceous glands produce excessive amounts of sebum. Sebum is the cause of oily skin and scalp. Increased facial sebum is also associated with the development of acne.

Sebaceous glands are microscopic glands in the skin that secrete sebum, which is made of fats, wax and the remains of dead fat-producing cells. Excessive sebum gives the appearance of shiny and greasy skin. In humans, they are found in greatest abundance on the face and scalp. Sebum is odourless but bacterial acting on it can produce odours.

Skin oiliness may vary according to age, gender, ethnicity and hot humid climate. During puberty, the activity of sebaceous glands increase because of heightened levels of the hormone known as androgens. In skin pores, sebum and keratin can create a “microcomedone” or “whitehead”.

A person with eczema can certainly suffer from acne as well as oily skin. 

A person with eczema can certainly suffer from acne as well as oily skin. As he enters puberty, a teenager with eczema can develop oily skin on his face (where the sebaceous glands are concentrated) while other parts of the body (with less sebaceous glands) remain dry. The increase in facial sebum can trigger acne.

In a person with eczema and acne, it is important that if he applies steroid creams to his face for his eczema, he avoid applying them over the acne-prone areas. This is because steroid creams can make the acne worse. Alternatively, he can use creams like Tacrolimus or Pemecrolimus to control his eczema as they are non-steroidal in nature and do not aggravate acne.

He should also use anti-acne cream only to the areas with pimples and avoid the eczematous areas as some anti-acne cream can cause skin dryness. Wash the acne prone areas with anti- acne wash while using a gentle soap for the rest of the face. Clean away excess oil from the face whenever possible. Do consult a dermatologist for advice and treatment.

Warts and HPV

Warts – Warts are growths on your skin are caused by an infection with human papilloma virus, or HPV. Types of warts include:

  • Common warts, which often appear on your fingers, toes and on the knees.
  • Plantar warts, which show up on the soles of your feet.
  • Genital warts, which are a sexually transmitted disease.
  • Flat warts are skin- coloured and can appear in any area of the body.
  • Periungal warts prefer to grow at the sides or under the nails and can distort nail growth.

Warts are contagious and may spread from one area of the body to another or to others. There is no way to prevent warts.

In children, warts often go away on their own. In adults, they tend to stay. If they hurt or bother you or if they multiple, you can remove them.

There are many ways of treating warts. They include freezing it with liquid nitrogen, applying chemicals, electrosurgery (using heat to burn the warts away) and laser treatment.

Sweat & Sports on Eczema

Marcie Mom: Sweat can be a trigger for eczema and teenagers are at a very active stage of their life. If a child’s eczema is often triggered by sweat, would you advise parents to encourage their child to take up an indoor sport?

Are there certain sports that you think are better suited to eczema children? For instance, is swimming or squash or gymnastics more suitable than soccer or tennis?

Dr Lynn Chiam: Sweat and heat can be a trigger for eczema. However, it is best for a teenager with eczema to lead as normal a life as possible and participate in the sport he likes. Unless the eczema is very severe and difficult to control, I will not limit the choice of sports the teenager chooses. It is more important to know about good skin care and to apply creams correctly, which will help improve eczema, than to totally avoid certain sports.

If a teenager chooses to engage in a sport that’s outdoors and sweat a lot, what advice would you give him/her to manage the eczema?

Swimming for long periods during a bad flare of eczema is not advisable as the swimming pool water may cause more skin dryness.

I will advise that if you participate in a sport that will cause you to sweat a lot, to take a damp cloth to wipe away the sweat immediately after exercising followed by drying the skin with a dry cloth. If possible, take a shower using gentle soap shortly after the exercise and apply moisturizer immediately after bathing.

Cosmetics for Eczema

Teenagers may start to use (i) cosmetics, (ii) hair gel, (iii) anti-perspirant or (iv) wax arms/legs or shave. What would be your advice to a teen with eczema who wants to do the above (i) to (iv)?

Cosmetics contain fragrances and preservatives which may lead to allergic contact dermatitis (a rash due to allergy to the ingredients). A person with eczema has poor skin barrier function and may be more prone to skin irritation caused by cosmetics. If a teenager’s eczema flares with the use of cosmetics, it is important that she sees a dermatologist to do a patch test to check if she is allergic to the ingredients found in the cosmetics. If so, she will need to avoid that particular ingredient by reading the product labels of the cosmetics she uses. Always do a test spot by placing a small amount of the cosmetic on the inner aspect of the wrist. If there is no reaction after 1-2 days, then the cosmetic can be used on the face. Try to avoid using cosmetics over the areas affected by eczema. Cosmetics with a high water content are at a risk of being contaminated by bacteria and can pose a health risk to the user.

Try to avoid using cosmetics over the areas affected by eczema.

Hair Gel on Scalp Eczema

If a teenager’s eczema affects the scalp as well, it is advisable not to use hair gel when there is a flare of the eczema. If the scalp is not affected, it is recommended that a small amount of the hair gel is placed on a small area of the scalp first and to watch for any reaction. If there is no reaction after 1-2 days, then the hair gel can be used on the whole scalp. Always wash away the hair gel at the end of the day.

Anti-Perspirant and Allergic Contact Eczema

Anti- perspirant contains fragrances and preservatives can lead to allergic contact dermatitis. Again, do a test spot on the inner aspect of the wrist. Do not use the anti-perspirant if he develops any reaction.

Shaving and Micro-tears

Shaving and waxing of unwanted hairs can lead to micro-tears in the skin. Patients with eczema have an impaired skin barrier function and can easily get skin infection through these micro- tears. It is not advisable to shave or wax your hair if there is a flare of eczema. Laser hair removal, which does not cause micro-tears in the skin, is a more suitable way of removing unwanted hairs for patients with eczema.

Doctor Q&A

Friday Q&A with Dr Jennifer Shu – Bathing for Eczema Babies

Dr Jennifer Shu Board certified Pediatrician Author Bathing for Eczema Babies

Dr Jennifer Shu is the co-author of the award-winning parenting books “Heading Home with Your Newborn: From Birth to Reality” and “Food Fights” as well as editor of the American Academy of Pediatrics’ book “Baby and Child Health” and the AAP’s parenting web site, Dr. Shu is also CNNHealth’s Living Well expert doctor and doctor on WebMD.

Parents of babies with eczema face unique challenges related to the management of eczema, very often, receiving many advice (from almost everyone!) on how to make the eczema go away. We know that eczema is a chronic condition, and while there’s no miracle cure, it’s certainly important to manage the eczema so that our babies can be well and happy. MarcieMom is privileged to have Dr Jennifer Shu, board-certified pediatrician and mom, to answer the questions unique to parents taking care of eczema infants.

Thank you Dr Shu, I’m so glad to have you answer some questions that I frequently hear parents of eczema babies ask, especially first-time parents who are often even more at a loss what to do. So let’s jump right in to having the top questions answered!

Question: I’ve written on showering my child and on bleach bath, but I know when it comes to bathing a newborn, there are many differing opinions on how often and how to bathe. Eczema can be triggered by sweat, heat and eczema skin tend to have more bacteria, e.g. Staph bacteria, thus bathing can help but moisture can also be lost in the process of bathing.

How often would you recommend  an eczema newborn to bathe, and while water alone is fine for non-eczema babies, would eczema babies require a bath oil or non-soap cleanser for every bath?

Dr Jennifer Shu: You can refer to the various links below –

1., relevant extract:

“Warm (never hot) showers may be preferable to baths. In addition, moisturizing baths in lukewarm water for 20 minutes add moisture to the epithelial layer and cleanse the skin by lowering the number of bacteria. Gently pat your child dry after the shower or bath to allow some water to remain on the skin. Apply a moisturizer or lubricating cream to the whole body within 3 minutes, while the skin is still moist. This helps to keep the skin from drying out. Your child may also benefit from wet wraps, particularly if your child is an infant or a toddler.”

2. Post from my colleague, Dr Jeffrey Benabio at:, extracted

Yes. Showering less frequently is often good for eczema.

Although showering moisturizes the skin, it also strips the oils off your skin. When the moisture evaporates, your skin is left dryer than it was before. Showering too much or using harsh soaps makes eczema worse and worse over time.

The best thing to do is to take a lukewarm bath or shower (hot water removes more needed oils), use only non-soap cleansers, then apply a moisturizer immediately after, while your skin is still damp. This locks the moisture in your skin, preventing evaporation and helps heal dry, eczema skin.

Doctor Q&A Eczema Tips

Reinforcing Amount to Moisturize Eczema Child

Dr Benabio (DermDoc) is board certified in dermatology and is a fellow of the American Academy of Dermatology. He is also the author of numerous scientific articles, a book and quoted in notable publications such as O, The Oprah Magazine, Dermatology News, Dermatology World, CNN and WebMD.  He is the chief of dermatology at Kaiser Permanente, San Diego.

Moisturizing Amount and Childhood Eczema with Dr Jeff Benabio

This is a combination of two previous posts – the first one was an explanation of Dr Benabio’s ‘Great hack to help your kid with eczema’ video that he tweeted me and the second a short Q&A with him. The videos are no longer available which is why I’ve combined the two posts into one to be more informative.

DermDoc Video on moisturizer use

The simple message is to moisturize your child enough.

How much is enough? It’s about half ounce a day, equivalent to about 12 pumps. Dr Jeff Benabio has an insanely simple way to hold your kid responsible for moisturizing enough, i.e. by marking the bottle. Also, parents tend to underestimate the amount of moisturizer to put on our child.

I’ve blogged about this before, as I also have wondered how much is enough. Here’s the link to my post How Much Moisturizing is Enough? I mentioned 400-500ml/week!

Causes of Childhood Eczema

DermDocchildhood eczema causes

Marcie Mom: In the video, Dr Jeff explained that eczema is mainly due to an overactive immune system and damaged skin, where the damaged skin allows bacteria to penetrate, resulting in a vicious cycle of inflammation, itching, scratching and more damage to skin (more on causes of eczema here).

Here’s a question – For parents whose children are more likely to have eczema due to family history of eczema in parents or siblings, what would you recommend the parents to do before pregnancy, during pregnancy, after birth to reduce the likelihood of eczemaand/or the severity of eczema in the child? 

Dr Jeff: Great questions here. Unfortunately, there’s little that parents can do to prevent it. There is some evidence that taking probiotics during pregnancy and up to 6 months post pregnancy if breast-feeding can reduce the risk of eczema in the child. There is some evidence that some foods can make atopic dermatitis more severe if the child is allergic to that food. Common suspects include: cow’s milk, soy, nuts, eggs, and wheat. There’s some evidence that living on a farm can help — I’m not kidding. Here are a couple of links to studies:

Doctor Q&A

Friday Dr Q&A with Dr Liew – Managing Allergy & Eczema at Childcare

Dr Liew is a pediatrician who practices at the SBCC Baby & Child Clinic, Gleneagles Hospital Singapore and is also a visiting consultant to KK Hospital. He subspecialises in allergy, immunology and rheumatology. He was also awarded several research grants to pursue clinical research in paediatric anaphylaxis, drug allergy, primary immunodeficiencies and Kawasaki disease.

Managing Allergy for Eczema Kids Dr Liew Woei Kang

This was an original four posts of Friday Q&A, combined into one more informative post. MarcieMom contacted Dr Liew on setting up an eczema fund in Singapore and subsequently collaborated on this Q&A.

Childcare for Allergy Kids

MarcieMom: Suppose a child who has an allergy has to have alternative care-giver, say at child care centre.

What would you recommend a parent to share with the childcare?

Dr Liew: Your allergist should be able to advice what the caregivers be taught. Written action plans for eczema are useful for daily skin care instructions, whilst food allergy/anaphylaxis action plans provide information on treatment in emergencies. There is continued public education regarding allergic conditions via hospitals and societies like AAA.

Food Allergy in Childcare

How should a parent besides obviously telling the teachers/ care-givers of the allergy, help to make it easier for the school to prevent contact with the food? 

For instance, is there a need to warrant 0% contact, for instance, the whole school shouldn’t even bring the food in?

Dr Liew: After a diagnosis of food allergy, it would be important to relay the importance of food avoidance and emergency care plans with the care-givers. Written food allergy/anaphylaxis plans are useful. The degree of strict avoidance varies accordingly to the food allergen and severity of allergic reaction. It would be better to discuss specific advice with your allergist.

Non-Food Allergens

What are the common non-food allergens?

And if it’s dust mite, how can a parent tell the school to keep the dust mite level low since house dust mite is something that can’t be totally eliminated? And if it’s dog droppings allergy, should a parent not even sign up a child care centre where teachers or even classmates have dogs at home? For common skin allergen like soaps and detergents, should a parent go as far as to monitor what detergent the child care centre or caregiver is using? (And the bigger question is – how can a child care centre with 70+ kids cope with so ‘many requests’ of a parent?)

Dr Liew: The most common environmental allergen is house dust mites in Singapore. House dust mite avoidance measures are useful to reduce the levels of protein, but results variable. I would not recommend schools to implement house dust mite avoidance measures as they are time-consuming and difficult to implement in the long term. Dog sensitisation is usually to the hair epithelia, rather than poo, and is not common in Singapore. Irritants like harsh soaps and detergents should be avoided in children with eczema and dry skin. It may be helpful to provide the school with your child’s soap substitute and moisturisers, and get the teachers assistance for application.

Allergic Reactions in Kids

How can a parent recognize an allergic reaction and more importantly, which are the symptoms that are signs of serious reaction such as anaphylaxis?

Mild to moderate allergic reaction include:

• Swelling of lips, face, eyes

• Hives or welts

• Tingling mouth

• Abdominal pain, vomiting

Antihistamines usually suffice.

Severe allergic reaction (anaphylaxis) include:

• Difficult/noisy breathing

• Swelling of tongue

• Swelling/tightness in throat

• Difficulty talking and/or hoarse voice

• Wheeze or persistent cough

• Persistent dizziness or collapse

• Pale and floppy (young children)

Epi-pens at Childcare

When should a parent prepare an epi-pen and how can the parent teach the child and the alternative care-giver on when an epi-pen is to be used?

Epipen should be administered for severe reactions. A written anaphylaxis plan should be provided with pictorial reminders on how to administer an epipen.

Outdoor Allergens

What are some common outdoor allergens in Singapore?

For instance, to certain type of trees or to certain pollen? Pollen counts are usually higher in the morning and on a warm, windy day versus just after a rain. Many places in Singapore are air-conditioned, is this better or worse off for a child with dust mite, pollen or certain allergy?

Dr Liew: Outdoor aeroallergens include tree pollen (Oil palm tree pollen is commonest), grass pollen are common in temperate countries with seasons, but is uncommon in Singapore. Air-conditioning is better tolerated for eczema patients but can worsen an allergic rhinitis. The impact on specific allergens are not great except moulds, as they may grow in poorly maintained air-conditioning units.

Air-conditioning is better tolerated for eczema patients but can worsen an allergic rhinitis.

Mold & Indoor Allergens

MarcieMom: Mold is another allergen and lots seem to be growing in my home!

If a child is allergic to mold, what steps should a parent take?

Also, for allergies like cockroach droppings, does it mean that the parent must diligently hunt for all droppings in corners of the home and remove them?

Dr Liew: Steps to reduce mould in the environment include a well-ventilated room, and if air-conditioning is used, frequent maintenance of the AC unit. Pest control measures are best for cockcroach sensitisation, as cockroaches often “roam” around and leave traces of protein.

Vaccines and Allergy

MarcieMom: On vaccines, there is so much discussion out there where even doctors are coming out to say that vaccines are unnecessary and pharmaceutical companies are coming up with more and more vaccines that are unnecessary and even harmful for our children. Some parents may be opting their child out of vaccines due to egg protein included in some of the vaccines.

What’s your recommendation on this and when should a parent seriously questions a vaccine before letting his/her child have it?

Dr Liew: Vaccines are the one of the proven public health measures to reduce mortality from infectious diseases. Vaccines are produced for significant infectious diseases. There is no link between vaccination and allergies. Traces of egg proteins can be found in influenza vaccines and specialised vaccines like yellow fever. Egg allergic patients should discuss the risk benefit ratios of receiving these vaccines. MMR vaccines are safe for egg allergic patients.


MarcieMom: On antibiotics, I’ve read online that antibiotics are mostly unnecessary since they are only effective against bacteria yet it is so common for general practitioners to prescribe antibiotics! (in fact, I always have to refuse the prescription because it’s just a common flu!) Antibiotics are also known to cause allergic reaction, what would be your recommendation?

Dr Liew: Antibiotics should only be prescribed for bacterial infections.


MarcieMom: On cross-reaction, it’s commonly heard of when a child is allergic to birch pollen, he/she is also allergic to apple. Or a child who is allergic to latex is also allergic to kiwi.

Can such allergy be identified by allergy tests?

Also, what are some of the common allergies that you can point our parents to, so that they are aware if their child is allergic to one thing, they should probably avoid something else.

Dr Liew: Cross-reactive allergens occur due to the similarity of one protein to another, usually within the same botany taxonomy. They can be easily tested by skin prick test or blood IgE testing. A good example would be most cow’s milk allergic patients are allergic to goat’s milk as there is an approximately 95% similarity between the two.

MarcieMom: Thank you Dr Liew, it’s such a great pleasure to have you explaining all these allergy questions that many parents have, we are all so grateful!

Doctor Q&A Other treatments

Combined Approach Series – Stress, Attitude and Habit Reversal

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

Habitual Scratching and Eczema with Dr Christopher Bridgett

3 Levels of Eczema Treatment

In the manual ‘Atopic Skin Disease’, three levels of treatment are stated, namely:

1. Emollient Therapy

2. Steroid

3. Habit reversal

It is advised in your manual that steroid should not be used without follow-up moisturizer but moisturizer can be without steroid application. In the course of recovery, level 3 can be stopped first, followed by 2 and 1. We’ve covered the basics of all three levels in previous posts. There are some further dimensions in the management of eczema as follow:

Stress for Eczema Child

1. StressStress is one of the possible triggers for eczema.

Can you help a parent to identify when a child is stressed and how to see if the child is stressed because of the eczema or because of something else?

Stress can cause emotional upset – unhappiness and apprehensiveness for example – in anyone, young or old. In a child this may include tearfulness, and avoidance behaviour, just as in an adult. Certainly having eczema itself is stressful, for both the child and the parents. Careful observation may clarify if something else is the source of stress: stress comes from common causes, even for the youngest child, and family upsets may be especially important to think about. If there are no other causes and the eczema is troublesome, then adequate treatment of the eczema will be stress relieving – for everyone.

How can a parent help a child to relax?

Helping a child to relax usually involves simple acts – giving attention, and comfort, with suitable play, and amusing distraction. Reading a favourite story is a tried and tested bedtime means of inducing relaxation and sleep. But when a child is stressed, enabling relaxation is more difficult, especially if the causes of stress are not identified and dealt with.

Positive Attitude

2. Attitudes – Positive attitudes are suggested in your manual, such as ‘Manage, Don’t be Managed’ and to be careful so the doctor/nurse does not to ‘spread’ helplessness during a consultation.

Should a patient comes across a doctor who is passive about managing the eczema, what can he/she do to change the doctor’s attitude?

(Obviously, the other choice is simply switch doctor! But as a service to other patients, someone ought to say something!)

I find myself saying something about this all the time! Of course the responsibility for a successful visit to a doctor rests with all those involved. Each person should consider first what they themselves can do, rather than seeing any problem as caused by someone else. Some really useful ideas about this were covered when Jennifer talked to me: see This might make a good topic for people reading this post to comment on here: I suggest your readers share their thoughts and experiences with you.

At some health centres and doctors surgeries there are patient discussion groups to allow people to share ideas on how things can be improved. Has anyone had experience of such a group? Does your doctor ever conduct a patient satisfaction survey?

Each person should consider first what they themselves can do, rather than seeing any problem as caused by someone else. 

Review of Habit Reversal

In The Combined Approach, follow-up visits include asking the patient or parent their (i) scratching frequency (ii) when there’s most scratching (iii) % of scratching from itch (iv) severity of eczema (v) % new eczema vs old and (vi) where most eczema.

If a parent cannot find a doctor or convince their current doctor to implement the Combined Approach, can the parents implement this on their own without a doctor doing the follow-up (i.e. monitoring scratching on their own)?

The questions that you detail are in the first stages of The Combined Approach, during the first 4 to 6 weeks when habit reversal is important. The later part of the programme we call follow-up, and then vigilance for acute flare-up is the important emphasis, with early and energetic treatment with topical treatment being the order of the day. Habit reversal is not important long term. It is optimal topical treatment that is essential to maintain the progress that The Combined Approach achieves.

How to use The Combined Approach depends on the resources available. The clinic-based format is very effective, but if it is not feasible a self-help format is a good alternative, as discussed at

Hopefully blogs like this, and websites like will now gradually help everyone everywhere to discover how to treat atopic eczema successfully. There is no need now for anyone to necessarily Live With Eczema: there is now a possibility to learn how to Live Without Eczema.

Doctor Q&A Other treatments

Combined Approach Series – Eliminate Habitual Scratching

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

Habitual Scratching and Eczema with Dr Christopher Bridgett

Development of a Nervous Habit

I read in your manual ‘Atopic Skin Disease’ of how a nervous habit develops, namely:

1. Normal initial specific response to an injury (or itch)

2. Increased frequency by positive reinforcement that leads to

3. Behavior (or scratching) becomes automatic

4. The habit generalizes to cause more situations precipitating the behavior

5. Decreased personal and social awareness

Introduction of Replacement Habit

Also illustrated in your manual, another habit is introduced to reverse the scratching:

1. New habit is opposite to the old habit

2. Can be maintained for several minutes

3. Socially acceptable and compatible with normal activities

4. Strengthen muscles antagonistic to those of old habit

The techniques used in Noren and Melin, 1989 study mentioned in Atopic Skin Disease are:

1. Clenching fists and counting to 30 as an alternative to habit of scratching

2. Pinching the skin where it was itching as an alternative to itch-provoked scratching

Can you explain to our parents how to tell their child to clench fist and pinch skin? Is this something that can be understood by young children? And will pinching skin lead to the child using painful techniques to get rid of scratching? (I read in your manual not to say ‘Stop Scratching’, just as I’ve posted!)

The method of clenching a fist, then pinching the skin, is only suitable for older children, who are able to understand the instruction, and can accept responsibility for following the recommendations. The younger child requires a different approach which sees the parents as responsible for the treatment, with an adapted programme in between: see

So, no pinching small children please!

And yes – it is important to avoid saying “Stop Scratching” – you are quite right, of course!

Parents noting child is scratching
Parents noting child is scratching (picture credit

Register Scratching Frequency

In The Combined Approach, the first homework assignment to patients is to register the scratch frequency. This aids in the analysis of the scratching habit, following an ABC format of understanding the antecedents, behavior and consequences. Do you normally explain the ABC to patients before requesting them to register their scratching frequency? How can a parent help explain this to a young child? How can a parent help a child to count the scratching?

Dr Bridgett: The explanation of the ABC normally comes after registration, as part of the instruction of how habit reversal works. See the patient handbook for Older Children:

The younger child has a different treatment programme, without any counting of scratching: for the younger child it is the parents who are responsible. They can achieve awareness of the childs behaviour without using a counter.


MarcieMom: Thank you Dr Christopher Bridgett for explaining habit reversal that is part of The Combined Approach. In our next post, we will understand the three levels of treatment and conclude the series.

Doctor Q&A Other treatments

Combined Approach Series – Topical Treatment

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

Habitual Scratching and Eczema with Dr Christopher Bridgett

Explaining Topical Treatment – Moisturizer

The Combined Approach includes topical treatment using emollient and steroid. Moisturizing is a HUGE part of topical treatment, as emollients both lubricate and moisturize. Dr Bridgett’s advice on moisturizing is Thinly, Gently, Quickly and Often. There are a few other points mentioned in the ‘Atopic Skin Disease’:

  1. Thinnest possible application without ‘rubbing it in’
  2. More on exposed areas such as the head, neck and hands
  3. Pump dispensers preferable to open tubs due to bacteria infection
  4. Applying topical steroid first, then emollient over both the skin and the steroid
  5. Cream preferred over lotion

Can you explain why thinnest possible application is preferable for emollient?

(I’d usually slather on my child as I find applying a thin layer leads to more rubbing to spread the emollient)

Also, can you explain why topical steroid first?

(I’d written on this here and it does generate some discussion!)

Can you explain why cream is preferable over lotion?

Dr Bridgett: Your three questions answered:

  • Thin applications of moisturizer allows heat to escape, but insulates against water loss.
  • If moisturizer is applied often enough, when the steroid is applied directly onto the eczema, it is applied to skin that has been recently moisturized. We get then the best results by putting moisturizer on over topical steroid, and moisturizing all the skin, not just that which has the eczema.
  • The thicker the moisturizer, the better the moisturizing effect. Also, often there are less additives in thicker moisturizers, as thicker moisturizers “keep” longer. There is less chance that a sensitivity reaction will occur with an ointment, compared with a cream. See

Explaining Topical Treatment – Steroid

It is stated in ‘Atopic Skin Disease’ manual that steroid cream work by inhibiting protein synthesis, secretion of products, cell division and migration of cells. The epidermis can benefit from reduced cell division, and the dermis from reduced cellular and lymphokine activity. Can you explain what this means, and

why it is important to continue steroid treatment after epidermis healing (‘2-stage in steroid effect’)?

Dr Bridgett: It seems the steroid anti-inflammatory effect is partly achieved by reducing over-activity in the skin, allowing natural healing then to lay down healthy skin again. By the time the seems good to look at, the healing is not complete through and through – there is more that is needed under the surface, so we recommend continuing with the topical steroid, beyond The Look Good Point: do not stop too soon. See

Many parents are very concerned with the skin-thinning side effects of steroid and also the ‘withdrawal’ symptoms once steroid treatment is discontinued. I read in your manual that side-effects are associated with inappropriate use of topical steroid and the risk is usually inadequate treatment (i.e. stopping steroid cream too early or using one of too low strength).

How do you normally convince parents that steroid cream is safe? And what guidelines would you give them to gauge if the steroid cream of correct potency, frequency and amount is used?

Dr Bridgett: Steroid side-effects come especially from using topical steroids long-term and in an unsupervised way. The method we use in The Combined Approach includes more supervision than is usually given, with a programme of several clinic visits, involving careful discussion of all anxieties and concerns. Using The Combined Approach, including therefore habit reversal, which allows natural healing alongside the good steroid effect. Then less topical steroid is used overall, for good effects, not side effects!

We offer information about the potency groups of the topical steroids, and how they are usually used. The thicker the skin, the stronger the topical steroid to be used. See

Each application of any cream needs to be sparingly applied – whether it is an emollient or a topical steroid: only a shine is required.

MarcieMom: Thank you Dr Christopher Bridgett for explaining the topical treatment that is part of The Combined Approach. In our next post, we will understand more on habit reversal techniques.

Doctor Q&A Other treatments

Combined Approach Series – Habit Reversal

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

Habitual Scratching and Eczema with Dr Christopher Bridgett

What is Combined Approach?

The Combined Approach is about using conventional topical treatment (steroids and moisturizers) together with the elimination of self-damaging behavior using habit reversal techniques. ‘Atopic Skin Disease’ was published in 1996 as there was much success using The Combined Approach, which was reported at the European Congresses on Dermatology and Psychiatry in 1991 and 1995.

Patient Improvised Distraction vs Combined Approach

MarcieMom: Dr Bridgett, can you briefly explain the difference between The Combined Approach versus an eczema patient using his/her own ways to divert attention from scratching?

Dr Bridgett: The Combined Approach is an exercise in behavioral medicine, and has two elements combined:

1. Optimized conventional treatment (emollients and topical steroids usually) : this is an important part of the approach, and cannot be overlooked!

2. Habit reversal: a formal behaviour modification technique: it requires, when offered to Adults and Older Children, first a period of registration using a hand tally counter – this is continued, as habit reversal is introduced. The inventiveness of the eczema patient is very useful in introducing new successful habit reversal behaviours, but some structure, discipline and supervision is linked to the success reported by many patients, and this requires reference to written material, and is often usefully supported by contact with others.

Also, if an eczema patient or parent of eczema child comes to know of your approach, can he/she simply pass your manual to a dermatologist that he/she is seeing?

The manual is available for anyone to consult and follow if they wish, and both nurse practitioners and medical practitioners are successfully using The Combined Approach. An important alternative is to use the self help format set out in the book The Eczema Solution by Sue Armstrong-Brown.

When is Habit Reversal Most Effective?

The main idea is that scratching can often become a habit – that is, the adult or child with eczema then scratches not only because of itch. It is mentioned that adults with severe eczema can benefit most from The Combined Approach. Why is this so?

Can you share with us pictures of before and after eczema and what was the habit that was eliminated that led to an improvement?

Dr Bridgett: Habit reversal is most effective

  • in combination with optimized conventional treatment, and
  • when there is evidence of chronic eczema – in adults or children – that is to say, the thickened skin called lichenification, which is due to regular rubbing and scratching that has become a habit, complicating atopic eczema. Any rubbing and scratching of the skin can become a habit, but each person can have their own particular problem. 

Habitual Picking during TV

In the first pictures below the patient was habitually picking the skin of her forehead when watching TV, resulting in chronic eczema. When habit reversal was added to optimized topical treatment the skin healed very quickly.

Before & After Pictures of Forehead, contributed by Dr B scratching habit associated with TV
Before & After Pics of Forehead, contributed by Dr B

In the next pictures, the patient had developed a habit of using the rivets on her jeans to scratch against:

Hand Eczema worsened by rubbing against jeans before habit reversal
Before The Combined Approach
Rubbing of hands against jeans rivets
Before The Combined Approach
After Hand Eczema
After The Combined Approach

Combined Habit Reversal with Topical Treatment

I note that The Combined Approach does start with understanding and explaining the importance of topical treatment, as eliminating scratching is not a stand-alone treatment. Would explaining the structure of the skin and how a weak skin barrier is prone to water loss be important in the first visit? If yes, could you do a quick introduction for our parents to understand?

Dr Bridgett: Yes, The Combined Approach always covers the importance of skin as a barrier, and the importance of optimal topical treatment.

The skin has two layers, epidermis and dermis. The outer epidermis, which carefully replaces itself every four weeks, is important in preventing water getting out from inside, and irritation and infection getting in from outside.

Acute eczema involves inflammation of the epidermis. It’s structure then becomes weakened, allowing excessive water to escape. Extra moisturizers are then needed to stop excessive water loss, and anti-inflammatory topical steroids are also needed. And that’s not the whole story: the inflammation releases itchy substances that cause scratching – and this scratching stimulates over-activity of the epidermal cells. If the emollients and topical steroids are used correctly the situation quickly returns to normal. If not, the scratching continues, becomes a habit and the damaged and sensitive skin of chronic eczema is the result.

For more on skin structure, acute and chronic eczema see

MarcieMom: Thank you Dr Christopher Bridgett for giving us an understanding of the Combined Approach and showed us some of the successful cases. In our next post, we will understand more on the use of moisturizers and steroids as explained in the manual ‘Atopic Skin Disease’.

Doctor Q&A

Friday Dr Q&A with Dr Liew – Allergy Tests

Dr Liew is a pediatrician who practices at the SBCC Baby & Child Clinic, Gleneagles Hospital Singapore and is also a visiting consultant to KK Hospital. He subspecialises in allergy, immunology and rheumatology. He was also awarded several research grants to pursue clinical research in paediatric anaphylaxis, drug allergy, primary immunodeficiencies and Kawasaki disease.

This was an original 4 week Friday Q&A, combined into a single more informative post.

Children’s Allergy Basics

Thank you Dr Liew for taking time to help answer these questions, we’ll start with the basic information on allergy.

What is an allergy? For children with eczema, should parents send their children to allergy tests or should only those with eczema of a certain severity do so?

Dr Liew: An allergy is simply an abnormal immune reaction to a common protein. Symptoms are varied depending on trigger and organ involvement. The most common reaction is on the skin, resulting in itchy rashes like urticaria (hives) or eczema flares.

Atopic eczema starts essentially as a skin barrier defect, with resultant dryness, itch and allergen sensitisation later. It is not a pure allergic disease. Skin tests for eczema patients are generally not necessary, as the most common allergen is house dust mites. Food triggers are more commonly in young infants with significant eczema despite good skin therapy.

Allergy vs Intolerance

MarcieMom: Allergy and intolerance are often mixed up; can you explain the difference between the two, specifically:

How a parent can correctly identify if the child is allergic or intolerant and what follow-up action they should take in each case?

Dr Liew: Allergy and intolerance result in adverse reactions, but the key difference is that the former involves the immune system, whilst the latter do not. If the immune system is involved, there is a potential for severe allergic reaction called anaphylaxis with continued exposure due to immune memory. There is no risk of anaphylaxis in intolerance. Eg. Cow’s milk allergy can result in hives, vomiting and wheezing; in contrast, cow’s milk intolerance presents with diarrhea in lactose deficient individuals.

Skin Prick Test for Kids

Common questions on allergy tests: There are a few allergy tests available – skin prick test, blood IgE test and patch test.

Can you explain a little more about these tests, how it is done on a child and how can a parent decide which to bring their child for?

Dr Liew: The type of allergy test recommended is based on the allergy symptom of the patient. As eczema is a mixed IgE/non-IgE driven disease process, tests for IgE like SPT and blood tests may be useful if positive, as targeted elimination may be attempted. If the tests are negative, empiric elimination of 2-3 weeks duration may still be considered if there appears to be a consistent food trigger.

Prolonged food avoidance however is not necessary and may result in malnutrition.

A skin prick test (SPT) is probably commonest and simplest allergy test performed in outpatient clinics. Essentially it is a scratch test with either a needle or plastic device, thus introducing a tiny amount of allergen protein under the skin surface. The test is completed within 15 minutes and measurement taken. A positive reaction appears as a small hive-like wheal and surrounding redness. It is good for identification of IgE mediated allergic reactions, and also for trending allergy sensitisation over time. Antihistamines would need to be ceased for 5-7 days, and there must be an area of clear skin (preferably the back in young children) for the test to be done. This is my preferred allergy test as there is minimal pain (especially with plastic devices), and results immediate. SPT also correlate better with allergic reactions if properly performed, as it takes into account the blocking antibody responses when the body is “outgrowing” an allergy.

Blood IgE Test

Allergen specific IgE test can also be easily performed for IgE mediated reactions. This is sometimes preferable if the patient has severe eczema and unable to tolerate cessation of antihistamines, or has minimal normal skin to perform the SPT. Blood tests are generally more expensive, as each allergen protein tested cost around $30. Results are usually known within a week.

Patch Testing

Patch tests are designed to test for delayed allergic reactions, rather than acute IgE reactions as the above 2 tests. Patch tests involved placing small area of allergen protein coated on wells or filter paper, and leaving them as a skin patch for 48 to 72 hours. A reading is then performed to look for delayed hypersensitivity reactions and the skin reaction graded. As there are several confounding factors for a successful test, patch tests are currently not recommended for clinical use but confined to research studies.

What to do after Your Child is Tested Positive for Allergens?

Given that allergy tests are not 100% accurate, parents may start to rely on an elimination diet strategy. 

Can you explain how much you would rely on each allergy test and whether they serve a different purpose in your diagnosis?

Dr Liew: Standard allergy tests are accurate, but have their limitations. Unvalidated tests for food allergy include blood IgG testing, intradermal skin testing, applied kinesiology, electrodermal testing, hair mineral testing, and iridology, and should not be performed. Eczema is a chronic medical condition with no curative treatment currently, and some patient would undertake extreme measures to look for the “elusive trigger”.

I would remind your readers that eczema is a skin disease, and not an allergic disease. Removing triggers can reduce the eczema, but will not cure it.

Food Elimination for Kids

Empiric food elimination may be considered for 2-3 weeks if a consistent food trigger is suspected. An objective assessment should be made if food elimination has resulted in any change. Food triggered eczema would improve significantly with elimination. If there is no improvement, as in the majority of cases, the food should be introduced and assessment made if there is a change. I would caution regarding multiple food elimination as I have seen really malnourished and stressed out patient and families.

Young Children’s Developing Allergy Profile

MarcieMom: I understand that it’s good to send the child for a re-test, to check if he or she has outgrown any allergy or developed new ones. 

What’s the reason for the change in the allergy profile of the child? Also, how often do you recommend a re-test and would your recommendation differ for a child who has different type of allergies and/or differ for a child who has different level of severity in eczema?

Dr Liew: Retesting is sometimes required in food allergies, but generally not necessary for eczema. The allergic profile of an individual changes according to his/her immunity and exposure to environmental proteins. We often see food allergens being “outgrown”, but a gain of house dust mite sensitisation with time. Retesting is usually considered if there is a new allergic disease eg. Allergic rhinitis, rather than based on fluctuation in eczema severity.

Common Pediatric Allergens

Based on your experience and knowledge of research studies, what are the common allergens in children? 

Dr Liew: The most common allergens depend on the allergic conditions. For eczema, older patients tend to be sensitised to house dust mites, but not food allergens. Some young infants with eczema has food sensitisation and trigger. The most common food allergens in eczema children include egg, cow’s milk, wheat, peanuts and soy. Some forms of food allergy eg, allergic enteropathy presents with isolated intestinal symptoms without skin involvement.

If a parent suspect a food is causing an allergy, should the parent insist on it being an item to be included in allergy test? 

As a pediatrician, would you test the child on what the parent suspect?

Dr Liew: A detailed history would be obtained prior to allergy testing. If there is a suspected food trigger, I would usually test it. I would usually encourage targeted testing, whereby only the relevant food items are tested. For eg, should the child be tolerating cow’s milk formula for the past 3 years, and eczema commenced after 3 years old, cow’s milk protein is unlikely to be a food trigger, and should not be tested.

Gluten and Eczema

MarcieMom: Gluten has been gaining more awareness and with many food packaging labeling gluten-free, some parents may think it’s gluten that’s causing the eczema. 

Again, how can a parent identify if it’s gluten (is it even a common trigger?) that’s triggering the eczema?

How can this be differentiated from celiac disease?

Dr Liew: There should be a close temporal relationship between food ingestion and eczema flare. If there is inconsistent relationship, it is unlikely a food allergy. Celiac disease is an immune-mediated reaction to glutens, resulting in malabsorption in the gut, and resultant bloatedness, diarrhea and weight loss.

Doctor Q&A Eczema Tips

Sensitive Skin Product Series – How to Manage the Diaper Area?

I ‘met’ Laura Verallo Rowell Bertotto, the CEO of VMVGroup, on twitter and learnt that her company is the only hypoallergenic brand that validates its hypoallergenicity.

VMV Hypoallergenics is founded in 1979 by Dr. Vermén Verallo-Rowell who is a world renowned dermatologist, dermatopathologist and dermatology/laser surgeon, also an author, esteemed researcher and speaker. 

Sensitive Skin Skincare Product Interview series with Dr Vermen Verallo Rowell VMV Hypoallergenics
  1. Sensitive Skin Product Series – What is Hypoallergenic?
  2. What does Natural Skincare Product mean?
  3. What is considered Organic and Non-Comedogenic?
  4. What does Suitable for Eczema Children mean?
  5. What is Patch Testing (for skincare product ingredients?)
  6. How do you read ingredients on skincare product label?
  7. What does Irritant-Free mean?
  8. What ingredients in skincare product to avoid?
  9. How is Coconut Oil used in skincare?
  10. What is product cross-reactivity?
  11. How many ingredients in a skincare product?
  12. How to use skincare products on Sensitive Skin?
  13. How to manage the diaper area?
Grandma Minnie's Oil's Well Nurturing Do-It-Oil (picture from
Grandma Minnie’s Oil’s Well Nurturing Do-It-Oil (picture from

Marcie Mom: I note with interest that your product Grandma Minnie’s Oil’s Well Nurturing Do-It-Oil can prevent diaper rash.

What is the ingredient that prevents this rash and how it is different from the off-the-shelf diaper rash cream?

Dr. Verallo-Rowell: The USDA- certified Organic Virgin Coconut Oil and Monolaurin

Both ingredients – no reported allergies, irritations from either one.

1. Virgin coconut oil prevents the diaper rash by its giving an additional barrier film of protection on top of the skin to help protect the skin from irritating chemicals: urine, feces, sweat, preservatives, possibly antiseptics that may be used by manufacturers of diapers. Paper / tissue products are often preserved, some even with formaldehyde or formaldehyde-like chemicals. In addition, virgin coconut oil under the influence of natural skin bacteria that contain lipases (the same lipase enzymes that break down the sebum/fats produced by our skin glands to produce fatty acids that give the skin is acidity or acid mantle – an innate antiseptic function from the skin) – produce monoglycerides of its lauric, capric and caprylic fatty acids.  These are well studied to have broad-spectrum antiseptic properties.

2. The purified monolaurin produced in the laboratory of Dr. John Kabara wrote and worked on this ingredient since the 1960s… is added for additional protection of the skin.

Laura: Most diaper rash creams primarily contain just zinc oxide and petroleum jelly.

One dermatological (prescriptive) diaper rash ointment contains an antifungal drug (many diaper rashes are actually a fungal condition) and cannot be obtained without a prescription (it also costs around US$300).

We mimic both the effects of the above in Oil’s Well in that the Virgin Coconut Oil provides a bit of the barrier function of zinc oxide and petroleum jelly, and the monolaurin provides an antiseptic, antibiotic and antifungal action.  Note that monolaurin is also present in breast milk as another innate or natural antibiotic provided by nature from breastfeeding infants.

Prevent Diaper Rash

Marcie Mom: For prevention of diaper rash, your recommendation is to apply where the skin comes into contact with wetness. However, for eczema rash, I read that it’s least likely to be where the skin is wet.

Dr. Verallo-Rowell: Need to know the context of this statement because wetting the skin in those with eczema does make the skin more moisturized (water is the best moisturizer) but that wetness must not be chronic to macerate it such as in the diaper and around the mouth areas from saliva, mucus, sweat, food, etc.

Diaper Rash vs Eczema

Marcie Mom: My baby often gets rashes and scratches around the diaper waist band and the upper thigh joint areas. How can a parent differentiate between diaper rash and eczema rash? And would applying moisturizer on the rash area that’s covered by the diaper makes the rash worse?

Dr. Verallo-Rowell: Yes. Can be from pressure (a form of dermographism) or actual irritation (rarely at that age, allergy), by the chemicals in the elastic material of the waist and thigh band or even the chemicals in laundry soap.

How can a parent differentiate between diaper rash and eczema rash?  By the presence of the rash in other areas more commonly involved by atopic eczema rash in babies: outer areas of the upper and lower extremities, the face.

And would applying moisturizer on the rash area that’s covered by the diaper makes the rash worse? Yes if the moisturizer has ingredients that are irritating to the skin usually by virtue of its scent, preservatives, antibiotics, dyes, non-medical grade lanolin, etc. Note that vitamin E and tea tree oil, propolis, and some other natural ingredients are top allergens in the allergens list.

Marcie Mom: A BIG THANK YOU to Dr. Verallo-Rowell and Laura for helping us in this series on sensitive skin products. We’ve learnt SO much from you and SO much more confident on how to choose and manage the sensitive skin of our children.

Doctor Q&A Eczema Tips

Sensitive Skin Product Series – How to Use on Sensitive Skin?

I ‘met’ Laura Verallo Rowell Bertotto, the CEO of VMVGroup, on twitter and learnt that her company is the only hypoallergenic brand that validates its hypoallergenicity.

VMV Hypoallergenics is founded in 1979 by Dr. Vermén Verallo-Rowell who is a world renowned dermatologist, dermatopathologist and dermatology/laser surgeon, also an author, esteemed researcher and speaker. 

Sensitive Skin Skincare Product Interview series with Dr Vermen Verallo Rowell VMV Hypoallergenics
  1. Sensitive Skin Product Series – What is Hypoallergenic?
  2. What does Natural Skincare Product mean?
  3. What is considered Organic and Non-Comedogenic?
  4. What does Suitable for Eczema Children mean?
  5. What is Patch Testing (for skincare product ingredients?)
  6. How do you read ingredients on skincare product label?
  7. What does Irritant-Free mean?
  8. What ingredients in skincare product to avoid?
  9. How is Coconut Oil used in skincare?
  10. What is product cross-reactivity?
  11. How many ingredients in a skincare product?
  12. How to use skincare products on Sensitive Skin?
  13. How to manage the diaper area?
Sensitive skin of child includes the eyelid eczema
Sensitive skin of child includes the eyelid

Sensitive Skin Parts of Eczema Skin Child

In our previous interviews, we have learnt what to look out for in the product packaging, including understanding the list of ingredients. In this interview, we wish to focus on the use of sensitive skin products on the parts of the child which are more delicate.

Marcie Mom: Thanks Laura for taking time to help us learn more about managing the delicate parts of our child’s skin. First, let’s all be on the same page relating to what defines delicate skin?

Is it where the skin is thinner, like eyelid, face, neck, underarm and groin area?

Dr. Verallo-Rowell: Yes, where the skin is thinner: eyelids, neck, groin because of the easier absorption of chemicals. Plus, often wet areas such as cheeks, around the mouth from milk and food, neck and maybe the chest, and of course the diaper areas where maceration and heat “thins” the skin. Also from trauma and sweating of physical activities in school and at play with the use of play devices or clothing and shoe wear — hence the need sometimes for milder laundry soaps.

PLUS the following conditions:

–  Those diagnosed with an atopic problem: asthma, hay fever, and of course atopic dermatitis/ including a family history especially when (+) in both sides of the family. To treat and to prevent barrier loss because barrier dysfunction is a basic problem in those with atopic skin.

–  Those with medical conditions that make them “sensitive” Example: being off and on antibiotics a lot which disturbs the balance of naturally opposing bacteria and fungi in skin and the natural, healthy dominance of one over the other; those on maintenance drugs which make them prone to drug allergies or even photosensitivity; those who are obese and prone to sweatiness (or who are otherwise prone to sweatiness).

Washed-off Product Use

Marcie Mom: I also read that rinsing the product immediately is stated in many of your products’ instruction. For eczema children, they may need to soak in bath oil (my baby soaks in colloidal oatmeal bath oil).

How long would you advise parents to let their child soak?

Dr. Verallo-Rowell: I generally like colloidal oatmeal bath oil but am careful to read the ingredients list for any additional ingredients as listed above and elsewhere. For the more sensitive I prefer the pure virgin coconut oil in water for 5 to 15-minute soaks.

Marcie Mom: And can they do so if they have a rash at the groin area?

Dr. Verallo-Rowell: Yes with the virgin coconut oil. I have seen extremely irritated skin, however, where even water makes them sting. In these cases, I prescribe the total removal of all products with just a bit of the VCO applied very lightly and gingerly, section by section — which I’ve found to be soothing until the oil can be applied all over. Once less sensitive, soaking in it can be done.

Laura: In case you’re reading instructions of “rinse immediately” for things like shampoo…this is important for ALL wash-off products. Wash-off products contain ingredients that are, as the name implies, meant to be washed off (such as surfactants or soaping/bubbling ingredients). Their action is cleansing, and they are not meant to stay on the skin for more than a few seconds at a time in the shower or bath. But oils and moisturizers? Or oils in a soak? These are usually fine to “marinate” in for a while 🙂 Again, with the caveats above of hypoallergenicity.

Shampoo & Shower Tips

Marcie Mom: When I’m showering my 2 year old, I apply shampoo on her hair and bath oil on her tummy, back and legs. For her face, neck, underarm and groin, I don’t apply any bath oil on them but just rinse with water (I assume some of the bath oil would inadvertently flow to these areas when I’m rinsing). Is this the correct technique and clean enough?

Dr. Verallo-Rowell: Wise and smart. Another technique I use is the pure VCO as the cleansing oil on any irritated/irritable/potentially irritable skin.  It’s all in one: functions as a mild cleanser, barrier and for healing.

Marcie Mom: Lastly, the eyelid. Eyelid eczema is not uncommon for children and furthermore, children tend to scratch their eyes when sleepy or tired. I normally wipe my baby’s eyes with cotton pad soaked in slightly warm cooled boiled water followed by a thin layer of moisturizer.

What would be your advice on treating rash on the child’s eyelid? Is there any ingredient that is a no-no for the eyelid?

Dr. Verallo-Rowell: Wet with a little water the way you do it above, then apply the VCO alone or with pure plain petroleum jelly to lock in the water.  The oils “melt” in a few minutes. Gently pat into the skin and if necessary (not usual) wipe off any excess to avoid their getting into the eye.

Laura: A nice alternative to the plain petroleum jelly can be our popular Big, Brave Boo-Boo Balm, which is petroleum jelly but with the coconut-derived monolaurin.

Marcie Mom: Thanks so much again, it sure gives me some peace on what I can do for the sensitive part of my baby’s skin.

Doctor Q&A

Friday Dr Q&A with Prof Hugo – Skin Prick Test

Q&A Senior Consultant Allergy Immunology Professor Hugo for EczemaBlues

Professor Hugo van Bever is a Senior Consultant in Pediatric Allergy and Immunology at the National University Hospital, Singapore. He is an active member of the board Asia Pacific Academy of Pediatric Allergy, Respirology and Immunology. He is also my co-author for Living with Eczema: Mom Asks, Doc Answers!

This is originally a series of Friday Q&As in 2012 which has been combined into one informative post.

Eczema Baby Scratching Eyes

MarcieMom: Babies tend to scratch their eyes when tired. Also, I notice that my baby’s eyelids (where eyeliner is applied) look oily. To soothe the discomfort, I would wet a cotton pad with lukewarm boiled water and clean outwards. This is sometimes followed by moisturizing sparingly when her eyelid is dry.

How would you recommend a parent to reduce their child scratching eyes?

Prof Hugo: Keep eczema under control and apply a preventive approach.

Skin Prick Test for Kids

Marcie Mom: Today’s questions is on skin prick test, something I always recommend parents to do (in this post).
In a skin prick test, typically a few common food allergens such as egg and milk will be tested instead of all possible food that the child may eat. Why is testing a few of these food allergens sufficient to diagnose if there’s an underlying food allergy?

How often should a child get retested for food allergy? And what type of patients needs to be retested regularly?

Anti-histamines should be avoided before a skin prick test so as to avoid incorrect results (due to no reaction seen when there should be one). What else should a parent take note before bringing the child for allergy test?

Prof Hugo: Because only a few foods are involved in eczema, mainly in young children. These are: cow’s milk, egg, wheat and soy. Other foods are very seldom involved in eczema. In older children food allergy is usually not involved in eczema. Older children have mainly an allergy to house dust mites.

If the child improves there is no need to repeat skin prick test.

Skin prick test should be performed only when the child is in good health (no ongoing infection, no fever) and did not take antihistamines for at least 3 days. Antihistamines may suppress the skin prick test’s results, leading to false negative results. Skin prick test also needs an area of normal skin. In cases of severe eczema, skin prick test’s results are difficult to interpret. A blood test might be an alternative.

Topical Steroid as Treatment

MarcieMom: Many parents are worried about applying steroid cream for their child’s eczema. Recent research has shown that there is no major negative effect on the skin of children who have applied topical steroid over approximately 10 months, including no evidence of skin thinning.

What guidelines will you provide parents when applying steroids for their child (in terms of when to apply, how much to apply and which part of the skin to apply which steroid’s strength)?

Prof Hugo: Use mild steroids (for children) maximum 2 x day. Use them only on active inflammation (= “red” patches) and use them after cleaning the patches. Don’t use steroids on a dry skin or on old lesions.

Oral Steroid as Eczema Treatment

Marcie Mom: I must thank you again for helping Marcie with her eczema. I noticed that it got much better after the one-time oral steroid course you prescribed (read more in this post).

Oral steroid such as prednisolone is sometimes prescribed for children with severe eczema. Can a child only be prescribed oral steroid once? I’ve read horror stories online of how some doctors negligently keep prescribing oral steroid to the point that it no longer works for the child. How can a parent assess if the doctor is taking due care in his prescription for their child?

Prof Hugo: Oral steroids should be avoided, especially because eczema is a chronic disease, and oral steroids cannot be used chronically. Only in severe flare-ups a short course (5 to 7 days) is recommended. In some children (exceptionally) a longer treatment can be needed. However, this should be given in an EOD dose (= every other day). It is all a matter of trust in your doctor. If your child has severe eczema, needing oral steroids, I advise to see a paediatric allergist or paediatric dermatologist.

Alternative Eczema Treatments

Marcie Mom: Lots of parents are looking for a way to manage their child’s eczema (though a reminder that eczema is chronic, no miraculous cure) and may be willing to try ‘alternative treatments‘.

Many alternative treatments, including using natural remedies are marketed for eczema. Personally, I prefer sticking to moisturizing and appropriate use of steroid under doctor’s instruction. However, I understand the anxiety parents have when their child’s eczema hasn’t responded well to their doctor’s treatment.

What advice would you give a parent when deciding if they should try out a natural remedy? What is safe for them to try and what should they be wary of?

Prof HugoOnly use treatment that has been scientifically proven to be safe and effective. Many alternative treatments are available, without any study and without prove of effect: don’t try them out!

Partially Hydrolysed Milk

Marcie Mom: I have experienced switching to partially hydrolysed milk when Marcie was diagnosed with eczema.

Some research showed that giving babies partially hydrolyzed milk may reduce chance of milk allergy. I understand that it doesn’t alter the allergic profile of a child but may reduce chances of allergy as part of the milk protein is broken down. What is an allergic profile (is it part of DNA)?

Prof HugoHydrolysed milks can prevent cow’s milk allergy: that’s all. They have no effect on the long-term development of allergy. An allergic profile refers to the clinical presentation of allergy, and has nothing to do with DNA.

Food Restriction in Early Childhood

Marcie Mom: I also read that restricting a food in early childhood and introducing it later may lead to even more serious allergic reaction. What’s your understanding of how the same food allergy could progress from childhood to adulthood?

Professor Hugo: This is very individual and still confusing, because an intervention cannot be beneficial for all children, but should be tailored. More research on this is needed.

Vacuum Cleaner Selection

MarcieMom: Do you think the expensive vacuum cleaners are worth investing in? What should a parent look out for when buying a vacuum cleaner?

Prof Hugo: In case of house dust mite-allergy, a decent vacuum cleaner is recommended. However, most companies have no research data on their vacuum cleaner. Don’t spend too much money!

Sun & Haze Affect Kid’s Eczema?

MarcieMom: I read that the sun can dry the moisture on skin. Should children with eczema avoid the sun?

Prof Hugo: Active eczema (= skin inflammation) should avoid the sun.

Marcie Mom: I noticed that whenever there’s a haze (from neighbouring countries burning forests), my baby scratches a lot more. What could be in a haze and why does it irritate my baby’s skin?

Prof Hugo: Never been proven that the haze (= a type of pollution) has effect on eczema.

Doctor Q&A

Sensitive Skin Product Series – Understanding Coconut Oil

I ‘met’ Laura Verallo Rowell Bertotto, the CEO of VMVGroup, on twitter and learnt that her company is the only hypoallergenic brand that validates its hypoallergenicity.

VMV Hypoallergenics is founded in 1979 by Dr. Vermén Verallo-Rowell who is a world renowned dermatologist, dermatopathologist and dermatology/laser surgeon, also an author, esteemed researcher and speaker. 

Sensitive Skin Skincare Product Interview series with Dr Vermen Verallo Rowell VMV Hypoallergenics
  1. Sensitive Skin Product Series – What is Hypoallergenic?
  2. What does Natural Skincare Product mean?
  3. What is considered Organic and Non-Comedogenic?
  4. What does Suitable for Eczema Children mean?
  5. What is Patch Testing (for skincare product ingredients?)
  6. How do you read ingredients on skincare product label?
  7. What does Irritant-Free mean?
  8. What ingredients in skincare product to avoid?
  9. How is Coconut Oil used in skincare?
  10. What is product cross-reactivity?
  11. How many ingredients in a skincare product?
  12. How to use skincare products on Sensitive Skin?
  13. How to manage the diaper area?
Table to explain processing of coconut types and of other oils (provided by Dr Verallo-Rowell)
Table to explain processing of coconut types and of other oils (provided by Dr Verallo-Rowell)

Certified Organic VCO

Marcie Mom: I read with interest that your products contain USDA-certified organic virgin coconut oil and monolaurin (derived from coconut oil) that is a substitute for paraben.

Do all products containing coconut oil have the same antibacterial, antiviral and disinfectant properties that your product have? Could the ‘wrong’ coconut oil actually be an allergen?

Laura: There are currently no reports of reactions to coconut oil but yes, there are different types of coconut oils. Ours is USDA-certified organic because the entire farm is organic…no fertilizers, nothing…and because the method of extracting the oil is organic…nothing is added; we use first and cold-pressed oil…not even heat is used and no chemicals. Some other coconuts are grown on non-organic farms or the oils/other extracts are processed using other chemicals that could be allergenic. Others still are sold with additives like preservatives or flavor or stabilizers or fragrance. Those would definitely increase the likelihood of a reaction.

Virgin coconut oil is well studied to have anti-viral properties and has even shown some success in managing herpetic flareups that are resistant to valacyclovir. Virgin coconut oil should have these properties, but we can only vouch for the one we produce because we control it from seed to bottle, and it is the oil with which all our clinical studies were done.

Monolaurin has a slew of studies as well proving its similarity in efficacy to several broad-spectrum antibiotics, antivirals, disinfectants (even 70% isopropyl alcohol) and antifungals, but without the side effects like increased tolerance to treatment or dryness. I should also point out that our proprietary preservative system that replaces parabens is not just monolaurin…it’s a delicate balance between this and several other ingredients…it’s a big headache, if I’m to be frank 🙂 But such is our mandate 🙂

Dr. Verallo-Rowell: Yes. No matter how processed, the composition of all fatty acids in the oil removed from the coconut meat is about the same: myristic (15%), lauric acid (46-50%), Capric (6-8%), Caprylic ( 6%). These are all medium chain and saturated.

Could the ‘wrong’ coconut oil actually be an allergen? Yes, because of processing. RBD (primarily a cooking and/or industrial oil) vs. virgin coconut oil.

See table above that explains processing of coconut types and of other oils.

Marcie Mom: Thanks! Coconut oil is increasing popular as an ingredient and your information on it is precious to parents when evaluating what product to buy.

Doctor Q&A Eczema Tips

Sensitive Skin Product Series – What Ingredient to Avoid

I ‘met’ Laura Verallo Rowell Bertotto, the CEO of VMVGroup, on twitter and learnt that her company is the only hypoallergenic brand that validates its hypoallergenicity.

VMV Hypoallergenics is founded in 1979 by Dr. Vermén Verallo-Rowell who is a world renowned dermatologist, dermatopathologist and dermatology/laser surgeon, also an author, esteemed researcher and speaker. 

Sensitive Skin Skincare Product Interview series with Dr Vermen Verallo Rowell VMV Hypoallergenics
  1. Sensitive Skin Product Series – What is Hypoallergenic?
  2. What does Natural Skincare Product mean?
  3. What is considered Organic and Non-Comedogenic?
  4. What does Suitable for Eczema Children mean?
  5. What is Patch Testing (for skincare product ingredients?)
  6. How do you read ingredients on skincare product label?
  7. What does Irritant-Free mean?
  8. What ingredients in skincare product to avoid?
  9. How is Coconut Oil used in skincare?
  10. What is product cross-reactivity?
  11. How many ingredients in a skincare product?
  12. How to use skincare products on Sensitive Skin?
  13. How to manage the diaper area?
List of Ingredients that could Irritate in skincare product
List of Ingredients that could Irritate Skin

How to Choose Moisturizer

Marcie Mom: For a parent on a tight budget (also considering long term and frequent use of moisturizers), should he/she start the child on the cheapest lotion/cream available? If not, is there certain baseline to start with, for instance, it must state ‘suitable for infant with eczema’ or not contain ‘perfume’?

Dr. Verallo-Rowell: The answer is no. Many cheap products are strongly/nicely scented to cover up for the natural scent of less-pure cosmetic ingredients versus, for example, pharmaceutical-grade or higher-quality or purer ingredients, which are frequently more expensive. Some cheaper products are dyed with relatively cheap ingredients to add attractiveness in children’s eyes. Cheap or expensive, preservation is also problem, as are added antibiotics. All these are allergens and break down the skin’s natural barrier.

Many cheap products are strongly/nicely scented to cover up for the natural scent of less-pure cosmetic ingredients

Make function be the basis for your choice. Remember that in different forms of eczemas you pay attention to the skin’s outermost barrier layer: genetic innate barrier dysfunction initiates atopic; allergic or irritant reaction breaks down the barrier in contact; food around the mouth area can physically act on the barrier, and secondarily, bacteria cross damaged barrier in all types of eczemas. Hence to keep the barrier as intact as possible:

Place the least irritating, partially occluding product you can find without any of the above: scents, preservatives, antibiotics, dyes.

Mineral oil and pertroleum jelly are long time favorites of us dermatologists. They are cheap and excellent barriers, but they are petrochemical derived. Consider non-preserved, non-adulterated oils. For this my favorite is virgin coconut oil because it needs no preservation and is broken down by lipases of friendly skin bacteria into monoglycerides with antiseptic properties. I have a published paper on VCO vs. Olive oil in Atopic Dermatitis that includes comparison on Staph. Aureus action by both oils.

Can you list for us some common irritants and list them on a scale of 1-10 (1 being the most likely to cause allergy)?

It’ll also be great if you can let us know if there are other common names for these irritants.

Perfume, Fragrance

Benzyl alcohol (Phenylmethanol / Phenylcarbinol), also
named as Natural grape aromatic preserves & scents in
“fragrance-free products
Carvone (d-carvone, d-1-Methyl-4-isopropenyl-6-cyclohexen-2-one, essential oils from dill, caraway seeds, spearmint, orange peel
Cananga odorata(Ylang ylang, Cananga distillates)
Cinnamic aldehyde (Cinnamaldehyde),
from bark camphor, cassia cinnamon trees
Colophonium Rosin (Abietic acid, alcohol, Abitol), a resin
from pine tree
Extracts of common plants of the (Astraceae/ Compositae
family: yarrow, mountain arnica, German chamomile,  
feverfew, tansy) – Botanic addictives


Bacitracin  (An Antibiotic )
p-Chloro-M-Xylenol (Chlroxylenol, PCMX)
Formaldehyde (Formalin, Methaldehyde, Methanal)
Diazolidinyl urea (Germall II) and    Imidazolidinyl urea
(Germal 115, Eukyl K 200)
Dimethylol dihydroxy ethyleneurea (DMDHEU)
DMDM Hydantoin (Glydant)
Quarternium 15 (Dowicil 200)
Methyldibromo glutaronitrile + 2 phenoxyethanol
(Eukyl K 400)
(MCI/MI Eukyl K100, Kathon CG)


Methyl, Ethyl , Propyl, Butyl Paraben.  Please see also above in Preservatives

Propylene Glycol

1,2 Propanediol


Lanolin alcohol, Wool Alcohol


Disperse blue 124/106  Mix (Thiazol-azoyl-p-phenylene
diamine derivative dyes)

Conventional emulsifiers

Stearamidopropyl dimethylamine  (Amidoamine)
Dimethylaminopropylamine (DMAPA)
Cocamide DEA (Coconut Diethanolamide)
Cocamidopropyl betaine
Oleamidopropyl dimethylamine
Decyl glucoside  from glucose (corn starch) & decanol fatty acid from coconut
Ethylenediamine dihydrochloride (Chlorethamine)

Mineral oils – actually quite skin safe. A favorite among dermatologists.

Paraffin – same as mineral oil.

Sodium Lauryl Sulphate – An Irritant especially when present in higher concentrations. Not too common as an Allergen.

Doctor Q&A

Sensitive Skin Product Series – Understanding Suitable for Eczema Children

I ‘met’ Laura Verallo Rowell Bertotto, the CEO of VMVGroup, on twitter and learnt that her company is the only hypoallergenic brand that validates its hypoallergenicity.

VMV Hypoallergenics is founded in 1979 by Dr. Vermén Verallo-Rowell who is a world renowned dermatologist, dermatopathologist and dermatology/laser surgeon, also an author, esteemed researcher and speaker. 

Sensitive Skin Skincare Product Interview series with Dr Vermen Verallo Rowell VMV Hypoallergenics
  1. Sensitive Skin Product Series – What is Hypoallergenic?
  2. What does Natural Skincare Product mean?
  3. What is considered Organic and Non-Comedogenic?
  4. What does Suitable for Eczema Children mean?
  5. What is Patch Testing (for skincare product ingredients?)
  6. How do you read ingredients on skincare product label?
  7. What does Irritant-Free mean?
  8. What ingredients in skincare product to avoid?
  9. How is Coconut Oil used in skincare?
  10. What is product cross-reactivity?
  11. How many ingredients in a skincare product?
  12. How to use skincare products on Sensitive Skin?
  13. How to manage the diaper area?

What does Suitable for Baby mean?

MarcieMom: Suitable for Eczema Child/Infant – These are the most important keywords for a parent looking for sensitive skin products for his/her child with eczema – how much surer can it be when the product is labelled (and often prominently so) that it can be used for infant with eczema!

Can you explain to us what ‘suitable for use for infant’ and ‘suitable for eczema’ really mean? Also, is there a regulatory body that governs the use of such terms on product packaging?

Laura: Again, great question, and not as confusing as it may seem with some simple guidelines (but yes, still not regulated terms so there is definitely self-education needed).

Suitable for infants: Here is the premise we at VMV operate on. Baby skin is formed and functioning from a very young age (neonatal and even younger — in utero by the end of the 1st trimester). But during the first few months of life, immunological functions are still undeveloped. For example, atopic dermatitis (an allergic disease that needs immune-forming cells to make IgE immunoglobulin) is not often seen until after the 3rd month of life. Because infant skin is newer to the world, building up its defenses, and as the surface area of skin is greater in babies (they absorb anything topically applied more than adults), baby skin care should be very safe yet still protect against micro-organisms. This, at VMV, has meant products with as few or ZERO of all known allergens (plus other things that are NOT allergens but known to have irritant responses and other safety issues, like SLS and phthalates)

PLUS the inclusion of a very safe antibacterial-antiviral-antifungal-anti-inflammatory in all formulations. We also use coconut oil and its derivatives a lot because many have been found to actually be present in mother’s milk, studied extensively, peer-reviewed and published multiple times.

Baby Skincare hould be very safe yet still protect against micro-organisms

What does Suitable for Eczema mean?

Suitable for Eczema has similar requirements. Eczema is actually atopic dermatitis. I left the more detailed definition to my mother, Dr. Verallo-Rowell, as this is her forte and I believe you and your readers would appreciate a doctor’s definition:

Dr. Verallo-Rowell: Eczema is actually a more generalized term for any skin eruption characterized by edema within the epidermis and dermis clinically seen as tiny itchy bubbles that ooze and become little bubbles or vesicles, even blisters. Then, exposed to the air, they dry up and become crusts. With chronicity this wet phase may not be as obvious, and becomes replaced more by dry, thickened, very itchy patches and plaques. Atopic dermatitis is the prototype example of this process but it may be seen in other conditions such as allergic and irritant contact or photocontact dermatitis, eczematous drug eruption and secondary reactions to a primary diagnosis.

Laura: Because “eczema” is actually a very general term, a specific diagnosis can be a powerful tool towards consistent and sustained management. A specific diagnosis usually also comes with an identification of the possible triggers for an individual’s flare-ups. Because babies cannot yet be patch tested, however, the alternative is frequent and controlled observation of what seems to cause eruptions (this is also why it is so important to use few products…so it’s easier to observe what the trigger/s might be) and strict prevention.

For the many conditions that can fall under the mantle “eczema”, they all benefit from the same ultra-über safety that we would do for baby products, i.e. ZERO of all known allergens, etc. plus the inclusion of a very safe antibacterial-antiviral-antifungal in all formulations. Why? With eczema, when the skin develops fissures or cracks, this becomes welcoming to opportunistic microorganisms to enter the skin, which can lead to or exacerbate itching and further dryness…which can lead to more cracks (which can lead to more infection) and more scratching (which can spread infection)…more risk of microorganisms, etc. in a vicious cycle. This is why we put the skin-safe but powerful antibacterial-antiviral-antifungal-anti-inflammatory (monolaurin) in all these products.

Marcie Mom: Thanks Dr. Verallo-Rowell and Laura, I think we’ve covered the more common terms which parents of eczema children look out for in labels and discussed whether they are truly meaningful and beneficial. Look forward to learning more from you in our next blog interview.

2015 update: Skin facts series that cover more on baby skin –

Baby skin’s increased transepidermal water loss

Baby skin’s increased chemical penetration

Baby skin’s reduced lipids

2018 update: The above terms continue to be unregulated; read FDA current regulatory guidelines, and you can do your part! If you have a rash reaction to the products, you can report to FDA here. Complaints made to the product companies need not be reported to the FDA by the product company – in an August 2017 study by Dr Steve Xu (a featured guest on this blog’s series on contact dermatitis in children) Adverse Reported to the US Food and Drug Administration for Cosmetics and Personal Care Products:

It was noted that in 2014, the FDA sent letters to manufacturers Chaz Dean and Guthy Renker LLC in response to 127 consumer complaints of hair and scalp problems related to the WEN by Chaz Dean Cleansing Conditioners. Only then did the FDA discover that the manufacturers had already received 21,000 consumer complaints of scalp irritation and alopecia. (Italic text from

As cosmetics products (including shampoo and moisturizers) do not require any regulatory pre-approval, it is super important for consumers to take action to alert FDA on any adverse reaction. Apart from WEN shampoo above, another recent instance whereby consumers’ complaints to FDA and Better Business Bureau have raised awareness of possible adverse reactions is Monat shampoo, read here. Read also EWG article on myths of cosmetics safety

Doctor Q&A

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

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

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!


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