Double whammy? Contact dermatitis in atopic dermatitis child
Can my Child have both Atopic and Contact Dermatitis?
Contact dermatitis is more common in adults, but it is possible that a patient with atopic dermatitis also have contact dermatitis. The logic is that eczema skin barrier is defective, thus more vulnerable to hypersensitive reaction to chemicals. The chemicals which I’ve found from recent years’ studies which affect eczema patients (not necessarily children) more than non-eczema patients are
Surfactants cocamidopropyl betaine (CAPB), from AAD study. Also quaternium-15, imidazolidinyl urea, DMDM hydantoin, and 2-bromo-2-nitropropane-1,3-diol (from another AAD study)
How does dermatologist treat Contact Dermatitis?
The treatment is similar to atopic dermatitis, so in a sense it may not be as critical if the two cannot be differentiated. The difference is that without avoiding the substance that is causing the hypersensitive reaction, it is then not possible to keep it from causing the rash. Moisturizing, medicated cream, compresses to relieve itch and soothe skin, and antihistamines for reduced scratching at night may be prescribed.
In finding out which are the irritants involved in contact dermatitis, a patch test can be carried out (read more here). Patch test involves placing the suspected irritants/chemicals (note: there is a ‘science’ as to how much to put and how to prepare the liquid, don’t try to do this yourself) on paper tape on your child’s back or arm. The tape will be left on for about 48 hours and observation be noted by the dermatologist.
Is my child more likely to have contact dermatitis as an adult?
I haven’t come across such study, but it makes sense to figure out the irritants early and to avoid them. Also to treat the eczema promptly and take measure to protect the child’s skin barrier so that it is more robust against irritants when the child is older. (At the same time, I’m thinking she has got to fend for herself when old, I’m not going to say ‘Stop Scratching’ till I’m 60 year old!)
What are the preventive measures for contact dermatitis?
We’ve covered the basics and the conclusion may be to be aware of contact dermatitis and promptly remove the suspected irritants. When the child is older, say 5 year old, bring him/her to a patch test.
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.
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)
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.
Rosacea
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 (picture credit Dermnet NZ)
Psoriasis
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)
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 Lynn: In 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
Facial eczema. This happens in individuals with eczema and facial eczema is more common in infants.
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.
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.
