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Helping kids with itchy skin: tips for eczema management and treatment during a pandemic

Five clinical pearls on how to manage and treat atopic dermatitis in school-aged children who may be having a tougher time with pandemic-era hand-washing protocols.

School boards across Canada report that children have been remarkable at navigating the pandemic-era hand-washing and mask-wearing protocols at school, but for children with atopic dermatitis, the COVID-19 precautions could irritate their sensitive skin.

The Eczema Society of Canada publishes guide to help parents, teachers and daycare providers support children with eczema, but the society recognizes that the rules in the 2020-2021 and present school year may be more challenging for young students with itchy skin.

Despite the extra hand-washing, the advice for managing atopic dermatitis in this age group remains the same.

Here are five clinical pearls to manage and treat eczema, or atopic dermatitis, in school-aged children.

1. Recommend using a good moisturizer

The mainstay of eczema management is using a moisturizer to soothe the skin and help it retain water. As for which one to recommend, Dr. Sandy Skotnicki, a dermatologist in Toronto, has a list of a gentle moisturizers listed on her website called The Product Elimination Diet

Dr. Yana Simice, a family physician with a dermatology focus, president of the Primary Care Dermatology Society of Canada and clinical instructor at the University of British Columbia, said that she even includes a link to Dr. Skotnicki’s website when writing consult letters.

“The reason I use that as a tool in my practice literally every day and send patients to it is that it lists, in each category, products that are non-irritating, not-fragranced, very friendly for eczema and also lower probability of allergens,” she said. “That way people can pick their favourite moisturizer of choice.”

Resources from the Children’s Hospital of Eastern Ontario suggest avoiding creams or lotions with urea or alpha hydroxyl acids. The Eczema Society of Canada also has a seal of acceptance on certain products. The society has assessed these products with a formal scientific review.

Children can bring moisturizer to school and apply it after washing their hands. Dr. Simice said that children can also sleep with moisturizer on and, if the child will tolerate it, they can sleep with cotton gloves on over top of the moisturizer. “It is possible to get kids to wear gloves overnight and their hands will get better,” she said.

As for masks, Dr. Rachel Asiniwasis, a dermatologist in Regina, told the Eczema Society of Canada that soft, non-irritating fabrics are best for children with atopic dermatitis. Masks should be washed between uses with detergents friendly to sensitive skin, she said.

Read: Atopic dermatitis patients may be at higher risk of COVID-19 because of comorbidities

2. Counsel how to wash hands carefully

There is some evidence that handwashing done with warm water instead of hot water is more protective for eczema, said Dr. Amanda Ramdyal, a family physician and assistant professor of family medicine at McMaster University in Hamilton, Ont. She suggested that children to dry their hands gently.

Physicians should ask patients what they are using to clean their skin. Some patients may use natural soaps, but “not everything that is natural is good for the skin,” Dr. Simice said. She suggests soaps with lower pH. Soaps and cleaners are included in Dr. Dr. Skotnicki’s website.

Dr. Simice said that children should bring their own soap to school. Soap supplied by schools tends to be basic and strip the skin’s surface of their natural oils that are protective against dermatitis.

Hand sanitizers may irritate or sting the skin of children with atopic dermatitis. “There are hand sanitizers that have lower alcohol bases or have different types of moisturizing elements in them, those are the types I would recommend.” Dr. Ramdyal said. Some schools may allow children to bring in their own hand sanitizers.

Read: Raising eczema awareness with world’s most uncomfortable bed

A photo of light-skinned child's hands with atopic dermatitis

3. Find a treatment that works

Corticosteroids remain the first-line therapy for children with eczema, but there are some parents who don’t want to use them on their children.

“There is a lot of steroid-phobia online that parents will read about and they will worry,” Dr. Simice said. “My message to parents is always that steroids are first-line, we’re very comfortable with them, they’re very safe to use, and yet there will still be parents who will be very uncomfortable.”

Other options exist. Topical calcineurin inhibitors are an option when children don't respond to corticosteroids or when parents are nervous about topical steroids, Dr. Simice said. These are equivalent in strength to a low- to moderate-potency steroid and can be used for chronic, severe eczema. They include pimecrolimus (Elidel), which comes as a cream, and tacrolimus (Protopic), which is an ointment.

“They’re great for tricky areas like the face where certainly you can have more local side effects from the steroid,” Dr. Simice said. 

Some patients report a burning or stinging sensation upon application, which makes them intolerable for some patients. “If patients can tolerate them, they’re great,” she said.

“I like ointments because they tend to work better, so I tend to lean to the tacrolimus one because it is an ointment-based. The pimecrolimus is a cream so it may be more aesthetically desirable on the face,” Dr. Simice said.

While there were initial concerns that topical calcineurin inhibitors may increase the risk of cancer in children, the Canadian Dermatology Association released a statement in 2018 saying that there is no evidence of an increased risk of lymphoma or other cancers in children treated with topical calcineurin inhibitors. The CDA reviewed clinical studies and post-marketing data.

Crisaborole (Eucrisa) is the only topical phosphodiesterase inhibitor approved in Canada. It can be helpful for some cases of eczema as an add-on to topical steroid treatment, Dr. Simice said. Like topical calcineurin inhibitors, some patients complain of a burning sensation when they apply the cream.

Read: Derms report seeing more perioral dermatitis and erythematous rash during pandemic

4. Provide samples

The cost of topical calcineurin inhibitors and the phosphodiesterase inhibitor is the biggest downside of these treatments. Pimecrolimus and tacrolimus both cost approximately $140 per 60 g tube, according to CADTH. The cost of crisaborole is similar at $138 per 60 g tube. All must be applied twice daily. In contrast, generic topical corticosteroids cost between $10 and $15 for a 50 g tube.

Dr. Simice suggests having samples of these medications available so patients can see how they feel on their skin.

“It is good to have some of these on hand in the office so you can see what they’re like,” she said. “For 100 g you’re looking at $200 – imagine if they buy it and it is intolerable.”

5. Recognize eczema along the spectrum of skin colours

Dr. Simice shared a story from early in her practice when she saw a First Nations woman with nummular eczema. Dr. Simice didn’t initially recognize it because she had only seen it previously in people with lighter skin tones.

“As physicians it is important to familiarize ourselves with how skin conditions present on different colours of skin,” she said.

Inflamed skin on darker skin can look more violaceous compared to the reddish hues seen on lighter skin, she said. She tends to search for images of skin conditions using the online tool VisualDx, which has more photos of conditions in skin of colour.

“We’re at risk of undertreating eczema in skin of colour if we’re not comfortable understanding what it could look like,” Dr. Simice said.

Read: Skin across the spectrum: Dermatology education resources turn attention to caring for people with skin of colour

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