how to grade your child’s eczema (and why this matters!)
If it feels like you’re the only one whose child has sensitive skin or eczema, please don’t fret! One of the most common questions I get from families is about skin conditions like this. Knowing how to grade your child’s eczema is a key skill I think every parent should have — it will help guide your daily management, know if/when you need to see a specialist, and help with details in case you are concerned about co-existing allergies.
what to know
Eczema, often called atopic dermatitis, happens when there is some disruption or imbalance in the skin barrier. This causes a cycle of inflammation, itchy skin, and scratching. It can feel really frustrating as a parent - I’ve been there! Here are some things to remember — most childhood eczema does get better (people may grow up to have sensitive skin, but the more severe manifestations do often improve over time), and you can do a lot to help with symptoms. Let’s walk through it step-by-step.
Did you know that we categorize eczema into three grades of severity? We look at two big factors — skin findings and how it’s impacting your child day to day (i.e. how it’s affecting their quality of life).
mild: a few patches of of scaly pink/red/darker color skin, mild/intermittent scratching, and little impact on daily activities or sleep.
moderate: multiple patches of scaly pink/red/darker color skin, frequent scratching, local areas of thickened skin may exist, and some impact on daily activities and sleep due to scratching/discomfort.
severe: widespread patches of scaly skin, open cracked areas, bleeding/oozing, skin color changes, thickened skin (‘lichenified’ skin), persistent scratching, limits daily activities and impacts sleep and potentially growth.
While most cases of eczema don’t require a specialist, there are some times that seeing a specialist may be recommended. This is an area where I think there is a lot of hazy information online, so here are some evidence-based guidelines for when to consider seeing a specialist for your child’s eczema.
if your child has severe eczema or eczema that is not responding to your daily management
if there is an unclear diagnosis
if you suspect food allergies or immunodeficiency (see below)
Here’s how to know which specialist can help most with your child’s symptoms…
Dermatology: uncertain diagnosis, possibility of topical irritants that you’d like to figure out (contact dermatitis), history of recurrent skin infections, severe disease, daily management has not controlled symptoms.
Allergy: moderate or severe eczema (see above) and known or suspected food allergies, suspected environmental triggers, co-existing asthma, severe eczema
Immunology: suspected immunodeficiency, history of recurrent fractures or infections in older kids, severe eczema and growth concerns or infections
Eczema symptoms can often get worse at night, because there is a natural rise in histamine (which causes itching/scratching) at night. See below for some tips at nighttime.
what to do
Guess what? There is a lot that you can do for your child’s eczema day to day in your home — let’s work outside-in.
Irritants: avoid fragrances or perfumes around your child. avoid candles, incense, air fresheners, or diffusers.
Air: using an air purifier can help reduce fragrances/irritants. You can also use a humidifier to help with moisture in your child’s bedroom or wherever they spend a lot of time during the days - this can help a lot during summer and winter months, when air can be dry. We always have a humidifier handy during these months in the boys’ room.
Laundry: Use a fragrance-free and dye-free laundry detergent - avoid Dreft or other detergents with dyes and fragrances. I like Molly’s Suds a lot for our family, it’s helped a ton with all of our skin. Some dermatologists also recommend Tide Free and Gentle detergents or All Free and Clear.
Bath: Use a gentle, unscented soap (we use Pipette and love it, you can also try simple Dove Sensitive Skin Bar or Vanicream cleansing bar). Keep baths to lukewarm water and short (less than 10 minutes). Avoid bubble baths, as these can irritate the skin. Don’t use harsh washcloths to wash the skin - you can try cotton or bamboo towels and a soft washcloth. Pat skin dry gently.
Clothes: Focus on softer fabrics like soft cotton or bamboo for clothes and pajamas. Avoid wool or nylon, or if you live in a colder area and have to use them, use them over a cotton underlayer.
Bedding: Use cotton or bamboo sheets.
Daily moisture: This will help infinitely with daily care — focus on moisturizing to protect the skin barrier 2-3 times a day even when the skin is not flaring. You want to use a cream or ointment (which has more oil content and so acts as a stronger skin protectant) NOT a lotion (which has more water content, so doesn’t offer as much protection) — make sure to check before you buy a product. We have used Pipette baby balm with a lot of success, and for my family, I like that it doesn’t have some of the extra ingredients. Here are some other moisturizers that our dermatologists recommend: plain vaseline, Cerave moisturizing cream, CeraVe healing ointment, Vanicream ointment.
make sure to moisturize within a few minutes of getting out of the bath, while skin is still slightly wet.
Moisture before bed is key — you want to apply a thick layer of ointment and then put pajamas on immediately to seal it in. Since symptoms can often get worse at night, protect that skin barrier as much as you can.
Topical steroids: topical steroids do have a role in eczema management and can be helpful for flares, but the key is to know exactly when to use them and when to stop. You want your child to have improvement in that inflammation but also not to be on a treatment indefinitely, without goals of care and a plan for progress. Chat with your care team about an eczema action plan, so that you know exactly when to re-assess and how to gauge progress.
There is a lot of newer research on the gut and its role in eczema — many specialists are doing research on the role of probiotics in care. I’ll be sure to keep you updated as the evidence becomes more clear and as guidelines come out.
Always feel free to call your care team or seek help if you have ANY concerns. You’re doing so great.
Sources: https://www.chop.edu/clinical-pathway/atopic-dermatitis-determine-severity-flare
