Beyond The Rash: Understanding Childhood Eczema With Confidence

Original article here

If you’re navigating childhood eczema, you’ll know just how overwhelming it can feel. From sleepless nights and uncomfortable skin to endless advice around diet and triggers, many parents are left unsure what’s actually helpful — and what’s not.

According to Adele Durge, a Paediatric Allergy Clinical Nurse Specialist at the Allergy Centre of Excellence (ACE), this confusion is incredibly common. With over 25 years of clinical experience — and as a mum to two boys with allergic conditions — Adele has supported countless families through the complexities of eczema and food allergy.

In this expert guide, she cuts through the noise to explain what’s really behind childhood eczema, how it links to allergies, and the practical steps parents can take to manage it with confidence.

The downlow on childhood eczema

As a Paediatric Allergy Nurse Specialist, most children I see in clinic present with a degree of eczema; from babies with severely inflamed, broken skin, from the tops of their heads to the tips of their toes, to older children with mild patches that come and go in the folds of their elbows and knees. As well as treating the uncomfortable, sleepless child, parents also need support. For the proactive parent, the sheer volume of conflicting advice, especially regarding diet, can be overwhelming. Misconceptions and trivialising childhood eczema often get in the way of successful care. I also experienced this as a mum of two babies with eczema and tummy symptoms.

Eczema or Atopic dermatitis (AD) management has moved beyond “putting out fires” to treat flares and toward proactive, evidence-based prevention and care that restores the skin barrier.  For this, we consider what might be causing the eczema, what might be triggering flares, and how we can prevent them.

The great diet debate: Allergy, intolerance, or irritation?

One of the first things parents ask me is whether food is causing their child’s eczema. Understandably, when you’re desperate for answers, diet feels like something you can control. But food and eczema have a complicated relationship. A good place to start is understanding three types of reactions:

Food allergy (IgE-mediated / Immediate): This is an immediate immune response, usually occurring within a couple of hours of contact. Skin symptoms might include sudden redness, itchy hives and swelling.

Delayed allergy: This is more insidious, often causing tummy symptoms and causing an eczema flare one to two days after ingestion.

Skin irritation: Some foods, like tomatoes, strawberries, or citrus fruits, can cause skin redness due to their acidic juices. Thankfully, this is not a food allergy, just irritation.

40% of children with eczema have food allergies

While up to 40% of children with eczema also have food allergies, food is rarely the primary cause of eczema. Instead, the conditions tend to co-occur as part of a wider genetic predisposition.

If food is contributing to eczema, it usually shows up in the first few months of life, with cow’s milk and egg being the most common culprits. Delayed Cow’s Milk Protein Allergy can present with symptoms such as worsening eczema, reflux, diarrhoea, mucus / blood-streaked stools, and poor weight gain. First thoughts may be to cut these foods out of your child’s diet completely; however, unnecessary elimination diets can be dangerous. Restricting foods without professional guidance can lead to nutritional gaps and increase the risk of developing a true allergy.

If you suspect a food is causing contact irritation, a simple trick I often share with parents is to apply a thick layer of greasy emollient around their cheeks and chin 10 minutes before eating, and then use a spoon to feed them directly into their mouth. This acts as a barrier, so the food juices don’t irritate the skin.

Eczema and the risk of developing food allergies, asthma and hay fever

Eczema is often the first step in the “atopic march”. Early-onset, moderate–to–severe eczema in the first year is strongly associated with the development of food allergies. Food proteins and environmental allergens such as house dust mite, pet dander, pollen and mould spores can sneak through the broken skin barrier, causing food sensitisation, asthma and hay fever. One thing I always tell parents is to check their child’s skincare products. “Natural” creams with almond, coconut, shea, or oat can cause sensitisation if the child isn’t already eating those foods regularly. If your child has eczema, I recommend avoiding such food-based creams.

Keeping tight control of eczema to maintain a healthy skin barrier, followed by the early introduction of allergenic foods into the weaning diet, will help reduce the risk of developing these subsequent conditions.

Top tips for allergy prevention in children prone to eczema

• Treat eczema flares early and effectively to restore a healthy barrier
• Don’t use skin products containing food oils, and wash your hands before applying
• Refer to the BSACI ‘Infant feeding and allergy prevention’ booklet for parents.
• Avoid baby-led weaning when eczema is flaring, and limit contact of foods with skin by keeping them clothed at mealtimes
• Only introduce allergens when their skin is in good condition, applying an emollient barrier around the mouth, cheeks and chin and delivering food directly into the mouth on a spoon.

Should you ask for allergy testing?

It’s worth considering if:

• Eczema is moderate to severe and not improving with medicated treatmenT
• Your child has immediate reactions to specific foods

A specialist needs to determine whether the reaction is immediate (IgE-mediated) or delayed. Then, targeted allergy testing may be undertaken, including skin prick testing or a blood test.  I recommend families avoid broad food allergy panels (these tests look for sensitisation to hundreds of foods) sold online or in high-street shops; these often produce false positives, leading to unnecessary, stressful and risky dietary restrictions.

What else could be driving the eczema?

Parents often attend clinic with a long list of foods which they suspect are causing frequent flares of eczema, but it is usually not a food at all. There are many internal triggers for eczema flares, including being too warm, stress, a bad night’s sleep, illness, teething, or any other inflammatory processes in the body. If your child is prone to eczema, this inflammation will express through the skin as well. The list of suspected food triggers is thrown out the window with the realisation that the little one has had back-to-back viral illnesses, driving their eczema.

The Greek origins of the word eczema mean thrown out by heat or to boil over. When children with eczema are overdressed, if their bath water is too warm, or during the heat of summer, their skin cells release the itchy, inflammatory chemicals, triggering a flare. It is important to keep children prone to eczema cool, with only light bedding and tepid baths.

When your child has eczema, it is a good idea to think about environmental triggers as well. Reducing house dust mites, particularly around the bedding, can help.

The microbiome, vitamin D, and the skin barrier

There’s growing evidence to show that a healthy microbiome on the skin and in the gut can reduce the risk of developing allergic conditions, including eczema. Enabling the immune system in the skin of a newborn to develop a natural microbiome and moisture balance, without over-cleansing or using too many products, is important. I recommend using non-toxic, non-bio washing detergents and basic emollients as a soap substitute.  Daily vitamin D is known to support the immune system and is essential in maintaining a healthy skin barrier. Taking vitamin D during pregnancy has been shown to reduce the likelihood of your baby developing atopic dermatitis. Children who are breastfed or take less than 500ml of infant formula a day should also receive vitamin D.

The evidence-based daily routine (that works!)

Treat flares early with medicated ointments

Unfortunately, eczema flares will not resolve with the removal of triggers alone. Only medicated treatments will reduce inflammation, allowing the healthy skin barrier to rebuild and the microbiome to rebalance. Modern topical steroids are extremely safe and can be used with confidence. For effective treatment, your clinician should match the medicine’s strength to the degree of inflammation.

Common mistakes are stopping too soon and not using enough; a fingertip unit is the best way to know you are applying it thickly enough for it to be effective. Undertreating eczema poses a significant risk to a child’s health outcomes and overall well-being, but the side effects of using topical steroids appropriately are very unlikely.

It is important to start topical steroids as soon as the skin starts to flare, rather than waiting for the inflammation to worsen and the skin barrier to break down. When an area starts becoming itchy, red and coarse, reach for the tube of steroid. Zapping it quickly means you won’t need to use the medicine for as long, and damage to the quality of skin can be avoided.

Bathing

During an eczema flare, your child should be bathed daily to reduce any bacterial overgrowth. The water should not be too warm, and an emollient can be used as a soap substitute. Bath oils have been proven to be ineffective and money down the drain! Between flares, families may choose to bathe as frequently as suits them. Recent research has shown that the frequency of bathing does impact the likelihood of flares.

Moisturising

Soaking then sealing with an emollient is a great way to keep the skin moisturised. Parents are often understandably frustrated, having tried numerous lotions, expecting that these will clear the eczema. But emollients are non-medicated, so they will not treat the inflammatory disease. They play another important role in eczema care by creating a barrier on the skin’s surface to prevent moisture loss and irritation, so they should be thought of more as maintenance or prevention. Ideally, parents should aim to apply a thick and frequent layer of emollient several times throughout the day. Ideally, not to apply emollient at the same time as the medicated treatments, so as not to dilute their effect (a gap of 20-30 minutes is great if you have time).

Prevent flares

Proactive therapy for children with frequent flares may include a topical calcineurin inhibitor. These are applied regularly to keep the immune system in the skin calm, reducing the release of the inflammatory chemicals to prevent flares. Some clinicians also recommend “weekend therapy” with topical steroids, applying these on two or three days a week between flares as prophylaxis, which is shown to be safe and effective.

Knowing which tube to reach for, where to apply it, and how long to use it for can be very confusing. I recommend asking your clinician for a written eczema management plan to support your care at home. Eczema shouldn’t control your family; with the right tools and a consistent routine, you can control the eczema.

When to get more help

Reach out to a clinician if:

• The eczema isn’t improving after two weeks of proper treatment
• There are signs of infection (blisters, weeping, crusting, sudden worsening)
• Sleep is significantly affected
• There’s a clear, immediate reaction to a food

Article by Adele Durge, Paediatric Allergy Clinical Nurse Specialist at the Allergy Centre of Excellence (ACE). Adele also supports parents via ACE’s new ‘Allergy Assist’ service.