10 March 2008
Dear Readers: Sincerely,
Dr. Warren hopes to help all who ask his advice and to enlighten all who read Ask Dr. Warren. For your own well being please keep in mind that advice you read here may not apply exactly to your own situation, and that if you are sick, no information on the web can take the place of a hands on examination by your physican who knows you and cares about you.
My second question: In your opinion do you think that severe eczema could be related to other allergies such as peanut allergy, pollen allergies, or maybe even the preexisting condition of asthma have something to do with it?
One more question, and I do apologize for so many at once: What would be the best treatment for an infant that had a severe form of eczema and dermatitis and had actually peeled their first and second layers of skin away around cheek area and forehead causing the development of wet eczema and possible intro of infection?
Thanks, and I look forward to recieving your responses.
Dear Aspiring Writer: Your first question is by far the most difficult. Eczema is really defined as a certain type of rash (defined by appearance) which can have multiple causes, and so is not all one disease. According to Behrman: Nelson Textbook of Pediatrics, Sixteenth Edition, Copyright © 2000 W. B. Saunders Company,
Eczema is a generic designation for a particular type of reaction pattern in the skin, which includes exudation, lichenification, and pruritus. Acute eczematous lesions are characterized by erythema, weeping, oozing, and the formation of microvesicles within the epidermis. Chronic lesions are generally thickened, dry, and scaly, with coarse skin markings (lichenification) and altered pigmentation. Many types of eczema occur in children; the most common is atopic dermatitis, although seborrheic dermatitis, allergic and irritant contact dermatitis, nummular eczema, and dyshidrosis also are relatively common in childhood. Various dermatoses that have pruritus as a common feature may become eczematized owing to scratching. Atopic skin is sensitive to many factors that increase pruritus, such as soap, wool, cool air, and food allergens.Atopic dermatitis refers to the type of eczema caused by allergies. Even there, research has not clearly demonstrated the mechanism by which allergies cause eczema. If you think about it, just having allergies does not mean a person will develop atopic dermatitis. I'm sure you know plenty of people with hay fever, allergies to medication, allergies to foods, or allergies to animal danders, who do not have eczema.
Once the diagnosis of eczema has been established, it is important to classify the eruption more specifically for proper management.
Behrman: Nelson Textbook of Pediatrics, Sixteenth Edition, Copyright © 2000 W. B. Saunders Company goes on to say,
The hyperreactive skin of atopic dermatitis differs from normal skin in its response to a variety of physical and pharmacologic stimuli. For example, within 1 minute a light mechanical stroke results in a white line with a surrounding blanched area. This phenomenon ("white dermographism") is not seen in normal skin, which becomes red. Involved skin has abnormal rates of cooling and warming in response to temperature changes, particularly in flexural areas. Paradoxical responses occur to injections of various pharmacologic agents, such as histamine, acetylcholine (blanching rather than erythema), and nicotinic acid ester. Adrenergic responses are decreased in lymphocytes and granulocytes in atopic dermatitis, suggesting that autonomic imbalance may be a basis for the abnormalities in the skin. The abnormal reactivity of the skin has a counterpart in the airway hyperreactivity of asthma; in both disorders, such hyperreactivity seems to be intrinsic to the disease, which may, in part, be due to the late-phase immune response. In addition to its genetic and atopic features, eczema is also characterized by cutaneous dysregulation of the autonomic nervous system, a reduced threshold for secondary skin infections ( Staphylococcus aureus, molluscum), skin hyperirritability, and exacerbation by stress.So, in answer to your second question, allergy certainly plays a role in certain types of eczema, and is related to asthma (which may also be triggered by allergy), although either condition may exist in a given patient without the other. The main importance in establishing an allergic cause of the eczema is to see if allergen avoidance, or at least general measures aimed at allergen avoidance, can improve the rash.
Contact dermatitis is an important cause of eczema in young children. According to Behrman: Nelson Textbook of Pediatrics, Sixteenth Edition, Copyright © 2000 W. B. Saunders Company,
This form of eczema can be subdivided into irritant dermatitis, resulting from nonspecific injury to the skin, and allergic contact dermatitis, in which the mechanism is a delayed hypersensitivity reaction. Irritant dermatitis is more frequent in children, particularly during the early years of life.Regardless of the cause of eczema, there are several features of all eczematous rashes which respond to the same treatment principles. Among the most important is to control itching in order to prevent the damage to the skin which occurs from scratching. Since eczema tends to be dry, avoiding drying soaps and liberal use of moisturizers after bathing is very helpful. Since inflammation of the skin contributes to the symptoms an anti-inflammatory steroid cream can be applied to the rash regularly to keep it under control. Steroid creams, ointments, and lotions come in different potencies, the strongest of which should be used only for short periods and should never be used on the face or genitals.
Irritant contact dermatitis can result from prolonged or repetitive contact with various substances that include saliva, citrus juices, bubble bath, detergents, abrasive materials, strong soaps, and proprietary medications. Saliva is probably one of the most common offenders; it may cause dermatitis on the face and in the neck folds of a drooling infant or a retarded child. Older children who habitually lick their lips, frequently without awareness, because of dryness may develop a striking, sharply demarcated perioral rash. Among the exogenous irritants, citrus juices, proprietary medications, and bubble bath preparations are relatively common; bubble bath dermatitis can be a cause of severe pruritus. Excessive accumulation of sweat and moisture as a result of wearing occlusive shoes may also be responsible for irritant dermatitis.
Quoting Behrman: Nelson Textbook of Pediatrics, Sixteenth Edition, Copyright © 2000 W. B. Saunders Company, one more time,
Effective treatment of atopic dermatitis requires control of the environmental precipitants of the itch-scratch-itch cycle that perpetuates the disease, beginning with avoidance of ingestant, injectant, contactant, and atmospheric factors that can trigger itching or scratching. Extremes of temperature and humidity should be avoided. A warm climate of moderate humidity is optimal for most patients. Sweating leads to itching and aggravation of the disease. Exposure to sunlight and salt water is of benefit to many patients.Keeping in mind the above principles, in answer to your third question, Burow's solution soaks to the weepy area followed by application of Aquaphor would probably be helpful to heal the area. Cetaphil cleanser should be used for washing the area instead of soap. A mild steroid such as Westcort or Elocon cream could be used in a short course and then should be switched to hydrocortisone cream (0.5%-1%) for long term management.
Garments should be made of a smooth-textured cotton; wool should be avoided. Infants should not be allowed to crawl on wool carpeting.
For the dry skin of atopic dermatitis, use of soaps and detergents that defat the skin should be avoided as much as possible. Bathing should be kept to a minimum. The purpose of bath oil or other creams applied to the skin is to seal water into the skin; bath oil is added to the tub after the patient has soaked for 20 minutes, thus sealing the moisture in the hydrated skin instead of excluding it as would occur if the oil were added before the patient enters the bath. The same principle applies to application of creams and lotions; they should be applied to the damp skin following a bath. Soaking in tepid water for 30 minutes two or three times each day followed by gentle drying of the skin and application within 3 minutes of an ointment base (Aquaphor) or a cream base (Acid Mantle) to maintain hydration of the skin is often helpful. Should bathing appear to make the condition worse, a nondrying, cleansing agent such as Cetaphil, a commercially available nonlipid lotion, can be used.
If a food aggravates itching, it should be excluded from the diet. Skin testing by the prick method is useful in excluding IgE-mediated food hypersensitivity. Positive skin test results must be assessed by properly controlled food challenges. Arbitrary exclusion of numerous foods from the diets of infants with atopic dermatitis without clear evidence that they are involved in the disease is irrational and can lead to malnutrition. Double-blind food elimination and provocative testing may identify the offending food. Subsequent elimination of the identified food from the diet will decrease symptoms (peanut, soy, egg, milk). Some children "outgrow" these food-induced symptoms, although allergy to peanut may be lifelong. Thus, reintroducing the offending foods may be possible within 2-4 years. Food allergen sensitization can be reduced by breast-feeding and by delaying the introduction of solid foods until after 6 mo of age. Breast-feeding mothers should avoid ingesting high-risk foods because some food allergens appear in human milk and can potentially sensitize an atopic infant.
Avoidance of mite allergens can improve control of atopic dermatitis. Such precautions may be appropriate whether or not specific sensitization to mites is demonstrable. Other aeroallergens also can aggravate atopic dermatitis beyond infancy.
Local therapy is the mainstay of management of atopic dermatitis. During acute flare-ups of the disease, wet dressings (e.g., Burow's solution, 1:20) have an antipruritic and anti-inflammatory effect. Topical corticosteroid lotions or creams may be applied between changes of wet dressings. The continuous application of wet dressings also has the advantage of immobilizing and protecting the affected parts and preventing scratching. Unless scratching can be controlled, it is almost impossible to manage the disease successfully, especially during infancy and early childhood. Fingernails must be kept cut as short as possible; restraints for the elbows to keep the hands from the face are sometimes necessary to control scratching at night. Itching is difficult to control with drugs. Drugs with both sedative and antihistamine activity, such as diphenhydramine (Benadryl), hydroxyzine (Atarax, Vistaril), or promethazine (Phenergan), are of value, but a nonsedating (Claritin) or low sedating (Zyrtec) antihistamine can also be effective without adverse effects on behavior, learning, or quality of sleep. In some patients, aspirin has a marked antipruritic effect.
When infection is present (acute weeping or crusting), antibiotics should be given systemically. Erythromycin or cephalexin is a prudent choice because of frequent resistance to penicillin of the infecting S. aureus. Antibiotics in topical medications not only are of little therapeutic value but also can lead to sensitization to the agents applied, particularly in the case of neomycin. Mupirocin (Bactroban) is an exception and is often helpful for localized infections. The possibility of superimposed contact sensitization must be considered when there is sudden exacerbation of atopic dermatitis to which a topical medicament has been applied. Parabens, mercurial compounds, and lanolin can all cause contact sensitization.
After the acute phase has subsided, topical application of corticosteroid creams and ointments is of great value in managing the disease. Topical triamcinolone acetonide ointment, 0.1%, is often useful but is best limited to 1-3 wk at a time; after improvement, substitute an even less potent corticosteroid if possible. It is safest to prescribe the least potent corticosteroid that affords adequate control. Their cost may be a serious problem. Cost can be reduced by purchasing relatively concentrated preparations in bulk, which the pharmacist can dilute to half strength with Aquaphor or a moisturizer (Eucerin), rather than purchasing equivalent material in 15- or 30-g amounts. Small amounts of steroid rubbed in well at frequent intervals give better results than large amounts applied only infrequently. Percutaneous absorption of corticosteroid occurs but is not generally clinically significant. Long-term topical use of steroids leads to an increase in growth of hair in some patients and to atrophy of the skin. The more potent topical steroids should not be applied to the face, genitals, or intertriginous areas, or to large areas for prolonged periods. Application of 0.5% or 1% hydrocortisone to the face is safe.
I have quoted Nelson's textbook liberally because I am not an expert on eczema, and I couldn't have said it any better. If you need clarification of any of the quoted text, please write back to me. One note of caution. I would advise against using aspirin without being advised to by the pediatrician. Although it is still available over the counter, there is a risk of Reye's Syndrome associated with the use of aspirin.
It has been probably almost 2 years since we started dealing with this "skin disorder" like we call it, and all started looking like a mosquito bite, (my daughter is allergic to insect bites) she gets swollen and fever very easily when she gets bitten by ants or mosquitoes. But it was not, started to crawl up to her knee very slowly, it is not a continuos path but it is well aligned all the way to behind her thigh. It has stopped there but the areas were it is already affected it seems like it heals an all of the sudden it comes back again! Just like it started.
They start looking like a red little rash, then they grow and the get swollen, after a couple of days they turn to a purple-like color, then black then they flatten and it leaves a black mark. The way we are able to just keep it there and not spread to other areas or for this not to keep "walking" we apply a tape called CORDRAN.
Our dermatologist is treating her with it for about 7 months now, we are also applying a cream called RETIN-A during the day. He says the name of it is "Litching Striatus" or something like that. ( you might know better how to write it) but I read a book and there I read that it is supposed to be very itchy.
We visited several dermatologists previous to this one and none of them were able to help us, they did a biopsy at the hospital and it came out to be ok.
The good thing about this is that it does not itch or hurt her, but it is already affecting her because of the cosmetic aspect of it. she is only five years old and kids at school are already asking her and teasing her because her front of the leg is marked with this black trail.
Please help me.
I will deeply appreciate it.
God bless you.
Dear IC: Lichen striatus may itch, but does not have to itch. I have no reason to doubt your dermatologist's diagnosis, nor am I in a position to come up with a better one. If you are not convinced that the diagnosis is correct or that the treatment is appropriate, you should consult a pediatric dermatologist at a university teaching hospital. Sorry I cannot be more helpful, but it is almost impossible to diagnose rashes without seeing them. In addition, I cannot come up with better answers than a specialist who has actually examined the child, especially since he is a specialist and I am not.
If the appearance of the rash is bothersome to you and the child, ask your dermatologist about what cosmetics would be safe to cover the rash.
Dear CC: The best way to protect your infant from catching your sore throat is, as you have been doing, careful hand washing and avoiding face to face contact (kissing). In addition, it would be helpful to wear a disposable surgical mask. These precautions would apply for a strep or viral sore throat.
Fever is a common sign of illness in infants with strep or upper respiratory viruses. Although infants do not have to run fever with these infections, they are more likely to run fever than adults even if they catch the infection from someone who did not have fever. Lethargy, poor feeding, and irritability are also signs of a sore throat; however, if you have been having other problems which cause your infant to act sick and cannot tell the difference, the best advice I can give is to see the pediatrician.
Dear Mrs. K: I am not a psychiatrist and have little personal experience using psychoactive drugs in children. My drug information source lists Endep as a medication for treating depression and provides dosage information for children 9 years and older. Endep certainly has a long list of possible side effects, but so do most other psychoactive drugs. Keep in mind that many patients may not experience any of the side effects listed for a certain medication during their course of treatment. Treatment decisions always involve weighing the benefits of a particular treatment against the risks. The risks of not treating must always be included in that equation. You should ask the psychiatrist treating your son to review the risks of the medication and compare it to alternatives so that you can understand why he has chosen this particular medication. I expect the psychiatrist has had good results with this medication which includes a good response with minimal, or at least acceptable side effects.
Common side effects include dry mouth, drowsiness, dizziness, urinary retention, rapid heart rate, blurred vision, increased appetite, confusion, and disorientation. Serious reactions include seizures, heart attacks, stroke, and decreased production of white cells (needed to fight infection) or platelets (needed for blood clotting).
Dear Jan: You present so many pieces of information, it's hard to know what's important, so lets start by weeding out the irrelevant details. It's clear that each one adds to your concern that you're dealing with a sick baby. The swelling of the infant's circumcision is not likely to be related to any ongoing problems. The delay in urination was probably related to the circumcision, although it could have been due to dehydration if the baby wasn't getting enough fluids, but there is no ongoing problem related to the urinary tract suggested by your story.
Thrush is a common problem in infants and rarely interferes with feeding.
The salient features of the story which suggest either a feeding problem or an intestinal problem are weight loss followed by poor weight gain, spitting or vomiting formula, screaming fits (? colic), and infrequent bowel movements. In addition, there have been episodes of blood in the stool. The blood could have been due to the rectal stimulation (suppository, thermometer); however it could also have been secondary to straining with a hard stool, colitis due to milk intolerance, or some other intestinal pathology. Passage of bloody mucus (not stool with some blood) associated with colicky pains (screaming, drawing legs up) could be something serious like an intussusception [a form of bowel obstruction where the intestine telescopes into itself], requiring urgent intervention.
Which came first, the feeding problem, or the bowel problem? It's not a simple question. If a baby isn't taking adequate feedings his bowel movements will be infrequent; however, if a baby is not passing his stool, it will certainly cause abdominal pains and a decrease in feeding. Does the spitting or vomiting represent an intestinal problem, feeding problem, or formula intolerance? Again, not a simple question. If a baby is feeding poorly, he may not spit up because he has little volume in his stomach. The vomiting associated with formula not seen initially with breast milk could have been due to the fact that the formula filled the baby's stomach whereas the initial nursing did not. If the baby is now gaining weight well, the spitting may not be significant, but if the baby continues to gain poorly, is colicky, and is spitting excessively, he could have a formula intolerance. Most baby's tolerate breast milk well, although it is not impossible for a baby to react to nursing if he is sensitive to something in his mother's diet. If mom's milk supply is now adequate, it would be best to eliminate all formula and watch mom's diet, avoiding all spices and cow's milk. If this cannot be done, instead of soy, try a hypoallergenic formula such as Nutramigen or Alimentum.
Whether or not to further evaluate the baby depends on what is happening now. If the baby is still gaining poorly, further evaluation plus a feeding change is warranted. If the bowel movements continue to have blood or remain infrequent or require stimulation additional evaluation is needed. In addition, the baby's overall development needs to be considered. A 4 month old should be looking at things, reaching for things, smiling, verbalizing (not words, just noises other than crying). If the baby is not developing properly, there may be a primary problem related to the nervous system rather than the intestinal tract.
Thanks in advance.
Dear Ms. G: If your son has frequent or persistent leg pains interfering with activity he should be evaluated by his pediatrician or an orthopedist. Pain can be a sign that something is wrong, and if my impression of the frequency of your son's pain is correct (I get the impression this is more than an occasional problem) you need to be sure there isn't anything wrong before you allow him to continue all these activities, perhaps risking further injury.
General measures which may help would be to cut down on activity or eliminate it entirely for a few weeks to allow healing of any injured tissue, elevation and icing of the painful extremity after activity, and taking a medication like ibuprofen for its anti-inflammatory effect as well as pain relief.
Dear K: Uric acid crystals can occur in the urine at any age. They are more likely to occur when the concentration of uric acid is higher in the urine, such as when the urine is more concentrated as might occur if a person is dehydrated. Therefore, this occurrence could be directly related to your son's fluid losses from diarrhea, especially if his fluid intake has decreased.
Uric acid crystals look salmon pink when they deposit on the diaper. When scraped from the diaper the crystals are powdery. I cannot say that I have ever seen urine visibly discolored by uric acid crystals, so if you are seeing discolored urine rather than a pink powdery stain in the diaper, you would want to be sure it was not blood. If your pediatrician did a urinalysis, he would have checked for blood.
Any particulate matter in the urine (crystals, cells, or bacteria) would make the urine appear cloudy.
Also, even when I feed her lately, she will not finish her bottle most of the time. She will start "playing" with the nipple about halfway through and I have to be very persistent to get her to finish or even get close. She was taking 6 oz. for a while and now she only takes about 5 oz. (and does not seem hungry afterward but wants bottle after 4 hours instead of after 5 hours like she was going before) but starts giving me trouble after 3 1/2 to 4 oz. She is gaining great, 75th percentile there, but I would like her to finish her bottle so she will go longer between feedings. Any advice? I did switch from a slow to a medium flow and different shaped nipple but that does not seem to matter.
My final question concerns her sleeping. She is thankfully sleeping through the night now most of the time. However, lately she will be having restless sleep (making a lot of noise like she is awake although her eyes are closed) around 3:00 am and then again around 4:00 or so and it always wakes me up. Sometimes she will go back to sleep peacefully or sometimes I will give her a pacifier. Is this normal? Would starting some cereal at night help her sleep better?
Thank you in advance for your advice.
Dear CC: At 4 months most babies will take a feeding from anyone who feeds them; however, even though most have not developed stranger anxiety or separation anxiety, they certainly have learned the comfort of familiar routines, and the smell and feel of familiar people. Your baby may indeed have a preference for being fed by you, but that does not mean she cannot be fed by anyone else. In fact, when you are not present, it may be easier for someone else to feed her, but even if she does not take well to feedings by others, she should have the experience now. Strong bonds between mom and baby are essential for the baby's well being, but for both their sakes, mom and baby should have periodic breaks from each other.
GE reflux could play a role in the problem. If dad holds the baby differently than you do, it is possible that the baby has more reflux with him feeding. Perhaps he doesn't burp the baby at the proper intervals. In seeking a solution, be careful not to undermine his confidence in his ability to feed the baby. Indeed, his lack of comfort or tension associated with feeding the baby may come across to the baby. It may be that they both simply need more experience with each other to become comfortable.
In addition, consider that there may be a coincidence of timing. You say the most recent episodes occurred "the past few nights in a row and only when he has been feeding her." No matter what caused your baby's irritability, it may be more related to the time of day than who was feeding her.
The change in your baby's feeding problem could be related to reflux, but could also be the normal course of events for her age. By 4 months of age the baby's growth rate starts slowing down. Some babies who have been previously large (75th percentile is the upper edge of average) since birth may even fall into a lower niche based on their true genetic potential. This may all result in a baby eating less. If your baby's growth remains satisfactory, you should not be concerned about the decreased feeding. You have actually gotten used to an unusual feeding problem which you should, perhaps, realistically not expect to continue. Few baby's feed every 5 hours. Every 4 hours is quite reasonable. In addition, larger volume feeds in the stomach may lead to more reflux, so that your baby may be happier with the smaller, more frequent feedings.
There are a number of things which could be disturbing your infant's sleep. Since she is not waking for feedings, I have no reason to think hunger is one of them. At 4 months she could be starting to teethe. She might be dreaming. Infant sleep patterns change after the newborn period. Since your daughter is sleeping through most of these events, her stirring does not necessarily mean her sleep is disturbed. If she is sleeping in your room, perhaps it is time to move her so you don't hear every noise she makes. She could possibly have problems with reflux disturbing her sleep, in which case, decreasing the volume of her last feed and giving her cereal along with it may indeed help.