Why is eczema not improving in the child despite treatment?

Question

Hello doctor,

My 5-year-old girl has been having eczema since she was 3 months old. She was scratchy all the time (at least every four hours). Even though we have applied moisturizers such as Aveeno, it has not helped her. When doctors prescribed topical steroids, we used them, and she felt better.

But as soon as we stopped steroids, she got the eczema back. As the doctors told us, we believed that as age progresses, eczema would subside. But she has even now, and in fact, it is a little worse than before. We stopped steroids about six months back and are trying to manage without them.

One thing we noticed recently is that when we did not apply any oil or moisturizer (coconut oil or moisturizer never really helped), she did not scratch in the daytime. But at night, between 12 AM and 2 AM, she has been scratching all the time without sleep and sleeping again. We are really worried that she will carry this lifelong, and we are stressed.

Also, we do not want to use steroids and would like your opinion on that, if there is any complication, if we avoid steroids completely and just leave her in this routine in the hope of getting better (we do not want her body to get used to steroids).

After reading the above points, please advise on how we should handle her without much medicine, if possible.
Should we avoid moisturizer and oil, as she is not scratching in the daytime (rough patches still exist, though)?
When will she get better, or at least have less and more manageable eczema? Will it be at least in her teenage years?

Please help.

Answer 1

Hi,

Welcome to icliniq.com.

I understand your concern and will try to help you with it.

You have put your query with a nice description, but I think you have uploaded the wrong images (attachment removed to protect patient identity). So, if possible, share the correct images. From your description, it seems to be atopic eczema. It is endogenous eczema, which may have several aggravating factors:

Predisposition may come from the hereditary mechanism.
Other first or second-degree relatives may have features of some kind of allergy or atopy.
Seasonal changes may also affect the disease course.
Some foods like groundnut, cow milk, and an egg may cause the problem.

It starts with dry skin. Then some tiny lesions, sometimes oozing, scaling, and crusting. They may coalesce to form large plaques. So we have to put the first check on dry skin by using plenty of moisturizers.

It is best to use it just after taking a bath, tap the water with a towel softly, then apply moisturizer within 3 to 5 minutes of the bath.
Apply 3 to 4 times a day as per the requirement of the skin to combat dryness.
The dry or cracked skin may produce a stinging sensation, a burning sensation initially, but it will go away on its own.
Or you can try a different moisturizer, even a good petroleum jelly or coconut oil is also perfect.
Topical steroids are useful during exacerbation of the disease.

Steroids come in different potencies, and I hope your doctor had prescribed a low-mid potency one like Hydrocortisone, Desonide, Flucinolone, or Fluticasone. Among these, Desonide is best according to efficacy and safety. There is nothing like being habitual. You can stop anytime. But try to stop in a tapering way, like initially daily, then alternate day, then weekends, then stop.

Your baby is 5 years old, so you have one more option to replace steroids. Topical Tacrolimus 0.03 % ointment. Once lesions are clear with the use of a steroid, then you can shift to Tacrolimus. Or on the face, it is alone sufficient. No need to use steroids on the face. How to manage with minimal medicine:

Moisturise as much as possible.
Taking care of dry skin, avoid woolen cloths, clean the bed mattress, and bed sheets. Do not perform dusting or cleaning in front of the child.
Use a synthetic detergent in place of soap or use a moisturizing soap.
First, use Tacrolimus 0.03 % ointment if not controlled, then topical steroid for a few days, then again maintain with Tacrolimus.

Can moisturizer be avoided? No. Apply with a soft hand; do not massage vigorously.

When will she get better? Usually, 80 % children become better by the age of 12 to 13 years. But it depends on several factors like family history, exposure to aggravating factors, and management of exacerbations. You have to pamper the skin of your baby, care during cleaning, tapping, and applying moisturizer, all of which are needed. There are several other ways to treat exacerbation, so you should not be worried.

Thank you for consulting me.

I hope this helps.

Please feel free to reach out in case of further queries.

Thank you.