Question 1

Just recently there seems to be a growing Twitter conversation taking place about the use of “Bleach baths”. This sounds on the face of it to be quite a dangerous practice to be undertaking without proper supervision. Please can you advise me of the bleach that is being used and what the dosage of bleach/per bath full of water is? As eczema can cause weeping of the skin, what is the advice about how/when this procedure should be used and how often? What level of eczema suffering can/cannot use this procedure?

Answer

The background for this debate is the result of publicity surrounding a study from the states. In the study, researchers randomly assigned patients who had infection with Staphylococcus aureus to either a bath with sodium hypochlorite added or normal water baths. They also prescribed a topical antibiotic ointment or dummy ointment for them to put into their nose - a key site for growth of the bacteria. Both groups also received 2 weeks of antibiotics before the baths and nasal ointments. It showed that children who had the sodium hypochlorite baths improved more than those that didn’t. It is difficult to base changing practice on one single study and the authors also acknowledge that larger and further studies should be undertaken to assess the efficacy and long term safety of bleach baths. What we do know is that Staphylococcus aureus is an important trigger for flares of atopic eczema. There are high levels of Staphylococcus aureus on the skin of children with atopic eczema. If there are high levels of the bacteria on the skin and the eczema gets worse despite treatments we would say that the eczema is infected and would treat with antibiotics and topical steroids. That’s why it is important to actively treat the eczema with emollients to prevent the dryness and reduce the inflammation with active treatments such as topical steroids. We do sometimes use emollients and bath products with antiseptics to try and reduce the bacteria on the skin of eczema patients. Although a recent Cochrane systematic review did not find any evidence to support the additional benefit from anti-staph interventions.

As this study has hit the headlines it is important to say that managing eczema requires a comprehensive package of care and if the child’s eczema is severe and not responding they should be referred to a specialist team as per NICE 2007 guidelines.

I would NOT encourage parents or patients to start adding bleach to baths as they could do more harm than good. Getting the concentration wrong could result in you burning your child. In this country health care professionals have guidelines on how best to manage conditions such as eczema using the best scientific evidence. So please if you have any concerns regarding your child’s eczema ask for help. We do know that many parents get frustrated and exhausted with their eczema journeys but please ask for help don’t go it alone.

Question 2

What is the best treatment for eczema around the eyes?

Answer

Eczema around the eyes does provide us with more of a challenge. For patients and children as it is a very visible area can cause a great deal of distress for children. They may be conscious of their appearance and may get called names as a result. Eczema around the eyes can be made worse for several reasons. The face and eyes especially are more sensitive to environmental factors such as temperature change with the weather and seasonal changes. Children who have hay fever and pollen allergies often find their eyes get worse during the hay fever season. If the skin is dry the pollen particles get trapped on the eyelids and can penetrate the skin to cause a flare of eczema. Also other airborne allergens such as animal dander, HDM and fragrances can also cause problems. It is important therefore to keep applying emollients to protect the skin after it has been washed and if the child is exposed to air borne allergens it is a good idea to wash their face when they come in from outside and then reapply the emollients. If the eczema does not improve on the face and neck I would arrange patch testing to see if there is any specific allergy to things coming into contact or touching the skin. This test involves us applying patches to the child’s back which are left in place for two days, removed after two days and the dermatologist looking to see if there are any positive results after a further two days. Parents are often anxious about using topical steroids to the face and especially the eyes. We will only use mild to moderate potency steroids on the face and eyes for a few days at a time. If these measures don’t help there are other treatment which are know as topical calcineurin inhibitors : tacrolimus (Protopic®) or pimecrolimus (Elidel ®) which we do use and are usually started by specialists. The concerns with using steroids especially around the eyes are skin thinning, increased pressure in the eyes (glaucoma) and cataracts. These are extremely rare if treatments are used correctly. I have never seen any problem with glaucoma or cataracts in the >15 years I have been using these treatments.

Question 3

What type of sun blocks should eczema sufferers use? Are there any that should be avoided at all costs?

Answer

Finding a suitable sunscreen or sun block is very much trial and error. What suits one person may not suit another? Ideally find one that suits the whole family as they are not available on prescription for children with eczema. For good sun protection use a sunscreen of at least SPF 15 (SPF 25 or more is recommend for children). Check the label protects against UVA and UVB radiation. The sun protection should be applied regularly during the day, especially after swimming. If using other topical treatments such as emollients and topical steroids let them sink in completely before you apply the sun protection (approx 30mins). If the sun blocks sting, it could be because the eczema is under treated, so it is important to make sure that the eczema is well treated before going on hols.

Question 4

Each spring Josh’s eczema is worse due to tree pollens. Should he take antihistamines? Have you any advice about what else I can do make him more comfortable?

Answer

There are many triggers which make eczema flare and air borne allergen such as tree pollens are one. Children who have eczema flares linked to air borne allergens often have a very red / pink face , itchy eyes, nasal congestion and when they rub their skin you notice white lines . This is known as dermographism (skin writing) and is often triggered by allergy. The mast cells in the skin release histamine and this results in wheals and the appearance of white lines after scratching. If this is the case I would give a trial of non-sedating antihistamines to see if this makes a difference. I would also adopt some of the principles I have mentioned in the earlier question 2.