Nothing will send more shivers down the spine of my husband, an emergency physician with over three decades of experience, than an infant with a rash! “Pediatric Pearls” has visited the integrative approach to common rashes (November 2020) in the past, but the topic of pediatric eczema requires its own space and place. So, why do bumps on a little one’s skin make a grown man cry like a baby?

The very term “eczema,” encompasses many other varieties of dermatidities, promoting confusion from its nomenclature. The historical naming of this disorder is attributed to ancient physicians, said to have given the name to “any fiery pustule on the skin.”¹ The word likely derives from the Greek word, ekzema, meaning “something thrown out by heat,”² which creates a strong visual image of the appearance of an eczematous eruption. The actual term “eczema” refers to a group of inflammatory skin conditions in the same family, including nummular eczema, atopic/contact/dyshidrotic/seborrheic dermatitis, and lichen simplex. The most commonly used term in pediatrics is atopic dermatitis (AD), which is also the most common inflammatory skin condition of childhood. It is defined as an often chronic and relapsing disease, usually beginning in infancy or childhood, and can be the beginning of the ‘atopic march’ (followed by allergic rhinitis and allergic asthma).³

Of concern, the prevalence of AD has risen three-fold over the past few decades, now encompassing 30% of children of all skin types and ethnicities. Notably, one-third of children with AD will experience moderate to severe disease, with children of African American and Latino descent experiencing more severe AD.⁴ One in four adults report adult-onset of initial symptoms, so AD is not age-dependent. Eighty percent of individuals affected with AD experience disease onset prior to six years of age, and many will “outgrow” AD by adolescence or adulthood.⁵

The clinical impact on children, particularly infants from this disorder is the “itch,” followed by dryness and a predisposition to skin infection. A profound sequelae from the relentless itch is sleep disturbance which can occur in approximately 60% of children with AD.⁶ The occurrence of sleep issues is what will create desperate parental measures bombarding the office with calls and emails. The scratching of the lesions by the child creates the thickening and plaques of the skin as well as the potential risk of secondary infection. Although superficial bacterial and fungal infections are common, the prevalence of even more serious systemic infections are higher in adults with AD as compared to those without AD.⁷

If not managed early, children with AD can go on to develop food allergy, allergic rhinitis, and asthma as mentioned above, which can persist for years. There are other additional co-morbid conditions associated with AD, including autoimmune, cardiac, ocular and neuropsychiatric conditions.⁸ Children with AD are more likely to experience ADHD, depression, anxiety, and suicide.⁸ The rash can be particularly upsetting to parents since the skin involvement can be extensive and some children can look reptilian from the scaly lesions.

Another way to approach thinking about AD is analyzing the various endogenous and exogenous factors that can contribute to the pathogenesis. Endogenous factors include immunologic and genetic abnormalities (mutations in genes coding for skin proteins such as filaggrin), foods, and even emotional stressors. Additionally, children with AD may demonstrate reduced ceramide content in the stratum corneum of their skin. This reduction in lipids affects water retention and barrier protection function.⁹

The range of exogenous factors is extensive, including phthalates, cosmetics, dyes, chemicals, detergents, and pathogens. Phthalates may induce changes with increases of inflammatory cytokines secreted by barrier-defective skin cells via the production of a thymic stomal lymphopoietin.¹⁰ These mediators of immune regulators are important considerations in understanding the impact of environmental toxicants on immune function, particularly in vulnerable populations.

There is a misconception that eczema is a benign rash likely due to the fact that it is so common and can be managed with the slathering of various topical steroids. There could be nothing further from the truth. The action of steroids is suppressive and while they may give temporary relief, they rarely fix it by addressing the root cause. When they are discontinued, the skin resumes its job of being the child’s largest organ of detoxification trying to clear whatever insult the child is facing. It becomes a vicious cycle of expression, suppression, and expression of symptoms while the body tries to correct itself. Additionally, steroids can cause subsequent immune suppression as well as local thinning of the skin. There have been innumerable cases of parents dutifully applying steroid creams to the diaper area only to have to deal with raging secondary fungal infections causing further itching, pain, and overall discomfort.

The Case of an Itchy Baby

There are so many patients to discuss with AD, however, one particular baby comes to mind. Six-month-old Camille was born to healthy parents, had a normal vaginal birth, and has a healthy two-year-old sister. She was exclusively breast fed when she presented with AD literally from head to toe. The parents consulted her regular pediatrician who first prescribed a topical steroid. When she didn’t improve, a pediatric dermatologist was consulted, and she was given a topical anti-fungal with the steroid which seemed to further exacerbate her skin. The parents reported that the baby rarely had a decent night’s sleep since she was up scratching most of the night. Baby mittens and using diphenhydramine as a sleep aid offered minimal relief. The parents were exhausted.

However, an interesting event occurred during the evaluation and treatment of Camille. Mom developed COVID-19 during the initial stages of treatment, as well as the rest of the family, experiencing only a brief course of mild respiratory symptoms. The baby never developed symptoms and tested negative. I found this to be interesting and noodled around looking for why this might be. Research at the University of Florida showed that a combination of diphenhydramine paired with lactoferrin (a protein in human milk) impaired CoV-2 virus in monkey and human lung cells.¹¹ While this is preliminary research, this combination could have possibly protected baby Camille!

A Clinical Approach to AD

The bandwidth and the purse of each family must be taken into consideration when creating a treatment plan. I laid out a simple and doable program to tired parents:

• Discover and reduce/eliminate the offending agent(s)
• Soothe the inflamed skin
• Heal any potential contributing factors (intestinal permeability, dysbiosis, etc.)

Reduce/eliminate the offending agents. Food allergens are often the biggest contributing factor in my clinical experience as well as being documented in the literature.¹² For ease, cost and practical considerations, I first try an elimination diet, with cow’s milk, wheat, egg and soy being the most common offenders in infants. A careful environmental health review ensues, with a keen eye on the identification and removal of phthalates, artificial dyes and household chemicals.

Soothe the inflamed skin. While my focus is on treating the gut and resolving possible intestinal permeability and dysbiosis while trying to rebalance the activated TH2 pathway (which is responsible for the avoidable atopic march), an important initial goal is giving the baby and parents much needed relief. The skin is a large absorptive organ, so considerations in using the least toxic, most effective treatments are a priority in children. I use a concoction of homeopathic calendula (which has both anti-inflammatory and antiseptic properties), with added aloe vera gel, vitamin E, shea butter or coconut oil. Colloidal oatmeal in the bath (which contains starches and beta glucans [containing avenanthramides]) can help the itch from its anti-inflammatory and water absorptive functions.¹³

The homeopathic treatment of AD requires some experience, but learnable for integrative practitioners. I recommend buying a copy of The Homeopathic Treatment of Eczema by Robin Logan, which will greatly aid both clinician and patient.¹⁴ I initially prescribed Sulfur, which should be in every parent’s toolbox, known as the best skin remedy. It is also overprescribed and it should be used with care in cases where there is a history of suppression (e.g., from steroids). I used a 30c potency twice a day for a week and then reevaluated. While there was some clinical improvement, I knew we were close and reassessed the situation since there was just a minor clinical change. I opted for Calcarea sulfurica 30c, same prescription, based on the yellow crusts and scales as well as the cracks and desquamation noted on her skin. At the follow up visit, the baby was 80% better. I switched to a 200c once a week for four weeks and then held treatment. At that point, the AD completely cleared. Another miracle for homeopathy!

Heal any potential contributing factors. In this particular baby, I didn’t have to work on the possibility of intestinal permeability and dysbiosis. This may have been secondary to the young age of this baby as well as her having been exclusively breast fed, with Mom eating only organic foods. In an older child, I would have definitely assessed for gut issues, possibly tested using both food antibody and comprehensive stool analyses and treated either with homeopathics, herbal remedies, and nutraceuticals. I did begin the mom on a Lactobacilli/Bifidobacteria probiotic, omega 3s (1000 mg EPA and 600 mg DHA) and flaxseed oil since treating a breast-feeding mom is a great way to treat a sensitive baby. There are many herbal strategies for managing AD, including immune modifiers (e.g., echinacea root), anti-inflammatory herbs (e.g., licorice) and antiseptics such as goldenseal. However, care must be administered in treating infants with potent herbals, and because they respond so well to gentle, but effective homeopathics, this is the cornerstone of my treatment to ditch the itch.

References

1. http://cyclopaedia.org/chambers/chambersnotes.html

2. https://www.etymonline.com/word/eczema

3. Bieber T. Atopic Dermatitis; Ann Dermatol, 2010 May: 22(2): 125-137; 5

4. Silverberg JI, Simpson EL. Associations of childhood eczema severity: a US population-based study. Dermatitis. 2014;25(3):107-114

5. Weidinger S, et al. AD. Atopic dermatitis. Nat Rev Dis Primers. 2018;4(1):1.

6. Chamlin SL, et al. The price of pruritus: sleep disturbance and cosleeping in atopic dermatitis. Arch Pediatr Adolesc Med. 2005;159(8):745-750

7. Narla S, Silverberg JI. Association between atopic dermatitis and serious cutaneous, multiorgan and systemic infections in US adults. Ann Allergy Asthma Immunol. 2018;120(1):66-72 e11

8. https://nationaleczema.org/research/eczema-facts/

9. Imokawa G, et al. Decreased level of ceramics in stratum corneum of atopic dermatitis: An etiologic factor in atopic dry skin? J Invest Dermatol; 1991 Apr;96(4):523-6.

10. Overgaard LE, et al. The association between phthalate exposure and atopic dermatitis with a discussion of phthalate induced secretion of interleukin-1beta and thymic stomal lymphopoietin; Expert Review of Clinical Immunology, 09 Mar 2016, 12(6):609-616.

11. https://m.ufhealth.org/news/2021/two-common-compounds-show-effectiveness-against-covid-19-virus-early-testing

12. Saavedra JM. Atopic Dermatitis and Diet. In: Kohlstadt I. Advancing Medicine with Food and Nutrients. 2nd Ed. Boca Raton: CRC Press; 2013. p. 438

13. Sur R, et al. Avenanthramides, polyphonous from oasis, exhibit anti-inflammatory and anti-itch activity; Arch Dermatol Res. 2008 Nov;300(10):569-74. 7

14. Logan R. The Homeopathic Treatment of Eczema. The Bath Press, Bath, Great Britain, 2001.