Facial eczema in an infant - Clinical Opal
Emily is a 6-month-old child who presents with red, papular, excoriated patches on her cheeks and around her mouth.
Her father, Craig, says a mild rash has been there ‘for a while’ but started to look a lot ‘angrier’ about three weeks ago. He tells you that Emily has also started to scratch a lot, and has drawn blood a few times in her sleep, so they now put mittens on her hands.
Craig took over parental care about 4 weeks ago. He gives Emily formula during the day and she is also trying a small amount of pureed fruit and vegetables. Emily is still breast-fed morning and night. He and Emily’s mother wonder if she could have a food or formula allergy.
On examination, you note an erythematous rash showing typical distribution for facial eczema, including lighter erythema along the hairline. The skin around the cheeks is dry, excoriated and crusted. There is no active weeping from lesions or signs of infection. You can see the top of her left lower central incisor has broken through the gum. You learn that Emily’s mother had eczema when she was a child, but ‘grew’ out of it. Using a scoring tool (e.g. vIGA-AD), you determine that Emily has moderately severe facial eczema.
What treatment do you recommend, and how do you address the parental concerns regarding food allergies contributing to the baby’s eczema?
Eczema (atopic dermatitis) is a common, chronic inflammatory skin condition that often starts in infancy.
While there is no cure, most cases can be controlled with regular and appropriate foundational care, which includes moisturising every day and avoiding triggers.
Given the moderate severity of Emily’s eczema, it would be appropriate to prescribe methylprednisolone aceponate 0.1% cream, to be generously applied to all affected areas, once daily for no more than 7 days. If eczema has not cleared, step down to hydrocortisone 1% or consider a topical calcineurin inhibitor until the skin is smooth and itch-free.
Provide Craig with an eczema care plan that includes written guidance for both parents to follow and a review date. If time permits include a demonstration of how to correctly apply topical treatments, or have Craig ask the pharmacist to demonstrate.
Include a discussion on bathing, daily moisturising and reduction of likely triggers. Dribbling associated with teething is also likely to irritate surrounding skin. Keeping the area well moisturised with a greasy barrier (e.g. Vaseline) before and after feeding should help. Clean her mouth using a soft wet towel (avoid wipes containing fragrance or preservatives such as MCI/MI). Some foods (e.g. citrus fruits, strawberries, tomatoes, tomato-based sauces) also irritate the skin around the mouth—this is not a food allergy.
Most food allergies cause symptoms (e.g. hives, vomiting and irritability) within 30 minutes of consumption. Only occasionally do they result in delayed eczema flare-ups. Modifying diet (i.e. restricting diet, changing formula) has little benefit. Elimination diets in children who do not have a confirmed food allergy can cause malnutrition and poor growth and result in the development of new food allergies.
Skin prick or RAST tests do not predict foods that trigger eczema and should only be undertaken if recommended and interpreted by a clinical immunology/allergy specialist.
Some evidence suggests that managing eczema well during infancy may reduce the chance of an infant developing food allergy.
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References
Atopic dermatitis (published August 2022). In: Therapeutic Guidelines. Melbourne: Therapeutic Guidelines Limited. Accessed 28 Sep 2023. https://www.tg.org.au
Australasian College of Dermatologists. Consensus statement: Topical corticosteroids in paediatric eczema. 2022. https://www.dermcoll.edu.au/wp-content/uploads/2022/09/ACD-Consensus-Statement-Topical-Corticosteroids-September-2022-.pdf
The Royal Children's Hospital Melbourne. Eczema: Clinical Practice Guidelines. https://www.rch.org.au/clinicalguide/guideline_index/eczema/
Eczema and food allergy - fast facts [Internet]. Australasian Society of Clinical Immunology and Allergy. 2024. https://www.allergy.org.au/patients/fast-facts/eczema-and-food-allergy
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