Dry Skin

Dry skin is often called eczema or atopic dermatitis. Whatever you call it, it’s itchy and annoying! We see it year round for various reasons. Managing it can be tricky, but there are things to do to help.

Eczema’s Snowball effect

It’s really important to keep skin well hydrated or it tends to snowball. The dry skin is broken skin, which allows water to escape, which further dries it, which leads to more evaporation…. Broken skin is more likely to become secondarily infected, which leads to more problems….

Itching dry skin also contributes to its worsening by further damaging the skin and allowing more water to evaporate, so try to keep fingers from scratching! (I know this is easier said than done.)

Eczema is not simply dry skin. It can cause significant distress to infants and children. The itch from eczema can impair sleep. It can distract from learning at school. Children with eczema have higher rates of anxiety and depression.

Eczema’s a chronic condition

Eczema doesn’t simply go away with good treatment: it can come and go even with the best treatment. It can therefore be a serious problem for families.

Your goal with dry skin is to hydrate it as much as possible to repair the skin barrier. We don’t always think about skin as an organ (like the heart and liver), but it is. Its functions are to help keep us at a normal temperature, to keep stuff (such as bones, blood, and nerves) inside our bodies, and it helps to keep some things (such as germs) out of our bodies. When skin is excessively dry, there is inflammation and cracking. This keeps the skin from doing its job. We must try to get it back to normal so it can help keep the rest of our body healthy.

causes of eczema

Eczema can be from many factors.

  • There is a genetic component, so if a parent or sibling has eczema, it is common for other family members to have it.
  • It is often worsened by environment, both cold dry air and excessive heat.
  • Clothing can irritate some skin, depending on the fabric and the detergent left in the fibers.
  • Any scented lotions or soaps can also irritate skin. (Don’t be fooled that “baby” soaps and lotions are better for baby. I usually say to avoid any of the baby products because they’re often scented. They make them to sell them, not to be better for baby’s skin!)
  • Allergies can exacerbate eczema.
  • Saliva is very harsh on the skin. Drooling can cause problems around the mouth, chin, and chest. Thumb or finger suckers often have red, thick scaly areas on the preferred finger from the drying effects of saliva.

foods and eczema

Ankles, elbows, and knees are common sites for eczema in babies.

The latest AAP eczema guidelines downplay the need to alter foods to treat the skin. There are some kids who have true food allergies that manifest as atopic dermatitis (dry skin), but the large majority of kids do not. Restricting their diet can lead to nutritional deficiencies without any benefit. Talk to you doctor if you think a food might be exacerbating your child’s dry skin.

My tips for treating dry skin:

Avoid Soaps

Avoid exposures to soaps because they further damage skin. Non-soap cleansers that are fragrance free are much more mild on the skin.

Soaks

Soaking in bath water or in the shower can help hydrate the skin. After bathing the skin should be only briefly dried (remove large water droplets, but allow the skin to still be moist with water) and moisturizers (with or without steroids) must be applied immediately afterwards to prevent water from evaporating out of skin.

Moisturize

Creases of the elbows and knees are common areas affected by eczema.

Moisturizers should be hypoallergenic, fragrance free, and dye free.

A good place to review if a product is good is on the National Eczema Association website.

I really like the moisturizers with ceramide. This has been shown to help heal the skin barrier without steroids.

Use moisturizers at least twice per day, more often as needed on the really dry spots.

Petrolatum Jelly

After the moisturizer soaks into the skin, cover extremely dry spots with petrolatum jelly.

There are studies that show putting petrolatum jelly on infants at risk for eczema daily for the first 6 months of life will decrease their risk of developing eczema. This can save you money since petroleum jelly is pennies compared to the cost of good moisturizers.

steroids

Steroids can be used for flares. They are available in 7 different strength categories. The stronger the steroid, the less often it should be used.

Over the counter hydrocortisone is a very mild steroid and can be used twice a day with mild flares.

Stronger (prescription) steroids should be discussed with your doctor if the eczema is more severe, but they can be safe and effective when used appropriately.

Bleach

Yes, bleach. Like what you use in the laundry or in the swimming pool. The bleach is thought to kill superficial bacteria that contribute to the chronic condition.

Bleach baths have been shown to help in moderate to severe eczema. Add 2 ounces of bleach to the bath water and soak the body (not the face) for 20 minutes a few times a week.

Antihistamines

Oral antihistamines, such as zyrtec, allegra, or claritin (or any of their generics) can help control the itch.

I recommend the long acting antihistamines over the short acting ones, especially overnight, to avoid gaps in dosing leading to the itch/scratch cycle despite the fact that diphenhydramine (Benadryl) works a little better for a few hours. Avoid topical antihistamines due to variable absorption from disrupted skin.

Increase the humidity

Add water to the air during the dry months. If your air conditioner is running you shouldn’t need (or want) to add humidity. If your heat is on, you might have an attached humidifier, which is great. You can also buy a room humidifier or vaporizer to add water to the air. When there’s more water in the air, the skin will have less evaporation.

More water

Use wet water cloths on dry patches. This can help get a child through an itchy time with a cool compress. It also helps hydrate the skin.

Since it might remove the moisturizer, re-apply moisturizer when the wet cloth is removed.

Some kids benefit from wet wraps. This is time intensive, but very effective, so worth trying for more severe eczema patches.

Limit scratching

If your child just can’t stop itching, be sure nails are clipped to help avoid scratching.

Sleeping with socks or mittens helps the inadvertent scratching during sleep. Many kids remove these, so sewing an old pair of socks onto the arms of long sleeve PJs can help. (Don’t forget to put moisturizer on first!)

Remove saliva

If your child drools or sucks a finger, wipe the saliva off regularly and protect the skin with petrolatum jelly.

Oils

Putting oil, such as robathol bath oil, in the bath water can help hydrate the skin.

 

prescription medicines

At times prescription medicines are needed.
These can include steroids, immune modulators, and antibiotics.
If your doctor recommends them, don’t be afraid to use them. Many parents under utilize medical treatments out of fear of side effects.
Yes, there are risks to all medicines, but there are also risks to having eczema untreated.
Discuss fears with your doctor to come up with a good plan that you both agree with. Don’t just not use the prescriptions.

get control!

Get control of your child’s eczema. If you can’t seem to do it alone, schedule an appointment with your pediatrician to see what else can be done.

For more information, see the American Academy of Pediatrics clinical report on eczema management and the American Academy of Dermatology’s Guidelines.

Products that I recommend

I only recommend products that I would recommend regardless of where you purchase, but if you use these links I will get a small fee for the referral. They should all be available at local stores too. They are in no particular order.

 

Body focused repetitive disorder treatments

I see several kids each year who pull hair from their scalp, eyelids, or eyelashes. This is called trichotillomania (sometimes shortened to trich). Treatment has historically been cognitive behavioral therapy, but I’ve seen good results with a supplement called n-acetylcysteine.

disclaimer

Because I see families struggle with this and other similar issues, I’m breaking my general rule of blogging within the realm of standard guidelines and am going outside of conventional medical advice to talk about an interesting new treatment that is showing positive benefit with studies. I say this only to caution the reader that you should discuss this with your child’s doctor about it and to remind you not to take this (or anything else I write) as medical advice.

 

Body Focused Repetitive Disorders

hair pulling, nail biting, skin picking, FBRD

Trichotillomania is more common in children who have anxiety, and it can also lead to more anxiety from the social isolation and bullying that result from hair loss. It’s a vicious circle where the self-inflicted hair loss is in itself distressing, but that distress leads to more pulling. Cutting hair short isn’t an effective treatment.

Skin picking and nail biting are similar body focused repetitive behaviors (BFRB).

Do dietary changes help?

There have been conflicting studies that suggest avoiding certain foods can help prevent the urges to pull hair. Some people report that avoiding sugar and caffeine helps. Since added sugar and caffeine are not parts of a healthy diet, I think whether or not it helps, avoiding added sugar and caffeine is a good idea for all kids.

What help is available?

The first treatment recommended for trich (as well as other body focused repetitive behaviors [BFRB]) is therapy. Treating BFRB should involve cognitive behavioral therapy or habit reversal therapy from a trained therapist with experience in this issue. During therapy they will learn to identify emotions, label them, and appropriately address them. In habit reversal therapy they learn to do another action instead of the hair pulling (or nail biting/skin picking). This might mean clenching fists, playing with play doh, or another activity.
Family support can help ease the anxieties that are caused by the behavior itself and it is important that family members praise the positive steps along the journey. There are support groups available in many areas.

Are there supplements that help?

A relatively new development in the treatment of trichotillomania and other BFRBs is a supplement called N-acetylcysteine (NAC), a glutamate modulator. NAC is available over the counter in stores that sell supplements and online for a relatively low cost. How NAC might work is not completely understood and well beyond the scope of this blog, but is reviewed in the Journal of Psychiatry and Neuroscience.

I’ve been recommending NAC for awhile now for trichotillomania (as well as nail biting and OCD) and have had mixed response, but overall positive. For those who did not find it helpful, I suspect they did not use it long enough since it can take over a month to see benefit. I think parents like the fact that it is a supplement, which is easier to provide than behavioral therapy, but therapy is still an important part of the treatment. Those who have the best results do therapy along with the supplement.

How long does it take to see results with NAC?

It takes about a month or two (studies show 4-9 weeks) of NAC to show benefit. Taking a supplement for that length of time without benefit can be difficult and might cause some to quit prematurely, but I’d recommend at least two months before deciding it doesn’t work. Talk with your child’s doctor before starting any supplement and before stopping it.

How much NAC do you give?

Most studies have been done in adults, so the best pediatric dose is not known. For adults and children over about 45 pounds, 600 – 2400 mg has been studied, but no ideal dose is known. It has been suggested about 60mg/kg/day for younger children, but there is no standard dose.

It may also be difficult to give to a child who cannot swallow the capsules. While in theory the capsule could be opened (and the powder is available in bulk), the taste and smell is of rotten eggs, so I cannot imagine a child taking it mixed in food or drink. Tips on teaching kids to swallow pills is covered here.

Talk with your child’s pediatrician before beginning any supplement, even though they are sold over the counter. This helps your child’s doctor know more about what is going on, what works and what doesn’t for your child, and to help monitor for possible reactions if they are known (especially if your child is on prescription medicines).

One dosing strategy for children over 45 pounds is to give a 600 mg capsule twice per day (1200 mg) for a week and increasing to 2 capsules twice per day (2400 mg) after 4 weeks if needed. I have also seen titration methods, beginning with one capsule daily for the first week (600mg), then one capsule twice a day for the 2nd week (1200mg), then 3 capsules divided in 2 unequal doses (1800 mg) for the 3rd week and 4 capsules divided in 2 doses (2 capsules twice per day = 2400 mg) thereafter.

Is NAC safe with other medicines?

NAC might interact with other medicines, so it is recommended to discuss interactions with your doctor and pharmacist.

Since antidepressants are often used in anxiety disorders such as trichotillomania, I have tried to see what interactions might be known. Research has shown that rats need lower doses of imipramine (a tricyclic antidepressant I don’t use in kids) and escitalopram (Lexapro, an SSRI antidepressant) when taking NAC, but NAC doesn’t affect the dose of desipramine (another tricyclic antidepressant) and bupropion (Wellbutrin). In contrast, NAC in the rats actually made fluoxetine (prozac) less effective, so higher doses were needed. Obviously people are not rats, and this is an area that needs to be further studied, but if your child is on any prescription medicines, be sure your doctor and pharmacist know that he is starting NAC.

If anyone knows of human studies or more information, please post in the comments below!

How long will NAC be needed?

It is thought that NAC is safe long term and might be needed long term since the underlying anxiety does not go away, only the symptoms are controlled with the NAC. This is an important reason to do the therapy too, since learning techniques to identify and appropriately deal with stressors can help life long without side effects.

When NAC is stopped, symptoms might return. I will often suggest a trial off NAC once all habits being treated have been gone for at least a month.

Weaning to a lesser dose for a few weeks is one way to test without going completely off, and I find many families feel more comfortable with a wean versus sudden stopping.

If symptoms resume, restart the NAC. (Note: This is my own version of what to do — I have not found guidance in the studies I’ve read. If anyone knows anything more specific, please comment below so we can all learn!) I did see one case report of a person treated for 6 months with NAC and the symptoms did not return for a full month after stopping NAC.

Is NAC safe?

Side effects are rare, but may include gastrointestinal upset, diarrhea, nausea, rash, vomiting and fatigue.

One study of AIDS patients used 8000 mg of NAC per day, showing overall safety at high doses. This is NOT the dose recommended for hair pulling, skin picking, and most psychiatric and neurologic disorders.

Some studies suggest kidney stones are more common at higher doses, but taking high doses of Vitamin C at the same time as each NAC dose can help prevent kidney stones from forming.

A supplement of Vitamin B6 has also been recommended by some because NAC increases the body’s use of Vitamin B6, but most children can get plenty of this vitamin from a healthy diet. Many foods are rich in B6, including fish, beef, poultry, fruits (not citrus fruits), vegetables, and grains. Vitamin B6 is also in most multivitamins, so if you choose to supplement, a standard multivitamin would be considered safe.

Talk with your child’s doctor if you plan on doing mega doses of vitamins, as that can sometimes be harmful.

What else is NAC used for?

When I was a pediatric resident, we used NAC for acetaminophen (Tylenol) overdoses. I hadn’t thought of it for many years, then a few years ago I started to hear of it being used for other things.

Research for using NAC for a variety of psychiatric and neurologic disorders in addition to trichotillomania is promising. There is evidence that NAC works for some symptoms involved with autism, Alzheimer’s disease, cocaine and cannabis (marijuana) addiction, bipolar disorder, depression, nail biting, skin picking, obsessive-compulsive disorder, schizophrenia, drug-induced neuropathy and progressive myoclonic epilepsy.

Disorders such as anxiety, attention deficit hyperactivity disorder and mild traumatic brain injury also have preliminary studies supporting NAC use but require larger confirmatory studies.

Suggested NAC

I do not typically recommend one brand over another, but supplements present a problem due to the lack of regulation. Investigations have shown that there is variability of what is actually in the product from bottle to bottle.

For kids who can swallow pills, I recommend Swanson Vitamins. During the study on BFRB’s done by Jon Grant, MD, JD, MPH, Swanson products were used because they were the only company in the US that would provide a certificate of purity and batch to batch sameness. For this reason I recommend Swanson’s for NAC as well as their other products if you will be taking a supplement.

For kids who can’t swallow pills, there is an effervescent tablet that I’ve heard works well. PharmaNac has 900 mg per tablet, and their website recommends 2-4 tablets per day. Note: Their website mentions a potential issue with some antibiotics and NAC, but those claims have been disputed. It would not be wrong to separate dosing of antibiotic and NAC, but it might not be an issue.

For More Information:

For more information, see Experts Consensus Treatment Guidelines for Trichotillomania and Skin Picking and the many other resources found on The TLC Foundation for Body-Focused Repetitive Behaviors.

KidsHealth has a Trichotillomania page for teens.

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Lip Licker’s Dermatitis

As the leaves fall and the wind blows, I know that I will start seeing kids with smiles bigger than life due to red swollen chapped lips. Parents frequently bring kids in year after year with this “recurrent rash” that comes every dry season and goes away (or at least improves) in the Spring. dry lips, cracked lips

Dry lips are a problem that tends to worsen with the treatment that comes most naturally: licking your lips. Saliva contains enzymes that break down food you eat — or the lips you are licking. It also damages regular skin, so the skin around the lips dries if licked, the skin on the neck and chest are affected in droolers,  and thumbs or fingers can get really chapped if they are sucked this time of year. The same theories discussed below can be used to treat other dry skin worsened by saliva.

What can help?

First, stop licking your lips! I know that’s easier said than done, especially for kids with a strong licking habit. If you catch them licking, offer a lip balm or suggest that they drink some water. Remember to praise them if they make a choice to do anything other than lick!

Licking lips leads to more dryness and irritation.

Adding humidity to the air helps and doesn’t require child participation (since they resist so much of what we do). Even if you have a whole-home humidifier, add a vaporizer or humidifier to the bedrooms each night. Be sure to keep it clean and out of reach of little hands.

Everyone should drink plenty of water throughout the day.

Seal in moisture with a lip balm or ointment. Ingredients such as shea butter, lanolin, petrolatum, sunflower seed oil, squalane, and vitamin E are common. Products with glycerin, hyaluronic acid, or sodium PCA also have been shown to help. The more often they are applied, the better they work, so try to keep them available throughout the day. (This might require talking to teachers to allow it to be freely available at school.) Waxes are good to avoid dry lips, but don’t help as much as a moisturizing product once the lips are already dry. Avoid products with eucalyptus, menthol, or camphor because they can increase dryness and irritation. Since flavored lip products might encourage licking lips, I suggest you avoid them. Use one with sunscreen when outdoors. Keep the balm handy throughout the day and be sure to apply after brushing teeth before bed. To avoid sharing germs, everyone should have his own, and I prefer sticks versus anything you dip your fingers into.  It is okay to apply the balm or ointment to the skin surrounding the lips if needed– for those kids who have a wide area they lick around the lips!

Many parents ask if their kids will become addicted to the lip balm. Simple answer: No. They might use it more frequently as they get used to the idea of using it instead of licking their lips when they feel dry, but that is a good habit, not an addictive behavior. As soon as the weather warms up, we don’t feel our lips being as dry, so we use the balm less often.

Avoid evaporation. Mouth breathing dries the lips, so try to get kids to breathe through their nose. Keep the wind off the lips with a scarf. The wind increases the evaporation of water from the skin, drying it out.