Episode Transcript
Hi and Welcome to Clerkship Ready: Pediatrics–a podcast aimed at helping you excel during your clinical clerkship in Pediatrics.
I’m Dr. Carly Pierson, and I am a Pediatrics Resident at the University of Virginia.
Today, we will be reviewing what you need to know before seeing your first patient with eczema. Eczema is such a common concern for pediatric patients, so this is a very important topic, and I hope you won’t find the subject too… dry.
SCRIPT:
Okay, but seriously, let’s talk about eczema! Eczema is a morphologic description for skin lesions characterized by itchy, scaly papules or plaques that are frequently inflamed. For reference, papules are elevated, palpable skin lesions less than 1 cm in size, whereas plaques are elevated skin lesions greater than 1 cm in size. So when you run your fingers over the skin, you will feel the bumps or the elevated plaques.
The term “eczema” can often be applied to multiple diseases, like atopic, irritant, or contact dermatitis. Irritant dermatitis occurs after external irritants (like soap or bleach) come into contact with the skin, and contact dermatitis occurs after external allergens (like nickel) come into contact with the skin. Atopic dermatitis, however, is what the rest of this episode will be about. We usually use the terms “eczema” and “atopic dermatitis” interchangeably, although the former is technically a description of how the skin looks, and the latter is a pathologic skin condition. Nevertheless, for the rest of this episode (unless otherwise specified), I’ll refer to the condition as eczema, as we often do colloquially.
Eczema is a common and chronic inflammatory skin condition characterized by itchiness and dryness. In fact, it affects about a quarter of the pediatric population. I see it nearly every day in my resident clinic, and it is definitely something you will see during your pediatric clerkship.
Pathogenesis:
Before we get to discussing the treatment of eczema, it is integral to understand its pathogenesis and to know how to identify it on exam. The pathogenesis of eczema is complex and multifactorial; it involves genetic predisposition, skin barrier pathology, environmental triggers, and immune dysfunction. Recently, the latest advancements in research have recognized the Th2 immune response in the development of eczema, which includes cytokines IL-4 and IL-13. Additionally, an upregulation of Th1 cytokines such as interferon gamma has been identified in chronic lesions of eczema.
Many studies have been conducted comparing both histological differences within skin layers and genetic differences among patients with and without eczema. Recent research has identified differences in both ceramide levels and potentially the amount of transepidermal water loss among Black patients compared to white and Asian patients, which may contribute to the development of eczema in this population.
Moreover, filaggrin has also been identified as contributing to the development of eczema. Filaggrin is a protein in the skin that binds keratin fibers, creating tight bundles, which strengthen skin cells and improve skin hydration. Dysfunctional filaggrin could impact the skin barrier’s ability to block entry of environmental antigens. Therefore, loss-of-function mutations in the gene that encodes filaggrin have been identified in those with eczema and other atopic disorders.
Lastly, the disparity among racial groups in developing eczema may be explained both by differences in the skin barrier, as previously mentioned, or they might be more accurately attributed to differences among social drivers of health, like decreased medical literacy, barriers to accessing healthcare, or inability to obtain treatment options–all which would lead to poorer outcomes while trying to treat eczema.
Who gets it:
So who gets eczema?
In the majority of children, eczema starts before 1 year of age. Many outgrow the disease, but the specific predictors of prognosis are not yet understood. A prospective study performed by the PASTURE study group in 2017 (doi:10.1001/jamapediatrics.2017.0556) indicated that approximately 60% of children who developed eczema by 2 years of age had resolution of their symptoms by 4 years of age, but those who have mutations in the filaggrin gene are more likely to have persistent disease. I’ll put the reference to this paper in the Show Notes, in case you want to look at it.
Additionally, as alluded to previously, compared with white children, eczema severity is increased in both Black and Hispanic children. Also, both of these groups are more likely to miss school and to receive medical care (in the primary care and emergency settings) because of eczema.
And lastly, children of parents with a history of atopic disease also have an increased risk of developing eczema. Remember: atopic diseases include things like eczema, asthma, and allergic rhinitis. There’s even a phenomenon known as “The Atopic March,” which is a common progression where eczema in infancy can precede the development of asthma or rhinitis later in life.
Clinical Presentation / Diagnosis:
Now that we know a little bit more about what might cause eczema and who might get it, let’s talk about how to identify it on exam.
Whereas any random skin lesion may be described as “a rash that itches,” eczema is often described as “the itch that rashes.” This is to say it starts as itchy skin, which is so bothersome to patients that it leads to scratching, triggering an itch-scratch cycle and resulting in a rash.
Eczematous skin lesions are often erythematous (reddened) or skin-colored dry patches or raised plaques, sometimes with associated papules. A very good indicator of where a child experiences his or her worst symptoms could also be marks of excoriation, indicating pruritus - or itchiness. Excoriations are caused by severe scratching, which leads to removal of the skin’s surface. Signs of more chronic involvement include well-circumscribed lesions, often with lichenification (in other words, a leathery thickening of the skin) due to epidermal hypertrophy. This occurs as a compensatory mechanism to provide protection against scratching.
Eczema in people of color may look a bit different than on lighter-skinned individuals. In these cases, the erythema might be less visible, and instead you would see skin-colored or brown papules, patches, or plaques. Occasionally these lesions can be violaceous, or purple-ish, as well. Sometimes, and this goes for lighter-skinned individuals too, it is easier to feel the rash than actually visualize any epidermal changes. Thus, I’d always recommend palpating patients’ skin, especially in the high-risk areas, which we’ll discuss now.
With infantile eczema, A.K.A. eczema that occurs in those less than 1 year of age, you will primarily see it on the face (cheeks), scalp or neck, trunk, and extensor surfaces of the extremities. Atopic dermatitis usually spares the diaper area; this is due to a diaper’s occlusive nature and the increased moisture in this region.
In older children (i.e. greater than 1 year of age), eczema is typically found on flexural surfaces, like ankles, anterior wrists and elbows, and posterior knees. If eczema persists into adolescence, it’s often seen on the hands and feet, as well.
There are other skin conditions that you have to think about in your differential diagnosis for eczema or atopic dermatitis. One is a tinea infection, or ring worm. Both nummular eczema and tinea may present as coin-shaped (discoid) lesions. (Reminder that “nummular” means “coin-shaped.”) However, ringworm is usually scaly with central clearing and an active erythematous border, which is a way to differentiate it from eczema. Another condition that should be in your differential is psoriasis, which shows up as well-demarcated erythematous plaques with silvery-white scales. The appearance of psoriasis varies by skin type—salmon pink in lighter skin, violaceous or bluish in darker skin. Unlike eczema, in older children, psoriasis favors extensor rather than flexor surfaces.
A parent may actually report that their child is experiencing restless sleep and an astute clinician should always consider eczema on the differential diagnosis. In this situation, it is important to rule out eczema as a cause, as approximately two-thirds of pediatric patients with eczema experience sleep disturbances. Young children in particular do not localize to areas of itchiness well and may instead appear to rub their heads back and forth during sleep or be really fussy overnight, and parents may not realize this is because of itchiness. Thus, it’s important to do a thorough skin exam in children presenting with this chief complaint.
A metric that I’ve used before when counseling patients with eczema is called the Patient-Oriented Eczema Measure (POEM). It is a 7-item questionnaire used to assess atopic dermatitis severity based on patient experience over the past week. It rates symptoms—itching, sleep, bleeding, cracking, dryness, peeling, and weeping—on a 0-28 scale–and is especially useful when monitoring clinical response to treatment, which we’ll get into next. I’ll put a link to the POEM questionnaire in the Show Notes.
Treatment:
Despite how common it is, treating pediatric eczema is often frustrating for both patients and physicians. This is partly because there are many conflicting treatment options, which leads to significant variability in practices. Additionally, parents may worry about medication side effects, misunderstand the chronicity of the disease, or lack the time and resources for adequate skin care.
In 2025, the American Academy of Pediatrics published an updated standardized guideline for treating eczema, and I’ll discuss some of the highlights published in that clinical report during the rest of this episode (10.1542/peds.2025-071812). I’ll also put the link to it in the Show Notes.
Ultimately, eczema treatment should focus on the triad of (1) skin care maintenance to repair the skin’s barrier defect and decrease the frequency of eczema flares, (2) topical anti-inflammatory medications to help with active flares, and (3) avoidance of triggers. Let’s talk about each.
Skin care maintenance means moisturizers. Evidence does not currently support one brand of moisturizer over another, but it is agreed upon that they should be fragrance-free. Other recommendations include using fragrance-free and clear laundry detergents and avoiding fabric softeners, dryer sheets, and all other scented products that may come into contact with the skin. Unscented bar soap is generally the safest option to use while bathing and can be applied to visibly dirty spots, the groin, and armpits; otherwise, using only water during baths or showers is recommended.
It is advised that patients use emollients liberally–a minimum of twice a day, but they can be applied as often as needed. Typical options I recommend for emollients include Aquaphor, Eucerin, petroleum jelly like Vaseline, or Cerave. It is important to note that very infrequently, patients’ skin can be sensitive to an ingredient in Aquaphor or Eucerin called lanolin - which is wool-based, so this is something to watch out for when counseling patients. These emollients can be applied to the whole skin, including on top of active flares where topical steroid medication was placed, just at a different time during the day. This staggering of application is done so as to not dilute the topical steroid.
Short daily baths with warm (not hot) water should be followed by moisturizer application immediately after the bath while skin is still somewhat damp. Bathing multiple times a day may actually irritate the skin, and it is not recommended. There is no concrete evidence in favor of bleach baths to decontaminate the skin, but they may theoretically reduce Staphylococcus aureus infection. However, various studies have shown that a much larger concentration of bleach than what is safe needs to be used in order to achieve that. Wet wraps, which include the wetting of cotton pajamas and wearing them for a short time after applying topical steroids, may also be beneficial because the occlusion and moisture of the wrap enhances penetration of the steroid. If the parents are worried that their child will get cold with the wet wraps, you can put a layer of dry pajamas on top of the wet pajamas, and that will help.
Topical steroids are the mainstay treatment for eczema, because their broad anti-inflammatory mechanisms address the underlying immune dysregulation that drives eczema, as we discussed at the beginning of the episode. There are many options for topical steroids, but the main thing to reassure families is that they are resoundingly safe to use in children. For smaller flares on sensitive areas like the face, a low dose hydrocortisone cream applied twice a day is usually enough. This can be used indefinitely. Other regions of the body from the neck down, like arms, legs, and torso, might benefit from a stronger steroid cream, something like triamcinolone or mometasone. These steroids may be used twice a day during flares for about 5 to 7 days at a time. This should be followed by a 2-day break, where patients should not apply the steroid. If the flare-up persists despite this treatment course, patients may repeat this regimen. While some attendings feel comfortable doing this long term, others don't. So check with your resident or attending to see what they prefer. Also, if those more heavy-duty steroids are being used for more than 2 weeks out of the month, then we usually recommend patients return to see us for a change in their treatment regimen. Once the eczema rash has healed, you may return to applying something less potent, like a low-dose hydrocortisone on hot spots once a day, as a preventative measure.
One treatment regimen option that we use when an eczema flare is not well-controlled or is spread too diffusely throughout the body is called the 5-10-15 Plan. This is a month-long, structured tapering steroid regimen, in which a strong steroid is first applied to the entire body for 5 days (like clobetasol 0.05% ointment), a less potent steroid is applied for 10 days (like mometasone 0.1%), and finally, the least potent steroid is applied for 15 days (like triamcinolone 0.1%). It is recommended that steroids are applied after bathing and patting dry, while the skin is still moist. The response to this plan gives us an idea of how severe the atopic dermatitis is and whether systemic therapy should be considered. If a patient’s eczema is refractory to this plan, that’s when we need to discuss things like phototherapy or medications like biologics. I won’t go into further detail here about these treatments because at that point, you would usually refer to a specialist, like Dermatology or Allergy & Immunology.
And now, for the last component of eczema treatment: trigger avoidance. As I’ve already mentioned, many scented skin products are eczema triggers. Other proven triggers include dry air, skin irritants (i.e., harsh soaps or detergents), perfumes, and contact allergens. While children with eczema are at risk for food allergies, the foods generally do not drive the eczema (with rare exceptions). Typically it is the eczema which leads to the development of food allergies due to inappropriate immune system exposure via the skin instead of GI tract. Thus, we do NOT recommend elimination of foods that may be suspected eczema triggers from patient diets, as this could lead to the development of a true food allergy later on.
Other tips to counsel parents on include keeping their child’s nails short to avoid scratching, washing new clothes before wearing them to avoid contact with any chemicals, removing itchy tags from clothing, and avoiding second-hand smoke.
Lastly, per the 2025 treatment guidelines, the use of a written eczema treatment action plan offered to patients and their families increases understanding of atopic dermatitis treatment and has been proven to positively impact patient outcomes.
Side-effects of steroids:
Let’s talk briefly about steroid side effects. Again, many parents are worried about applying steroids to their child’s skin, so counseling them on this apprehension is very important. I tell parents we do not have to worry about systemic side-effects here, like we do with oral steroids, and that the main risk factor with long-term topical steroid use is skin atrophy. And even then, atrophy is very rare, and it usually only occurs with higher potency use, older patient age (i.e. 60 years old and up), and continuous use without breaks for multiple weeks. Steroid withdrawal might also be a concern, but this only occurs when high potency steroids are used on thinner skin, like the face. Thus, if parents follow the instructions outlined in this episode, topical steroids are extremely safe to use.
Complications:
Another way I stress to parents about how important it is that we treat eczema is by discussing potential complications. The main complication I discuss with them is secondary infections, which can occur in untreated eczema with skin breakdown, leading to increased vulnerability to infection. These infections include tinea like we talked about, but also impetigo or staphylococcal infections. Another complication is called eczema herpeticum, an acute skin infection that is most commonly caused by HSV-1 and HSV-2. These patients are often very sick and may have to be admitted to the hospital for IV antivirals and antibiotics, so we definitely don’t want patients’ eczema to get to this point!
Summary:
Okay, so let’s summarize what we learned today! Eczema is extremely common, but its pathogenesis is complex and multifactorial. It may manifest differently on darker skin, so make sure you know how to identify it in patients of all skin types and use your hands to feel the skin instead of just using your eyes.. And finally, there are many options for treating eczema, but the main factors we focus on are maintaining moisture with emollients, decreasing inflammation with the application of topical steroids, and mitigating the chance of flares by avoiding triggers.
OUTRO:
Thanks for listening to Clerkship Ready: Pediatrics. I hope you found today’s podcast helpful and that you will now feel more comfortable recognizing and treating pediatric patients with eczema. Don’t forget to subscribe below and rate the podcast!
