Treating Baby & Children Eczema With A Dermatologist – The Eczema Podcast S2E8

Abby:  Hi everyone. Today I have Dr. Lio here. And we are going to talk about baby eczema and all things to do with eczema that includes toddlers and perhaps even children as well. Thank you for being here today Dr. Lio.

Dr. Lio:  Thank you for having me.

Abby:  I am so curious to see how baby eczema works and how to treat it because I know with adults there are so many more things that we can do. But I’m just curious as to how baby eczema works. And I’m just wondering if you can give us the breakdown and the summary of things that you’ve seen in your clinic as well.

Dr. Lio:  It’s really tough because when you look at all patients with atopic dermatitis, the vast majority of them are kids and babies. And that makes our life really tricky. Especially because for example in the US the FDA is now fast tracking a few medicines for atopic derm, but they’re for adults.

We know they’re going to hopefully come down to pediatric level soon, but that might not be for a while. And when we really limit it to the babies we have almost nothing. Because even things like tacrolimus and pimecrolimus are calcineurin inhibitors, the brand names, Protopic and Elidel, they’re not even approved for the babies.

In the US they’re approved only down to age 2 years. In Europe they’re approved down to three months in age apparently. But in the US that’s not the case.

The babies really have everything stacked against them and it’s so unfair because they often suffer the most. And they can’t tell us that they’re suffering, so it really stinks. We can’t tell them that it’s going to be okay.

What do we do for them? It is difficult because all the same principles apply. We have to fix the skin barrier, support it as best we can when it’s broken and try to supplement it so it can heal. We have to make sure there’s no bacteria on the skin, calming that down. We want a calm inflammation and we want to control the itch.

And all of those things are much harder in babies because their skin is really delicate. Everything we put on there they absorb at a much higher rate than more mature skin. And because their surface to volume ratio is so different to an adult. They’re really, really tiny. So they have all this surface area and not much inside space, than adult, much more volume for that surface area.

We don’t worry as much about side effects from things we’ve put on the skin for an adult. But for a baby we worry a lot.

And then to top it all off, to make our life even harder they’re growing, and everything is sensitive and delicate. Brain development, skin development, actual physical growth, all of these things can be damaged if we’re not careful. So it’s the most dangerous time to do anything, and yeah, they need us the most.

What do we do? All the same principles apply. We still really unfortunately need our topical corticosteroids for better or for worse because we know that’s the one way we can cool down the inflammation.

Before that of course we’re doing things like good moisturization, good bathing to see if we can protect them. But for the kids who are more severe we’re going to need almost for sure the top corticosteroids.

Sometimes we’re going to do things like wet wraps which can be incredibly cooling and soothing either or without steroids. We also will do things like some of the cooling creams and ointments to soothe the skin. We don’t really like a lot of the anti-itch creams because many of those affect the nerves and can be absorbed. So we don’t like to use those in the littlest babies. But we can do cooling creams.

The other thing that we’ll often do for them is oils on the skin. And we can do cooling and soothing baths. So lots of simpler approaches but we max out really quickly. For the severe cases we’re really limited.

We really can’t use light therapy in babies. The phototherapy is off the table. We can’t use really any of our systemic medicines like cyclosporine, or azathioprine, or methotrexate because generally the risks are too high in a little one. It becomes limited.

And I’ll tell you, my most difficult patients, the patients I worry about so, so much are my little babies that are maybe 6 months old who are just suffering. Cheeks often bright red, oozing, crusting, weeping, sometimes the scalp was involved, too often have seborrheic dermatitis and eczema. And it’s just terrible.

We’re trying to get them comfortable. We don’t want to cause side effects. The family’s upset. Nobody’s sleeping. And these are the tough cases that really challenge everyone.

Abby:  I know that we have covered in one of our other episodes about different types of baths for eczema. In babies can we do things like oatmeal baths, apple cider baths, bleach baths?

Dr. Lio:  All of the above, yes. And all of these slightly different things… For some of the babies we really like the bleach because, again, it helps with a little bit of the bacterial colonization. There’s some discussion that it might not be as good for the bacteria as we thought. But it seems to help. It definitely has that anti-itch and the anti-inflammatory effect.

Some babies that have this seborrheic dermatitis with the scalp involvement, they may have a little bit of yeast overgrowth too. So for those babies we can sometimes use dilute apple cider vinegar. And that has maybe a little bit more of an anti-yeast effect.

And then we even like things like oils in the tub. Or there are even some tar baths, some coal tar extract that can be used. Often there’s a little skin cancer warning, or cancer warning on those. But we feel that for that we use them, short periods, we’re not going to leave them on the skin. We’re going to wash them right off. The benefit seemed to outweigh the risks so we feel okay about that.

Abby:  That’s good to know. And then as for oils on babies, what are your favorite oils?

Dr. Lio:  Again, my usual is the sunflower seed oil which I really love. I love coconut oil. There are a lot of proprietary mixes too. I will say that there is a newer oil came out. I think [inaudible [00:05:58] markets it, but it was originally an older German product that they brought over. And it has a number of different oils mixed in. And it’s actually really, really nice.

I believe there’s an almond oil extract in there which makes me just a little nervous about nut allergy. But so far it seems to be really, really well tolerated. And the babies do great with it. There’s lots of different ones to use. Even jojoba oil is a wonderful wax. It’s like a natural waxy oil that’s really soothing on the skin.

Abby:  That’s great. The jojoba oil is a bit more expensive, but I know the quality is usually pretty good. And I’m just going to repeat this for people who didn’t listen to our other episode on pregnancy and eczema.

I saw an article where it said that sunflower oil weakens the barrier. But you were mentioning that the study is a big skew because the sample size was really small. And that you still see the effectiveness of sunflower seed oil in your patients as well.

Dr. Lio:  Absolutely.

Abby:  That’s something that my listeners can keep in mind. But Dr. Lio, do you find that babies who have eczema usually outgrow it? Especially the really severe cases like you mentioned.

Dr. Lio:  We think that about somewhere in the order of 50%-80% of children will actually outgrow their eczema in time. It seems to be related to the severity. So the more severity eczema is the less likely they are to outgrow it, and the more mild it is the more likely they are to outgrow it. That makes things a little bit confusing.

But for the most part most of the kids will get at least significantly better. I don’t ever tell the families that everyone’s going to get better. Because I have a group of adult patients who are pretty furious that they were told, “You’re going to grow out of this.” And they’re like, “I’m 40 years old and I haven’t grown out of it.” But I think most people get better over time.

Abby:  That’s really comforting to hear that most of them will outgrow it, especially for parents who are worrying a lot. In terms of treatment are there any other types of treatments that you usually do. For example, anything internal?

Dr. Lio:  There are two things I really like for all my patients to do. And this is a little bit controversial, but I really do like all the babies to be on a probiotic of some sort. I think that there’s probably at least a group of kids who does better when they’re on probiotics, so I think that’s one thing that’s nice.

And there have been a few papers that actually show that some probiotics, particularly the one lactobacillus types, they seem to be able to help leaky gut. And we know there’s this funny leaky gut, leaky skin connection, and when they actually measure the leaky gut, if you add probiotics you can actually show some improvement.

So probiotics I think are helpful, even though I agree there’s controversy and it doesn’t always help. And I think many patients doesn’t do a thing for. But I still think it’s safe and a reasonable thing to try.

The second thing is I like vitamin D. I have most of the babies on extra vitamin D if they’re not already. And again, controversial but some kids seem to do better with it.

Abby:  Someone was actually telling me today that they put vitamin D topically on the wounds and the rashes and it actually helped.

Dr. Lio:  Interesting. That I’ve not heard of. I don’t know much about that but that’s very interesting. That probably we need to look into. I’ll tell you, we use some vitamin D analogs, particularly in psoriasis, so kind of molecules similar to vitamin D. And some of them had been studied in atopic dermatitis.

Mixed picture. Sometimes it seems to help but topical vitamin D in theory can make things worse. So as weird as it sounds, oral seems good, but there’s not enough evidence. And I’d be very curious to know more about that. And that’s neat.

Abby:  They never figured out why some people get worse when they use atopically?

Dr. Lio:  It’s a little confusing. There was a beautiful paper a few years ago and it was talking about… You know that diaper cream? I don’t know if you have it in Canada but it’s called A&D ointment. Do you know those?

Abby:  I’m not sure.

Dr. Lio:  It’s like a diaper paste that has vitamin A and vitamin D. It’s been around for a long time. The paper was called “Why Vitamin A and D Ointment Has the Two Worst Things for Eczema” or something like that.

The idea was that you can show that the vitamin A derivatives can actually be pro-inflammatory. In this setting they can make things worst with inflammation. And the vitamin D topic make things worse. It’s interesting to think about this.

One of my favorite pearls, one of my teachers used to always say, “Some people come in with just hand eczema that looks terrible. Their hands are a mess. And a lot of times we don’t know if it’s eczema or psoriasis. It can actually be confusing.

What we’ll say is we’ll call it hand dermatitis. We don’t know which one it is. And we want to figure out what it is. Maybe we can do a skin biopsy. Sometimes that can help.

Maybe we’ll do something like patch testing to see if there’s an allergen driving it. Or we’ll cross-check the rest of their body.

But one of his favorite tests was to put vitamin D topically on there. And he said if it got better it’s psoriasis. If it flares up it’s eczema. Kind of a neat little pearl. But it was a vitamin D analog. It wasn’t pure vitamin D.

Abby:  What do you think about people who want to take their baby for an allergy test or a blood test? Does that actually help anything?

Dr. Lio:  It’s not a bad idea. And as we’re learning more about the role of food allergies… Historically you’ve heard people talk about this. They say food is driving this. You’re eating something that’s making your skin bad. We’ve got to figure out what you’re eating that’s making your skin bad.

But now, we’re turning everything upside down. It turns out that this is probably largely wrong, literally backwards, that the leaky skin and leaky gut, these two together… Because if we follow our skin around it becomes our gut. It’s all the same epithelium.

That leakiness is allowing allergens, some of which are food allergens to enter in, in an abnormal way. And the immune system is freaking out about those things.

We know in a mouse model, we can sensitive a mouse to a food through their skin. If you irritate the skin and put food on it over and over, then you feed them the food they will have allergy.

The role of the allergist isn’t, in my opinion, to just try to find the food that’s triggering in, which again, in my biased experience is not often the case or rarely the case.

In fact when it is we all do a dance. It’s like if one or two foods are causing your eczema you don’t have eczema. You have an eczematous food allergy. You don’t belong with me. This is not what we’re talking about with our eczema patients. You literally are a different disease.

It would be like someone saying, “My foot pain got better when I pulled out my splinter. What’s wrong with all of you people who have a broken bone?” “This is actually a different thing. This is a broken bone. You had a splinter. It doesn’t make any sense for you to tell people with a broken foot to say try to pull a splinter out. It’s crazy. It doesn’t make any sense.”

Same thing in this situation where it’s really a different disease. But what we want the allergist to do is check to see what you’re allergic for so far. And if you’re not allergic to things we want you to be exposed to those.

The big paper that came out last year called The Leap Study suggested that kids who get early exposure to peanuts may not develop peanut allergy. And this is a huge thing. Because I have a kid who is peanut allergic and I hate it because we’re always on pins and needles. And we learn the hard way. She had a peanut M&M, and bam, face blew up, vomiting instantly, the whole mess. So now we have to be ultra-careful. But if we could prevent that, that would be incredible.

Abby:  I have heard about that same study that you talked about where if you introduce those allergenic foods earlier it actually might help in preventing those allergies in the future, which is interesting.

Dr. Lio:  Isn’t that cool? But we just need to know. Because if you just feed somebody a peanut hoping that they’re not allergic it’s pretty dangerous. Ideally the allergist will help us take us through that. They’ll test to see what you’re allergic for. And they’ll say, “You’re okay to go ahead and do this.” That’s what I liked it for. But not so much for trying to find things that are triggering.

Abby:  If a baby is three or four months old does is it still make sense to see an allergist if they’re not really eating solid foods yet?

Dr. Lio:  I think it could, because usually you’re getting your anticipation for it. But I don’t think every kid of course, but kids with either a strong family history of food allergies, or atopic dermatitis, or kids with moderate or severe atopic dermatitis. I do like those kids.

And if you have a little bit eczema or in your arms or something, or a tiny bit of facial, I think you don’t really have to waste your time and energy, because it is expensive.

Again, personal experience with our daughter, our insurance paid for a portion of it But testing was something like $800. It was like, oh my gosh. I’m obviously in the medical profession, I did not expect that kind of a bill as a left-over.

It’s not a cheap thing. It sort of just reinforced what we knew. We knew the peanuts. We learned the hard way. Being cost effective and being smart about it.

Abby:  That’s good. Are there any other treatments for babies that we haven’t covered yet that might help?

Dr. Lio:  Some people have talked about actually putting breast milk on the skin. I do not think that is crazy.

Abby:  I heard about that.

Dr. Lio:  I don’t think that would hurt. It’s not a cure all. It’s not magic, but I think it can be good. We talked a little bit about moisturizers. And one of the most exciting stories that came out last couple of years, and is still developing. But moisturizing high risk babies, we can potentially prevent eczema.

We just wrote a paper. It just came out in JAMA Pediatrics just this week, where we talked about the economic impact of this, to just take a baby who’s at high risk, we know it cuts the development by about 50% if you just use a moisturizer.

So you could use plain petroleum jelly. It’s like a nickel an application or less. And they cut the development of eczema by about 50%. And so the savings to the system, and the savings emotionally, the quality of life savings, it’s incalculable. It’s gigantic.

Abby:  That’s amazing. My other question is if you’re treating babies, like we have to treat them so carefully. And I was wondering, let’s say when they grow to toddlers or children, how does that work? I guess we have more options for treatment, or do we treat the differently?

Dr. Lio:  I think the foundation of the treatment is really the same at any age. And we really try to use as little medicine as we can. The less, the better. If I can just get by with moisturizers and cooling wraps I’m happy. If we can use light therapy instead of cortisones I’m happy. If we are suffering and we are getting infections, then we need to go on something more, then I think we escalate.

But yes, as they get a bit older now, once we’re three, four, and five, unfortunately I even have kids that age who have to be on cyclosporine for a little bit, this powerful immunosuppression, I hate it. I don’t want them on it but these are kids who are literally going in the hospital time and time again. They’re like a burning patient. Everything’s open, bleeding, infected. They’re not sleeping. The parents are falling apart. They’ve used way too much steroids already.

So it’s like I can’t keep doing this. So we need to break the cycle. And for those patients who will use a more powerful medicine for a brief bit, get the immune system back under control, let the skin deeply heal, let them sleep properly again. Because behaviorally and developmentally this takes an enormous toll on the more severe patients.

But even in the mild to moderate kids they’re scratching, they’re ants in the pants, they’re uncomfortable. And I often say, if you’ve ever had an itchy spot or a poison ivy you can’t concentrate. Your whole day is screwed up. You’re paying attention to that instead of what’s going on.

And so for a three, four, or five year old this is an important time. They’re acquiring language. They’re learning about the world. And if they’re totally preoccupied with this and not sleeping, that’s bad.

Abby:  I completely agree with that. You have some really hard and challenging cases that you see.

Dr. Lio:  Definitely.

Abby:  Is there anything that we can do for the parents who in terms of support, especially with what they’re going through?

Dr. Lio:  Seeking a support group can be wonderful. We have one of the National Eczema Association support groups in Chicago. They’re all over. And doing something like that is wonderful for the whole family. I think you got to reach to other parents and families to get some support.

Things like hypnosis, meditation, acupuncture, any kind of relaxation stuff, yoga, all of those can be really helpful for the whole family.

There was also a really neat paper that showed baby massage helps both the babies and the parents. So parents can do baby massage.

Abby:  That sounds fun.

Dr. Lio:  Yeah. And usually I say do it with one of our natural oils. It’s good to do it with their coconut oil, or you could do it with our sunflower oil. And then you do that and it kind of calms everybody down, and it’s good for everybody. So that’s kind of nice too.

Abby:  That’s really, really great to hear. Thanks Dr. Lio. In terms of the closing, do you have any last words or advice, or maybe anything we left out in terms of treatment that you might want to mention?

Dr. Lio:  The good news is there are some new treatments coming down the line. And even though I think it’s been a bit disappointing so far with what the medical establishment has had to offer. A lot of patients are frustrated.

It’s like the same old thing. You hear that over and over online. “They just gave me the same stupid steroid. They did the same stupid thing.” Honestly, I feel like I do a lot of the same stupid stuff.”

But there is tremendous developments happening right now. So we have a bunch of new medicines in the pipeline for the first time ever. And we’re all giddy with excitement that we finally have new options. Mostly for adults it’s true.

But even for little kids, and then presumably over time we can be able to see what is really safe, what is really effective, can we use some of these in babies who require it. But even better, what if we learn how to prevent it?

I think we’re going to do that hopefully in the next 5 or 10 years. We’re going to have better knowledge on how to prevent and minimize it, which would be better than any of this other stuff.

Abby:  That would be so great. Because even among my friends I’ve never seen so many babies with eczema. It seems like it’s just really rapidly increasing. I don’t know if it’s an epidemic or not, but it just seems like a lot of my friends baby sat it.

Dr. Lio:  It’s pretty intense. We’ve seen just so many kids. The numbers are somewhere in the order of 15%, maybe as high as 20% of children will have some amount of it. That kind of includes everybody. But it’s still a lot of kids who suffer a lot.

Abby:  And that’s hard. But hopefully some of the treatments you mentioned today will be able to help some of the parents out there who are watching, so thank you so much. Do you have a website where people can find out more information about your clinic or where you practice?

Dr. Lio:  Yes. Please check out our website. We’re the Chicago Integrative Eczema Center. It’s Chicagoeczema.com.

Abby:  Thank you so much Dr. Lio.

Dr. Lio:  Have a good night.

Abby:  You too.