Eczema: triggers and grading

Eczema can range from mild to very severe, and it can be triggered by a wide variety of factors.

This article goes through how we grade it, as well as the most common triggers (and what to do about them).

Check out my prior article if you’re looking for more of an overview of eczema in children.

Evaluating eczema

When it comes to evaluating your child’s eczema, I recommend thinking about it in two steps. 

• How severe is it?

• Are there any common associations or triggers?

Grading severity

In general, we grade eczema according to how it looks, how widespread it is, and how much discomfort it causes. 

Mild: minor patches of dry (and itchy) skin, but not significant enough to impact day-to-day life/comfort or sleep.

Moderate: several patches of dry, scaly reddened skin that is itchy enough to affect day-to-day activities and sleep. Some areas have broken or thickened skin.

Severe: widespread patches of dry, red skin with some pigment changes and areas of thickened/cracked skin as well. Near constant itching and redness, and challenging to control. Has a significant impact on day-to-day activities and sleep.

The Pediatrician Mom tip: severe eczema is considered a risk factor for food allergies (along with having a pre-existing food allergy). For these children, it is important to discuss when and how to introduce the top 9 allergens with your pediatrician and to consider skin testing.

Mild and moderate eczema are not considered risk factors - and indiscriminate testing for this population can actually backfire on you because false positives or equivocal results can lead to restriction of allergenic foods inappropriately (which then can increase the risk for a food allergy). Your doctor can help you with navigating this.

The itch-scratch-inflammation cycle

When a trigger begins the itch-scratch-inflammation cycle, it can be hard to break. This is why knowing your child’s triggers can be helpful.

Common triggers

Children with eczema can react to anything (and to more than one thing), but there are some common triggers that come up again and again. Here is a list, along with what you can do to address each.

• Heat and sweat

  • Stay cool, choose shade.

  • Don’t overdress (especially for babies).

  • Lukewarm baths.

• Dust mites

  • Dust regularly and remove carpets.

  • Wash bedding in hot water weekly.

  • Consider hypoallergenic bedding.

The Pediatrician Mom Tip: stuffed toys are frequently overlooked as sources of dust. Make sure you wash them regularly!

• Soaps and household cleaners

  • Use hypoallergenic, fragrance-free, products without dyes or preservatives.

• Allergens (eg dander)

  • Keep pets out of bedrooms.

  • Discuss allergy medication with your pediatrician.

• Dry skin or scratching (causing trauma to skin)

  • Moisturize 2-3x per day with an ointment.

  • Consider a humidifier.

  • Keep nails short.

• Certain fabrics (eg wool, polyester)

  • Use loose, breathable cotton.

  • Wash new clothes before your child wears them.

What about food allergies as a trigger?

There’s a good deal of confusion around the relationship between food allergies and eczema. They can be related, absolutely. Severe eczema is a known risk factor for the development of subsequent food allergies, and we know that eczema is part of the atopic triad.

But many parents simply start elimination diets without thinking through the implications - remember, we know that early introduction to allergens is often protective when it comes to the development of later IgE-mediated food allergies. There are also nutritional implications to elimination diets, especially in children.

• If you suspect there’s a relationship between a certain food and your child’s eczema flares, start with a food/rash diary.

• Talk to your pediatrician before eliminating foods.

My child has some eczema. Should I just have her tested for allergies, to be safe?

I get why this is very tempting. But most experts recommend against random or “just in case” type testing, and this is not just because testing can be uncomfortable.

For a child with known risk factors (this includes severe eczema or a pre-existing known food allergy), this is the recommendation.

For mild eczema, however, testing is NOT routinely recommended. False positive tests are surprisingly common and can lead to inappropriate anxiety — but they can actually paradoxically lead to increased risk for food allergies.

Imagine this scenario

(I cannot tell you how many times I’ve seen this situation arise):

A parent has some concerns about food allergies in their child (based on “soft” risk factors such as allergies, eczema or asthma in other family members). Their child is potentially at higher risk for a food allergy than the baseline case. So they convince their pediatrician to do a barrage of allergy tests, and one or a few of them come back borderline — peanuts, eggs. Now you’re stuck: the parent will be instructed to avoid that food and eventually the testing will be repeated and/or an oral challenge will be conducted at the allergists office. This could take several months or even a year — and in the meantime, that (slightly higher risk) child is not benefiting from early and consistent introduction of the allergen.

So, bottom line is: random testing is not without consequence. Talk to your doc to determine what the best approach is for your child.

I hope this post gives you a sense of how to approach your child’s eczema in practical ways!