What is Eczema

What is Eczema (atopic dermatitis)

  • Eczema or atopic dermatitis (AD) is a very common recurrent, itchy skin condition in children.
  • Many patients have a personal or family history of other atopic conditions (eg. asthma, allergic rhinitis or allergic conjunctivitis). Many genes are involved in the formation of the skin barrier and its interaction with the skin’s immune system.
  • AD can improve as they get older. However, the condition can recur even after an inactive period.

How does atopic dermatitis present

  • AD commonly starts in infancy but some patients may present in childhood or later.
  • In infants and babies, AD commonly affects the scalp and face. In more severe cases, it can also affect the limbs and trunk.
  • In children and adolescents, AD commonly affects the flexural areas (eg. neck, elbows and behind the knees). It can become more generalised in more severely affected patients.
  • AD appears as red, scaly rashes with broken skin. Blisters may be seen. In long-standing cases, the skin can become quite thick.

Managing Eczema

What triggers or worsens atopic dermatitis?

  • Environmental
    • Changes in climate
    • House dust mites/ dusty environments
    • Heat, sweating
    • Smoking
    • Strong soaps, detergents, bubble baths
    • Pets, carpets, stuff toys
  • Infections
    • Flu, upper respiratory tract infections
    • Skin infections (eg. Staphylococcus aureus, Herpes simplex virus)
  • Insect/ mosquito bites
  • Vaccinations
    (However, we do not advise avoiding your child’s vaccinations.)
  • Stress
  • Scratching (itch-scratch cycle)

Food allergy

  • Food allergies may co-exist with AD but the role of food allergy in triggering AD is controversial.
  • Blind allergy testing for all food types in the absence of specific food allergy symptoms is not routine. Allergy tests may include skin prick tests or blood tests. Negative allergy test results may not rule out all types of food allergy.
  • If there is suspicion of a food allergy worsening your child’s AD, discuss this with your doctor, who will determine if further testing or referral to a paediatric allergist is warranted.

General advice:

  • Reduce the level of house dust mites. Avoid stuffed toys, pets and carpets in the home. Family members should avoid smoking.
  • Avoid strong soaps, chemicals and bubble baths.
  • Take a short (10 min) bath or shower daily with tepid or slightly warm water. Avoid hot showers or baths.
  • A soap substitute is recommended for patients with AD. Sometimes, an antiseptic wash may be prescribed for patients with repeated skin infections.
  • Avoid extreme temperatures. Avoid excessive sweating if possible. Consider stopping physical exercise when there are severe flares.
  • Minimise scratching. Cut and file fingernails regularly.
  • Moisturise two to three times daily with a fragrance-free moisturiser. Apply the moisturiser liberally over all skin surfaces, even on normal-looking skin. Your doctor will be able to recommend which moisturiser is suitable for your child.

Specific treatment:


Topical steroids:

  • Topical steroids are used as the main treatment of AD.
  • The strength of the steroids will depend on the age of your child, as well as the location and severity of the eczema.
  • They should be applied two to three times daily depending on the instruction of your child's doctor.
  • Topical steroids are to be applied on the red, itchy and bumpy areas. Once the rash improves, decrease the frequency of application. Stop application once redness and itchiness resolves and skin is flat.
  • Prolonged use of potent or super potent topical steroids without supervision can lead to side effects like skin thinning, easy bruising, stretch marks (striae) and increased hair growth.

Steroid creams:

  • Wet wraps may be used to increase the effectiveness of the medication and prevent the child from directly scratching the skin. They are not for use during active infection.

Topical calcineurin inhibitors:

  • These are non-steroidal creams used to treat AD, with a better side effect profile compared to topical steroids. Examples include Elidel cream and Protopic ointment.
  • Some patients may experience some burning or stinging sensation after initial application. This may subside after continued applications.

Oral anti-histamines:

  • These may help to relieve itch in some cases and help your child sleep better at night. However, long term use of sedating antihistamines is not recommended and proper topical application is still the mainstay of treatment.

Oral antibiotics:

  • Antibiotics may be needed for significant skin infections worsening the AD. Your child should complete the course of antibiotics prescribed.



  • Narrow band ultraviolet B phototherapy helps to reduce skin inflammation and flare episodes.
  • Short term local side effects include dry, red or itchy skin. Side effects do not occur in every patient and will be closely monitored.
  • Your child will need to come to the phototherapy centre twice a week for a few months.
  • Eczema can recur after phototherapy is stopped.



  • Medications like azathioprine, cyclosporine and methotrexate may also help to reduce skin inflammation and flare episodes. Although they may not cure AD completely, they may provide the child with a necessary respite from recurrent flares.
  • Each drug has associated side effects which will be closely monitored by your doctor via blood samples. Although long term side effects are unknown, the medication will be prescribed for the shortest duration possible with the lowest effective dose to help your child's skin condition improve.
  • Eczema can recur when the medication is stopped.
  • AD is a lifelong condition and flares can come and go. For serious cases, social life and academic performance may be negatively affected. Although there is no definitive cure, it is important to comply with treatment so as to improve the quality of life and avoid long term complications of AD.
  • Family and social support are important to the child. Family members must understand that it is not the child’s fault if he/she scratches non-stop as the itch is challenging to control. As the child gets older, stress from various sources (school bullying, exams, social situation etc) may trigger flares. Psychological counselling may be relevant in certain cases to help the child and family cope.

Living with Eczema

Steroid phobia
Irrational fear of topical steroids can result in under treatment of eczema, resulting in a poor quality of life and poor growth.

Why are topical steroids used to treat eczema?
Steroids occurs naturally in the body and controls inflammation. Topical steroids applied to the skin targets areas where it is needed the most.

What are the dangers of using topical steroids?
If topical steroids is used in its appropriate strength, quantity, duration and at the correct sites under your doctor’s supervision, skin damage is extremely uncommon. Without using topical steroids, the skin becomes thick, itchy and unsightly. Delayed use of topical steroids leads to worsening of eczema and stronger topical steroids will eventually be required for longer periods of time.
Topical steroid creams should be avoided on eyelid skin though as there is an increased risk of cataracts and glaucoma.

Myths about topical steroids
Topical steroids should not be used on broken or weepy skin: False
The skin is often broken and cracked if you have bad eczema, and topical steroids help to reduce the inflammation. If your skin is very weepy it may be infected, so antibiotics may be needed.

Topical steroids affect growth and development: False
Topical steroids is not the same as anabolic steroids sometimes taken by athletes. They are almost never absorbed into the bloodstream, and so will not affect growth and development or cause other side effects within the body. The body’s ability to fight infections will not be affected. Short courses of steroids may be prescribed for severe eczema flare-ups, but this will not harm the body in the long run.
On the other hand, untreated severe eczema can have a significant effect on physical, psychological and social development, and this can affect children’s growth and development. As the eczema improves with steroid application, the growth and quality of life may improve.

Topical steroids will make me dependent on them: False
There is no evidence that topical steroids cause dependence or addiction.

Topical steroids shouldn’t be needed if I use enough moisturiser: False
Moisturisers only help with the dryness of the skin. Red, itchy or bumpy skin requires topical steroids for effective treatment.

Topical steroids should always be applied in very small amounts: False
Too thin an application results in ineffective treatment. A useful way of knowing the correct amount of topical steroids to apply is to use the fingertip rule.

Alternative and complementary therapies.
Alternative and complementary therapies have not been tried and tested in clinical trials in the same way as topical steroids have. In fact, some may contain steroids in a higher concentration.
The role of food allergy in eczema remains uncertain. Dietary exclusion exclusions should be supervised by doctors as it may affect growth and development.

Topical Steroids.




Very mild

Hydrocortisone 1%

Face, neck, flexures, body, limbs

Desonide 0.5%

Face, neck, flexures, body, limbs


Betamethasone 0.025%

Face, neck, flexures, body, limbs


Betamethasone 0.05%

Body, limbs, avoid face, neck and flexures


Betamethasone 0.1%

Body, limbs, avoid face, neck and flexures


Body, limbs, avoid face, neck and flexures

Momethasone furoate

Body, limbs, avoid neck and flexures

May be used on the face for a short period of time

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