Why Does My Child Keep Getting Eczema Rashes?

Podcast Transcript

Speaker 3: Welcome to Little Health, a Cleveland Clinic Children's podcast that helps navigate the complexities of child health one chapter at a time.

In each session, we'll explore a specific area of pediatric care and feature a new host with specialized expertise. We'll address parental concerns, answer questions, and offer guidance on raising healthy, happy children. Now, here's today's host.

Dr. Jaclyn Bjelac: Welcome back to Little Health. I'm your host, Dr. Jackie Bjelac. I'm a pediatric allergist immunologist at Cleveland Clinic Children's.

Today as part of our season on pediatric allergy and immunology, we're talking about childhood eczema. This is a common skin condition and it can really impact a child's quality of life, including a few of mine. So join us as we talk about the newest strategies and treatments that can hopefully bring your little one some itch relief.

And our guest today is my colleague Dr. Brian Schroer. He is a friend and a pediatric allergist immunologist at Cleveland Clinic Children's. He specializes in treating children with eczema, so I'm really thrilled to welcome him to Little Health.

Welcome Dr. Schroer.

Dr. Brian Schroer: Dr. Bjelac, I Appreciate thanks for having me.

Dr. Jaclyn Bjelac: It is always a pleasure. So wanna welcome you to share just with the audience today, a little bit about yourself.

Dr. Brian Schroer: Yeah, so I went into allergy after realizing I think in third grade, that I wanted to be a physician. [Yeah.] But I didn't necessarily know what I wanted to do in my life and medical school, my dad's a dentist, but I, I definitely knew I didn't wanna be a dentist.

And we had some friends who were ENT surgeons, so I did want to go into ENT surgery. Hmm. But I actually grew up with really particularly bad eczema as a kid. Developed very bad allergic rhinitis or nose allergies and also had asthma pretty bad.

But one of the things that affected me the most was my nose allergies. Meaning that, uh, it would make me miserable every spring and fall and whenever I was around cats and dogs mm-hmm. The real thing I realized in medical school was you can't blow your nose during surgery.

So I was very fortunate during my medical school down in Florida to have met very prominent allergists early on and I saw what they were doing, how they were helping patients, how we could really significantly change people's lives, and it really opened my eyes to the opportunity to become an allergist. So that's what led me here.

Dr. Jaclyn Bjelac: Well, thank you so much for sharing and I hope that the listeners can hear that your life experiences have influenced how you went into this field, and I think honestly give you a lot of street cred for how you counsel people to manage these conditions.

So for me, eczema is one of the more common conditions that present in our clinic, and it happens to be one of my favorite things to treat because I really feel like it's a space where, as a parent it is eternally frustrating.

And I would imagine others would see that there's a lot of information out there on social media, you hear friends talking about it, and it's hard to know where to turn. So when you meet a family with eczema, just talk me through what they can expect at a visit with you.

Dr. Brian Schroer: Yeah, that frustration, you, you've, uh, seen people, uh, experience and the frustration our patients come in with is very common.

My conversations with individual patients may be different based on the age of the patient when they come in. Fortunately, as allergists, we see patients from six months old to 60 years old in some allergy clinics. In our clinic, we see kids under the age of 25 or so. I do think of ourselves as still children.

But when we think about a kid seeing us in allergy clinic, around five or six months old parents are oftentimes new parents. I'm the first of three boys, and oftentimes the, the first kid is the kid who develops allergies the most. And in that case, there's very little experience with a kid at two or three months old when eczema typically starts popping up and causing rashes either on the face or on the arms or on the belly to say, what is this? Why is this happening? What do I do about it?

And so for our first visit, I think it's really important to address those ideas, worries, concerns that people come in with. And of course, empathize with the frustration when it's expressed.

But when you think about what is eczema, this is a disease that basically your susceptibility to developing it, you're born with. The baby, had that chance to develop eczema with studies that have been able to predict who is gonna develop eczema, looking at tests being done on the first day of life.

Dr. Jaclyn Bjelac: Okay. So right when the baby's born, it's almost predetermined.

Dr. Brian Schroer: Who in a westernized society like America, is more likely to develop eczema, that's right. But yeah, when your child has these rashes that come and go, for seemingly no obvious reason. One of the biggest things I like to do is talk about not just what to do about it, but really sit down and spend time in the first visit, especially going over what it is and and why it's happening.

Dr. Jaclyn Bjelac: Can you share with the listeners now what is eczema?

Dr. Brian Schroer: When we think about eczema, it is a genetic disease in that you're predisposed to developing eczema. That being said, not everybody who has these genes develops eczema. For example, my grandparents probably did not have eczema. Mm-hmm. But my mother had eczema. I had eczema. My kids both have eczema to some degree.

The genetic predisposition does interact with the environmental factors in our, in this case, mostly modern westernized societies that allow the rashes to come on. The genetic predisposition comes from a skin barrier dysfunction that leads to two major things that cause eczema.

The skin barrier dysfunction, and I use the word dysfunction, meaning it doesn't work as well as it should, leads to water getting out of our skin faster, and so kids with eczema tend to have a lot of dry skin. But then that skin barrier dysfunction also leads to things getting into our skin that otherwise would not typically get through the skin.

So, for example, my brothers who don't have eczema, they did not have these things getting into the skin and leading to the inflammation that leads to the itchy rashes. So the, the ability for different things that get into the skin, such as allergens, a cat and dog allergen, irritants like chemicals or irritating substances from our modern world.

Bacteria that live on our skin normally can contribute to the inflammation, rashes. Fungus that live on our skin normally can contribute to the rashes. Such that a lot of infants who have eczema also have what's called cradle cap, which is a thickening of the skin in their hair. And that's due to the overgrowth of fungus, but also due to the inflammation that the fungus is causing in the skin.

So boiling it down, the skin problem in eczema is two major things. It's a dry skin, it, it's an itchy rash due to inflammation that is basically going on because of the skin barrier dysfunction in the top layer of our skin.

Dr. Jaclyn Bjelac: And you're mentioning that an important part of that kind of barrier breakdown is a change in the types of bacteria, fungus, things that belong on our skin. You know, we call this the microbiota, the microbiome. And we talked about that a little bit in our last episode with Dr. McDonnell about how the microbiome is supposed to be there and is an important part of the immune system interaction.

So does that contribute to inflammation and eczema?

Dr. Brian Schroer: Absolutely. If you talk to a dermatologist, they'll call themselves the original microbiome specialist because of course dermatologists who also take care of the kids with eczema deal with acne, which is a bacterial disease, or they deal with a lot of other skin conditions that are due to the bacteria, fungus, and other things that live on our skin normally.

But it's, it's absolutely the case that an overgrowth or the immune system not killing off the bacteria or viruses or fungus the way they normally do, which is part of the skin barrier dysfunction, allows these bacteria that live on our skin normally to overgrow and then contribute to more inflammation.

So it is a kind of positive feedback loop where in this case, the bacteria, the fungus, or even viral infections that are coming onto the skin can contribute to the eczema getting worse. The eczema meaning the itchy rash.

Dr. Jaclyn Bjelac: Mm-hmm. And I think this is a great time to point out, as someone who's personally experienced parental guilt around my kids' allergic conditions, what I am hearing is this is nothing that anybody did or didn't do, it just is.

Dr. Brian Schroer: No, absolutely. That's a great way to think about it. You know, we do see in our patients' families a lot of concern when their kids are having these rashes come on, especially when they're coming and going for no obvious reason. One of the biggest questions people ask is, what can I do to make it go away? And, and the implication being that it'll never come back.

But also the idea that they're doing something that is making it worse and they want to have a sense of control such that they can do something different and make it less frequent or less severe. And it is something that we can do. Uh, that being said, those things that are contributing, that we mentioned, the bacteria, the fungus, the viruses, the allergens, the irritants, these are things that are invisible.

And until they come into our clinic and we talk about it, parents often, or patients who are older, they have no idea that these things are contributing and therefore they can't control it.

Dr. Jaclyn Bjelac: Yeah. So when we come into the allergy clinic for an eczema visit, do you think that it's helpful to do environmental allergy testing?

Dr. Brian Schroer: When we think about all the different contributing factors for what makes the patients with eczema have rashes that come on, it is the case that environmental allergens, such as cat dander, dog dander, dust mites, and my joke is everybody has pet dust mites in their house.

And then at old ages 3, 4, 5, 6 years old, you can start developing sensitivity to outdoor pollens from tree pollen, grass pollen, weed pollen, such that when your kid goes outside in a nice summer day in Cleveland, especially in the spring, April, may, June, they are gonna likely get some pollen onto their skin and that is going to make their eczema worse.

But that pollen exposure is on top of everything else we just said. And in that case, doing skin testing or if you're not in in an allergy office doing serum IgE or blood allergy testing for the common indoor and outdoor allergens, cat's, dogs, dust mites, tree pollen, grass, pollen, weed pollens can be useful for identifying one of the many different triggers of eczema.

Dr. Jaclyn Bjelac: And then I think it can empower families, especially if they identify, you know, an allergic trigger in their home, like a beloved pet. I never tell people to get rid of their pets. That's not a productive conversation, and then they never come back. What are some things that we can do if you identify maybe a pet or dust mite allergen and you have a young kid with eczema?

What are some things that we can tell families to reduce those exposures in a way that might help heal the skin?

Dr. Brian Schroer: What I said before is while we can't necessarily make eczema go away forever and never come back, we do have many different things we can do to make it a lot less frequent that the rash is severe or come on less frequently.

So in that sense, if you are able to identify some indoor outdoor allergen, then what we do as the first line treatment of all allergies is avoidance, right? So if there are certain strategies you can use to avoid certain allergens, let's talk about them.

Let's go with the animals first. If you don't have an animal, one of the strategies would be don't buy an animal.

That would be an option. Prevention is much better than a cure. That being said, if you're like my family, I grew up with a dachshund named Schnapps that was definitely contributing to my eczema, asthma, and nose allergy. But I loved our dog growing up. It is just something to think about. What can you do to decrease exposure?

It is very difficult to avoid the allergens from dogs or cats because those allergens are light, they're sticky, they're floating in the air, they go all throughout the house. That being said, if you have the chance to maybe keep the dog or cat out of the patient's bedroom, that would be useful.

Dust mite covers, which are used for dust mite remediation also seem to decrease allergen exposure in the bed because it's easier to clean the dander outta the sheets, and at the very least, it's okay to pet your dog. But water does a very good job of washing allergens off of the skin. Don't even necessarily need soap.

So if the kid wants to play with their animal or somebody else's animal, like grandma's pets or their friend's pets, then wash the skin off after you do that, that will decrease how long that allergen is sitting on the skin.

Dr. Jaclyn Bjelac: These are great tips. Have we found that HEPA filters are helpful at improving eczema when we've identified environmental triggers?

Dr. Brian Schroer: You know, a lot of people will sell you things that may sound good and, and in some cases may work for certain things, but other times they won't. When we think about HEPA filters, they may decrease temporarily the allergen from cats and dogs, but it hasn't been proven to help kids with eczema in terms of decreasing exposure to the pet danders.

Let me jump into dust mites, which I didn't get to last time. Dust mite remediation or avoidance of dust mites involves buying special quote dust mite covers or hypoallergenic covers. These are special, tightly woven fabrics that go over the pillows and mattresses. And then you wash the sheets like everybody usually does once a week in hot water.

Dr. Jaclyn Bjelac: We don't wash our sheets that much in our house. I gotta be very transparent. But yes, in an ideal state.

Dr. Brian Schroer: Um, ideally you can do these dust mite covers and decrease dust mite exposure. But when we think about the characteristics of dust mites, they're very heavy allergens, unlike the cat and dog.

So they're really gonna be in your pillows and in your mattress, which is why we get exposed to them causing nose allergies 'cause they're really next to our face when we breathe 'em in at night. But because they're so heavy, they're really not in the air. Mm-hmm. And buying a HEPA filter for dust mites will not be helpful.

HEPA filters, however, have been shown to decrease exposure to outdoor pollens, especially for people, like many people in in northeast Ohio or other parts of the northern part of the country where you don't have central air conditioning. If you have central air conditioning avoidance, outdoor pollens would be keep the windows shut, keep the pollen outside, and use your central air conditioning to filter it out.

If you don't have central air conditioning, at least keep the windows shut and use the HEPA filter in the bedroom can be helpful. For dogs and cats, however, going back to the original question, the HEPA filters have not been proven to significantly decrease exposure for either asthma, nose allergies or eczema in this case.

Dr. Jaclyn Bjelac: So probably pretty low risk. But other than to, you know, the risk to your wallet, but probably won't be hugely impactful and improving eczema. But I'm hearing that there could be a lot of utility in identifying environmental allergens as, you know, a trigger for somebody's eczema. You know, when families come and they're like, we've tried everything. Sometimes environmental interventions make a huge impact.

Dr. Brian Schroer: That's right.

Dr. Jaclyn Bjelac: Another question that families have when they come to meet me, regardless of the age of their child I've found is, well, you know, we're talking about environmental allergens. What about foods? So have foods been shown to cause eczema and can we just test for and then avoid foods in a similar way as we might cats and dogs to help heal the skin?

Dr. Brian Schroer: You know, it gets back to the original thing I mentioned, which is when patients come in, they wonder what's going on and what can I do to make it go away? Even if a patient doesn't bring it up, I always bring it up myself because I know patients have thought about it at the very least.

So I always appreciate patients asking, you know, questions about things that they think are contributing and that's really useful 'cause I can't address a concern you have that I haven't heard about.

Dr. Jaclyn Bjelac: You're not a mind reader, Brian?

Dr. Brian Schroer: But we can take our experience like you and I have, where many patients ask about food allergy and let's talk about it.

When we think about their relationship between foods and eczema. A lot of people have been told by doctors through the years or here through other sources, either friends or families, that eczema is caused by food allergies.

But the reality of the situation, and funny enough, we've only really realized this, especially in the last 10 to 15 years, is that patients who have eczema do not get better when they avoid foods. Because foods are not one of the main causes of the inflammation in the skin that causes the itchy rashes.

We've already gone over all the many things that you don't see, like the bacteria, viruses, fungus, irritating substances, chemicals in our modern world and other airborne allergens. Those are going on because if you avoid food, guess what, you're still gonna have all those things contributing to the rash.

And what we've especially found over the last 10 to 15 years is that kids who have eczema are susceptible to developing a different kind of food allergy called anaphylaxis. Mm-hmm. Which is the type of allergy for which people need epinephrine or EpiPens.

And in that case, what we found over the last 10 years especially, is that avoiding foods is one of the main risk factors for developing anaphylaxis, and that's most common in patients who have eczema. Meaning that if patients with eczema avoid a food, they're more likely to develop anaphylaxis to the food that they're avoiding.

And the typical foods we start eating at four or five, six months old, including things like cow milk, hens eggs, or peanuts are things that are also the most common causes of anaphylaxis to food.

Dr. Jaclyn Bjelac: Hmm. I think this is an important point and I really love how you presented it. And I'll share just sort of anecdotally with everybody listening, that my third child had really significant eczema and milk protein intolerance, which are tummy troubles. When you enjoy milk when you're little, that nearly everyone outgrows.

And as we reintroduced milk, it seemed like his eczema got worse. And my husband said to me, why don't we just stop giving milk? And I said, because I don't want him to develop true milk allergy. Right?

So here's that risk benefit conversation that we've had a few times through this season of Little Health and Allergy Immunology. So many of the decisions we're making as parents are risk benefit. So we didn't avoid milk. The eczema got better as we addressed a lot of those other things you mentioned. Now he enjoys milk in all forms.

And I think that this is such an important message because the internet will tell you, and social media influencers will tell you that foods are the problem and we are telling you that the skin is the problem and can lead to true food allergy That's Right. I Love, I love the way that you phrased it.

Dr. Brian Schroer: Do you mind if I keep going on what you said there?

Dr. Jaclyn Bjelac: Please do.

Dr. Brian Schroer: For a second.

Dr. Jaclyn Bjelac: Please do.

Dr. Brian Schroer: You know when we think about how we take care of eczema, which I know we're gonna get to in detail in a second. [Yeah.] The hard work of taking care of eczema involves skin hygiene measures and use of topical anti-inflammatories to address the rash.

[Mm-hmm.] And a lot of times patients may go and see a clinician and they say, okay, avoid the food and on the same visit, tell 'em how to take care of kids' skin with, uh, non-medication, uh, regimens and give 'em medications at the same time. And the parents implement the hard work of bathing daily and moisturizing and using these topical medicines, and they also avoid the food.

And of course, the thing that made it all better must have been the food avoidance. Yeah. And

Dr. Jaclyn Bjelac: Well, it's the most obvious I think, really. Right? Like you made that huge change and the skin gets better. I think we all see that they go together. So it feels like that's what's happening. But you're saying in reality it was the other stuff.

Dr. Brian Schroer: That's right. And in that case, the typical treatments, which are not terribly hard though they do take some time, really are highly effective in the vast majority of patients with eczema.

And what I'll say is when we think about your story, I'll, I'll tell a quick story about my son who had very severe eczema at four or five, six months old, and the first time I gave him milk in the form of macaroni and cheese at the mall, he had hives all over his face and was sneezing. And he developed an acute allergic reaction.

Such that because of his history of cow milk allergy, I know personally how hard it is to avoid a food. Yeah, it's difficult to avoid one food, let alone multiple foods. [Mm-hmm.] And in that sense, the work of taking care of the skin and using topical medicines is far easier than cutting out a whole food group, including just one food, in this case, concerned in that case about milk for your child and mine.

And because of my oldest, my son who's now 15 years old, my philosophy when I see patients is this, when I think about food allergies, I want you to avoid the foods you have to avoid. So if you have anaphylaxis to a food; milk, eggs, peanut anaphylaxis let's avoid it. If you don't have to avoid it let's enjoy the food if you want to eat it. And let's of course eliminate as much gray zone foods as possible.

Let me get to the gray zone food question real quick. The biggest issue I also see in that same encounter is from the first visit is patients will ask me, well, why can't we just do testing for foods to see if they're gonna cause eczema or other things?

And the the thing I, I always tell my patients, no matter what reason I'm doing allergy testing for a food is this, our tests for food allergies are very good for one disease, but they're only very good in one direction. Our skin test or blood test for food allergy work for the disease called anaphylaxis.

And in that case, if the food that you test for is negative, your chances of having anaphylaxis to that food is very low. That means our skin tests have almost no false negatives. Mm-hmm. A false negative would be a test that was negative, but they do have a reaction.

Dr. Jaclyn Bjelac: Okay. So if you're skin testing somebody and their test is negative, their risk of anaphylaxis is very low.

Dr. Brian Schroer: That's right. The flip side of that though is not the same. Right. If you have a skin test to milk, egg, or peanut and the test is positive. What I tell my patients is that test does not prove that you're allergic to that food in terms of anaphylaxis. [Mm-hmm.] The ultimate test is, of course, eating it and seeing what happens.

So in my son's case, when he ate the milk, he had sneezing, itching, and, and hives all over his face. In his case, a test for milk would be a true positive. Mm-hmm. If you had done skin testing in your, your third child, then it might've been positive. But you wouldn't have known if it was a true positive or a false positive.

And the on- only way to know would be to eat, didn't see what happens, and you kept eating it. He was already having it in his diet, and it wasn't causing anaphylaxis. You already knew the answer to the question. It would've been a false positive in that case.

Dr. Jaclyn Bjelac: Yeah, you.

Dr. Brian Schroer: That's the problem with our tests.

Dr. Jaclyn Bjelac: Yeah. You word it a lot nicer than I do. I've just started to tell families our tests are hot garbage because  when you're looking at the question of, are foods making my kids eczema worse? We don't have a test for that. That's not what our tests are for. I wish we did.

As someone who has four kids with varying degrees of eczema, I really, really wish that there was a test. And in my heart, I know that even if it were positive, we don't wanna avoid the food.

So then what do we do? Right? Like I have been there. Team at like two in the morning, my kid seems itchy. I can't seem to figure out what the triggers are. How do we help heal the skin? How do we treat inflammation? How do we decrease the frequency of flare-ups to keep our kids' skin healthy and keep them happy and comfortable?

Dr. Brian Schroer: Yeah. After we talk about what it is, what's contributing, let's talk about how we take care of it. You know, my first comment there is that eczema is something we can take care of. [Mm-hmm.] We may not make it go away. It may go away on its own. We'll talk about that later.

But at the same time, we can do a lot of non-medical things to make the eczema rashes come on less frequently and less severely. So what I first start to talk about is skin hygiene measures, for example, uh, a lot of people are told don't bathe your kid daily if they're dirty because bathing daily makes the eczema worse. But that's to some degree an old wive's tale or an old doctor's tale in that.

When I was growing up, we didn't have what are called non soap cleansers, things that we used as soaps, like safeguard and regular soaps are very good at washing your body's natural moisturizers down the drain. And nowadays we do have what are called non soap cleansers that clean dirt and and stuff off your skin, but don't wash your body's natural moisturizers down the drain.

So bathing kids daily, if they're dirty or bathing infants every other day is perfectly fine in kids who have eczema. Using the non-soap cleansers, not to name brands, but there's a number of non-soap cleansers that are available on the market. Not terribly expensive. Uh, and I don't like to, I'm, I'm a cheap person. I don't like to pay for things that you don't need.

Um, so for example, in our family, we use, we use Unscented Dove Bar soap. Then after you give the child a bath, moisturizing the skin and the moisturizer that we recommend are generally creams or ointments that addresses the dry skin of the eczema. If you can control the dry skin, you're gonna make the rashes less frequent and less severe.

So use non-soap cleansers, bathe when you're dirty, bathe every other day in infants, and then moisturize after the bath. To get outta the bath apply moisturizer from head to toe. I'm talking like forehead, scalp, ears, neck, back, arms, legs, everything from head to toe. If you can start there, you're gonna significantly decrease the frequency and severity of the rashes, and you're gonna significantly decrease how often you need the medications.

Dr. Jaclyn Bjelac: This is a really important point, so I wanna pause here a minute and honor my postpartum 2:00 AM self who fell victim to targeted Instagram ads and purchased like $50 moisturizers online. 'cause they said that they would cure my baby's eczema. Dear listeners, they did not cure my baby's eczema and I was out 50 bucks.

Um, what moisturizers do we recommend? You mentioned creams and ointments. What is like an ingredient or something that we should be looking for in these creams and moisturizers? Because, you know, while they're relatively inexpensive, it gets really expensive to trial and error, all these different kinds.

So how do I know what moisturizer to put on my baby's skin?

Dr. Brian Schroer: I have three things to think about. One is to, to stick with companies that generally sell products for eczema as a whole. So there's a lot of companies such as Aveeno, Cetaphil Cereve, Vanna Cream, not to go specifically in alphabetical order that are just well known to have products that are efficacious, they work and generally they avoid including other potential allergens.

So one, you wanna do hypoallergenic skincare products, and two, you want to think about the differences between lotions, creams, and ointments.

Dr. Jaclyn Bjelac: What's the difference?

Dr. Brian Schroer: Yeah, it's a good question. And the biggest difference is how much water is in each of these things. Somebody might say, well, if you have dry skin, don't you want to add water to the skin? And the answer is, you know, water tends to be drying too. If you just put water in the skin, it would evaporate, and it doesn't necessarily keep the water in your skin.

Lotions are the type of moisturizer that has the most amount of water, in general, regulatory definition, around 80% water. So what I tell my patients is, one, they don't moisturize the skin quite as effectively, and you're essentially buying water.

Dr. Jaclyn Bjelac: Which we pay for in a bottle anyway. But to your point, what's better?

Dr. Brian Schroer: So the next step up from lotions is creams. And most of these products, whether they're from the companies I mentioned, or not, we'll say lotion, cream, or ointment.

So the next step up is creams, which are generally around 50% water. That's a nice, happy medium, and that the creams are generally easy to apply from head to toe. They're not necessarily feeling like greasy the way some ointments do. So if you had to pick for the widest range of patients with eczema the creams are generally where I would recommend.

With that being said, in in areas like Northeast Ohio, it get very dry in the winter, then you might need anointment, which is 20% water, but holds moisture into the skin better. Some of the more common ointments like petrolatum is, is no water. So a hundred percent ointment. Things like aquifers are are common available ointments.

If you stick to the companies that we mentioned, if you talk to your doctor, you're going to generally find products made by maybe evil corporations, but still because of that are widely available and they're generally very inexpensive [Okay] to find.

Dr. Jaclyn Bjelac: That's helpful. So.

Dr. Brian Schroer: One more thing actually, I'm sorry.

Dr. Jaclyn Bjelac: Go ahead.

Dr. Brian Schroer: The last thing is, sticking to these companies allows you to, to think about another aspect that patients ask me all the time about, which is what about putting natural stuff on the skin? I usually lead off, with the joke saying, you know, poison Ivy's Organic and non GMO, but I wouldn't necessarily put it on the skin.

There are a lot of creams and ointments out there that have things like lavender oil, tea tree oil, and these are things that are probably, in most cases fine, but in some patients with eczema, people can become allergic to those ingredients. And so that's why I would try to stick with a hypo skincare, creams and ointments, and try to avoid products that have a lot of natural ingredients.

Dr. Jaclyn Bjelac: That's really helpful, and I think it's important to point out that things like lavender and tea tree oil are included in some products because they do have some anti-inflammatory properties. And we have talked about how eczema is an inflammation problem.

So what do you recommend in your clinic? What do we do to treat inflammation that doesn't respond to moisturizers only? How do we help heal the skin?

Dr. Brian Schroer: One of the ways that eczema is referred to is that it's the itch that rashes. So the rash is there, you see it present, but even at 3, 4, 5 months old, you can see that the child, or of course at older ages is scratching the areas of the rash. And the more they scratch it, the more they open up the skin, the more they open up the skin, the more the allergens and irritants can get into the skin and lead to more itching and more rashes.

So you can control the dry skin as much as you want, but what we really need to do is control the itch and to help the skin heal by getting rid of the inflammation that's causing the skin to open up even more than the dry skin doing so already. And then what that means is using medicated topical anti-inflammatories.

There's many different anti-inflammatory medicines available. One of the most common, and because they've been around the longest, and therefore also one of the most effective, but also one of the, the cheapest versions is a topical steroid. People have heard about over the counter hydrocortisone, and that's basically safe for any kid at any age on essentially anywhere of the body.

But then if you need something stronger than the lowest potency, topical anti-inflammatory steroid, there is like hydrocortisone. We have a wide variety of other, more increasingly potent topical steroids, and we always wanna use the, the least potent that works. But also don't want you putting medicine on day after day and not having it actually work.

And by work I mean making the itch better and making the the skin heal and allowing the rash to kind of resolve, if not even completely go away. And then of course be ready to start it up again when the rash comes back.

Dr. Jaclyn Bjelac: And you mentioned we always wanna try and use a lower potency when possible. Are topical steroids safe? So many parents and families and patients ask me about the safety of topical steroids. So would love to hear your perspective on that.

Dr. Brian Schroer: Absolutely. One, they're very efficacious, they work. Two, when we think about any medication, we think about the side effects. Right? So you always want to think about medicines based on the benefit and then weigh it against the risk.

In terms of safety, topical steroids have been shown for over 70 to 80 years to be effective, especially safe when used the way we typically use it in eczema, which is as needed. Mm-hmm. We're gonna use the medicine when you need it, and we're gonna stop it when you don't need it. When used that way, it almost never causes the one side effect that we know that topical steroids have, which is that it may thin the skin.

There are areas of our body that have naturally thin skin, so the face, the armpits, and the bum, but other areas of the skin, you can use basically any topical steroid on because it's pretty thick. And so I have only seen one patient in my now 15 year career in allergy, where I've seen any of the real side effects of topical steroids leading to some of the stria or other permanent manifestations of thin skin, and that was in a patient who overused a very potent steroid in a way that they shouldn't have, but it wasn't their fault. They weren't told not to do that.

But in, in regular use, the topical steroids of any potency are very safe and effective for patients who have eczema.

Dr. Jaclyn Bjelac: That's reassuring to hear because I think when families finally make their way to us, they're frustrated and looking for something that works. So hopefully we can reassure them of the safety and also that it should be helpful for them. What are some other things that we can do from a medication standpoint to try and keep the skin from flaring up so we don't have to use steroids as often?

Dr. Brian Schroer: One of the ways that eczema is referred to is that it's the itch that rashes. So the rash is there, you see it present, but even at 3, 4, 5 months old, you can see that the child, or of course at older ages is scratching the areas of the rash. And the more they scratch it, the more they open up the skin, the more they open up the skin, the more the allergens and irritants can get into the skin and lead to more itching and more rashes.

So you can control the dry skin as much as you want, but what we really need to do is control the itch and to help the skin heal by getting rid of the inflammation that's causing the skin to open up even more than the dry skin doing so already. And then what that means is using medicated topical anti-inflammatories.

There's many different anti-inflammatory medicines available. One of the most common, and because they've been around the longest, and therefore also one of the most effective, but also one of the, the cheapest versions is a topical steroid. People have heard about over the counter hydrocortisone, and that's basically safe for any kid at any age on essentially anywhere of the body.

But then if you need something stronger than the lowest potency, topical anti-inflammatory steroid, there is like hydrocortisone. We have a wide variety of other, more increasingly potent topical steroids, and we always wanna use the, the least potent that works. But also don't want you putting medicine on day after day and not having it actually work.

And by work I mean making the itch better and making the the skin heal and allowing the rash to kind of resolve, if not even completely go away. And then of course be ready to start it up again when the rash comes back.

Dr. Jaclyn Bjelac: And you mentioned we always wanna try and use a lower potency when possible. Are topical steroids safe? So many parents and families and patients ask me about the safety of topical steroids. So would love to hear your perspective on that.

Dr. Brian Schroer: Absolutely. One, they're very efficacious, they work. Two, when we think about any medication, we think about the side effects. Right? So you always want to think about medicines based on the benefit and then weigh it against the risk.

In terms of safety, topical steroids have been shown for over 70 to 80 years to be effective, especially safe when used the way we typically use it in eczema, which is as needed. Mm-hmm. We're gonna use the medicine when you need it, and we're gonna stop it when you don't need it. When used that way, it almost never causes the one side effect that we know that topical steroids have, which is that it may thin the skin.

There are areas of our body that have naturally thin skin, so the face, the armpits, and the bum, but other areas of the skin, you can use basically any topical steroid on because it's pretty thick. And so I have only seen one patient in my now 15 year career in allergy, where I've seen any of the real side effects of topical steroids leading to some of the stria or other permanent manifestations of thin skin, and that was in a patient who overused a very potent steroid in a way that they shouldn't have, but it wasn't their fault. They weren't told not to do that.

But in, in regular use, the topical steroids of any potency are very safe and effective for patients who have eczema.

Dr. Jaclyn Bjelac: That's reassuring to hear because I think when families finally make their way to us, they're frustrated and looking for something that works. So hopefully we can reassure them of the safety and also that it should be helpful for them. What are some other things that we can do from a medication standpoint to try and keep the skin from flaring up so we don't have to use steroids as often?

But those are are two options that can be used if the typical therapies aren't as effective as you would hope.

Dr. Jaclyn Bjelac: That's great to hear that there's other non-medication options that we can use, you know, to treat inflammation and heal the skin. Would love to hear your thoughts on how we can support our patients who are managing eczema and are uncomfortable with the itch.

Maybe they're not sleeping well, maybe especially in our somewhat older patients, feeling self-conscious about the appearance of their skin. What are some of the things that at the Cleveland Clinic that we can offer families?

Dr. Brian Schroer: This is probably one of the most important aspects of it, and you think about to my childhood, thinking about how humid it was in in Florida, where I'm from, and not being able to fall asleep at times because I couldn't stop thinking about the itch or itching.

You know, I remember my mom saying that I would be, she'd be walking through the grocery store and people would walk around the cart and she would tell 'em that I had leprosy in a way that, [oh no] that would, uh, you know, be that would only sarcastic way my family works.

That's crazy, isn't it? Yeah. Just to see people, see a kid with a regular common skin condition who are, to some degree being shunned. That's for a parent of a young child. And then of course, if you're a teenager with this disease, it's hard to be a teenager at any point, especially nowadays. Mm-hmm.

And in that sense, those things are really important when we're seeing patients who have eczema to talk about, you know, ask about, and then of course if we can support them. One, just acknowledging that it is a thing. Two, if you can control the itch, it'll make it a lot less common that they need to worry about those things.

But failing that, and at the same time, we have a lot of good behaviors, uh, therapists who are really helpful for our patients dealing with chronic diseases here at the Cleveland Clinic Children's Hospital in a way that I've used their, their resources and their knowledge and expertise so many times it's, it's very effective and very hopeful. On top of all the skin hygiene measures and medications we can do.

Dr. Jaclyn Bjelac: That's great. A really good holistic approach. And then would love to hear before our time is done, what your favorite eczema skincare tip is.

Dr. Brian Schroer: My favorite skincare tip is, gosh, there's so, there's so many.

 If I had to pick my favorite, it's frankly moisturizing every day. If I had to pick one thing that you can do without all the other things that would make the kids' skin less frequently itchy and rashy, it would be moisturizing every day.

That being said, I'll say one more thing. When we go through our things that we just did for eczema, we talk about bathing daily, soaps, moisturizers, topical steroids. A lot of patients will say stuff like, I did that and didn't work, and I did this other thing and didn't work, and I did this other thing and didn't work. But what they didn't necessarily do, especially in kids with more severe eczemas, do it all at the same time. Yeah. So the other tip is try it all at the same time.

 It's hard to take care of a kid with eczema, especially severe eczema. It's a lot of work, but if you put in the work, you in most cases can significantly decrease how much they're having the rashes.

Dr. Jaclyn Bjelac: Well, thanks for walking us through a typical eczema visit with Dr. [absolutely] Schroer. I really appreciate you. And we acknowledge, and I think from our personal experience, both with you managing your own eczema and then the eczema in our offspring, eczema is a challenge.

And please remember that every step you take in caring for your child's skin does make a difference. And when you understand their triggers, have a consistent skincare routine and work closely with your healthcare providers, you can really improve their comfort.

And if you'd like to schedule an appointment with one of our pediatric allergist immunologists, please call 216.444.KIDS. That's 216.444.5437.

Speaker 3: Thanks for listening to Little Health. We hope you enjoyed this episode. To keep the little health tips coming, subscribe wherever you get your podcasts or visit clevelandclinicchildrens.org/little-health.