Rashes in kids... a few case studies for parents

I am not a dermatologist, but I see rashes all the time. Some are easy to identify, others I'm not sure what the cause is. In general physicians are taught to treat the symptoms of a rash. The standard dermatology lecture in a nutshell is: If it's wet, dry it. If it's dry, wet it. If it itches, use steroids. If it's infected, use antibiotics.

I'll go over a few made up case studies -- each one is a conglomeration of kids I've seen.

Case 1

Parents bring Itchy in for a well visit but mention that her skin has rashes on her elbow creases and behind her knees. Sometimes she scratches them to the point where they bleed. They've tried applying a pink fragrant lotion that they got as a baby gift, but she says it burns and didn't help.

Advice for this family would not include which of the following?

1. Use the lotion more often since the skin is dry
2. Stop the lotion because fragrant lotions can worsen this condition
3. This type of dry skin can be related to allergies and asthma, having one makes it more likely to have another
4. Controlling the itch is important because scratching worsens the rash

The answer is #1. This rash is most likely eczema, a fancy term for dry skin. It often develops in infants but improves as a child gets older. It is more common in kids with allergies and/or asthma. It can worsen with exposure to irritants (such as a fragranced lotion or soap) and allergens (food allergies and seasonal allergies). I've often heard this called "the itch that rashes". Scratching damages the skin, which allows water to escape, which dries the skin more, leading to more itching. This itch/scratch cycle worsens the rash and can lead to secondary infections. This can be a very frustrating condition because it will come and go for years in some kids. It's important to avoid irritants and use proper skin care. For more treatment, visit Dry Skin / Eczema / Atopic Dermatitis.

Case 2

Parents bring their infant in for her well visit and ask about a rash that's been there "for awhile" but doesn't seem to bother Baby. They aren't sure when it started. They can't recall any new soaps, lotions, foods, or other potential triggers. They describe it as red spots and they aren't sure if they're changing over time. Baby is eating well, gaining weight well, sleeping well, and not fussy. On exam, they show me the rash on the abdomen and arm, but I cannot see any red spots. 

What further questions might I ask and what advice might I give?

1. If this rash would be on your own skin, how would you treat it?
2. Treatment of the rash should be based on symptoms, and since there are no symptoms, no treatment is needed
3. Monitor for signs of itching, fussiness, fever, poor feeding, and other concerns
4. All of the above

The answer is #4 and yes, I see this non-existent rash all the time. It's not just my old eyes that can't see it -- I hear from pediatrician friends about this phantom rash too. I know parents worry more about their children than they worry about themselves, but sometimes they can realize the unfounded concern when I simply ask what they would do if this rash was on their own skin. Most say they wouldn't worry about it. Enough said. 

Case 3

Parents ask about a rash that appears sometimes after their school aged child showers. It doesn't itch or hurt. It is always on the chest and abdomen and sometimes on the legs. It looks like red splotches. They've tried various soaps and shampoos, but changing them doesn't seem to affect the rash. It isn't present on exam because it only happens after showers and lasts less than 30 minutes. They are concerned because it returns so frequently.

My advice to parents includes which the following?

1. Treatment of a rash should be based on symptoms, and since there are no symptoms, no treatment is needed
2. Use only cleansing products made for babies since your child is obviously sensitive to something
3. Turn down the temperature of the water in the shower to see if the rash "resolves"
4. 1 and 3

The answer is # 4. Again, I've been asked this type of question more than once. It also falls into the category of "What would you do if you had this rash?" Most parents would admit they wouldn't do anything since it didn't cause any problems and was brief. If they really think about it, they probably have had this "rash" after a hot shower. It's just flushed skin. If you enjoy a hot shower, it's okay if your skin flushes a bit.

Case 4

Mom brings Kiddo in because her nails are growing "funny." They have a horizontal crack and the tips are peeling off. They don't seem to hurt or bother Kiddo.

What further information would be important to know?

1. Was there any trauma to the nails?
2. Has your child been sick in the past 2 months?
3. Does kiddo use nail polish or fake nails?
4. Does your child pick at her nails regularly?
5. All of the above.

The answer is #5. The answer is usually in the patient history with this one. I've seen a number of kids with peeling nails recently because we had hand, foot, and mouth in the area about a month ago. Not all kids with that infection lose their nails, but it can happen. For more on this, including pictures, see Four Cases of Onychomadesis after Hand-Foot-Mouth Disease. Other causes of peeling nails include trauma and nail picking, nutritional deficiencies, nail products, chemical irritants, certain medications, infections, and chronic diseases. 

Case 5

Mom brings Snotty in because he's had a runny nose all week. On exam, he's found to have what mom thought was dried mucus under his nose, but the underlying skin is red and it's actually more of a crusting, not mucus. 

Treatment of this includes all except:

1. Using rubbing alcohol to rub off the crust
2. Antibiotic ointment
3. Washing the area
4. Avoid touching the area
5. Oral antibiotics

The answer is #1. That would hurt! This is a classic case of impetigo. Impetigo is a bacterial skin infection. It often happens when the skin is damaged (in this case from Snotty wiping his nose constantly) and if bacteria from the nose or mouth get into the skin. It can be treated with prescription topical antibiotic ointment in most cases, but some cases require oral (by mouth) antibiotics. Wash the area gently and soak crusts with warm wet cloths to help remove the crust. Complete removal of the crust isn't necessary though - that will happen naturally as the infection resolves. Touching the area can spread the infection, so avoid touching it and wash hands well after touching it!

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Dry Skin Tips

With the cold temperatures we've already seen this season, our skin is really taking a hit. Dry skin is often called eczema or atopic dermatitis. Whatever you call it, it's itchy and annoying!

It is really important to keep skin well hydrated or it tends to snowball. The dry skin is broken skin, which allows water to escape, which further dries it, which leads to more evaporation.... Broken skin is more likely to become secondarily infected, which leads to more problems....

Itching dry skin also contributes to its worsening by further damaging the skin and allowing more water to evaporate, so try to keep fingers from scratching! (I know this is easier said than done.)

Eczema is not simply dry skin. It can cause significant distress to infants and children. It can impair sleep. It can distract from learning at school. Children with eczema have higher rates of anxiety and depression.

Eczema doesn't simply go away with good treatment: it can come and go even with the best treatment. It can therefore be a serious problem for families.

Your goal with dry skin is to hydrate it as much as possible to repair the skin barrier. We don't always think about skin as an organ (like the heart and liver), but it is. Its functions are to help keep us at a normal temperature, to keep stuff (such as bones, blood, and nerves) inside our bodies, and it helps to keep some things (such as germs) out of our bodies. When skin is excessively dry, there is inflammation and cracking. This keeps the skin from doing its job. We must try to get it back to normal so it can help keep the rest of our body healthy.

Eczema can be from many factors.

• There is a genetic component, so if a parent or sibling has eczema, it is common for other family members to have it. 
• It is often worsened by environment, both cold dry air and excessive heat. 
• Clothing can irritate some skin, depending on the fabric and the detergent left in the fibers. 
• Any scented lotions or soaps can also irritate skin. (Don't be fooled that "baby" soaps and lotions are better for baby. I usually say to avoid any of the baby products because they are often scented. They make them to sell them, not to be better for baby's skin!)
• Allergies can exacerbate eczema.
• Saliva is very harsh on the skin. Drooling can cause problems around the mouth, chin, and chest. Thumb or finger suckers often have red, thick scaly areas on the preferred finger from the drying effects of saliva.

New eczema guidelines recently released downplay the need to alter foods to treat the skin. There are some kids who have true food allergies that manifest as atopic dermatitis (dry skin), but the large majority of kids do not. Restricting their diet can lead to nutritional deficiencies without any benefit. Talk to you doctor (and be sure they have read the newest on the topic) if you think a food might be exacerbating your child's dry skin.

My best tips for treating dry skin:

• Avoid exposures to soaps because they further damage skin. Non-soap cleansers that are fragrance free are much more mild on the skin.
• Soaking in bath water or in the shower can help hydrate the skin. After bathing the skin should be only briefly dried (remove large water droplets, but allow the skin to still be moist with water) and moisturizers (with or without steroids) must be applied immediately afterwards to prevent water from evaporating out of skin.
• Moisturizers should be hypoallergenic, fragrance free, and dye free. A good place to review if a product is good is on the National Eczema Association website. I really like the moisturizers with ceramide. This has been shown to help heal the skin barrier without steroids. Use moisturizers at least twice per day, more often as needed on the really dry spots.
• After the moisturizer soaks into the skin, cover extremely dry spots with petrolatum jelly. 
• Steroids can be used for flares. Steroids are available in 7 different strength categories. The stronger the steroid, the less often it should be used. Over the counter hydrocortisone is a very mild steroid and can be used twice a day with mild flares. Stronger (prescription) steroids should be discussed with your doctor if the eczema is more severe, but they can be safe and effective when used appropriately.
• Bleach baths have been shown to help in moderate to severe eczema. Add 2 ounces of bleach to the bath water and soak the body (not the face) for 20 minutes a few times a week.
• Oral antihistamines, such as zyrtec, allegra, or claritin (or any of their generics) can help control the itch. I recommend the long acting antihistamines over the short acting ones, especially overnight, to avoid gaps in dosing leading to the itch/scratch cycle. Avoid topical antihistamines due to variable absorption from disrupted skin.
• Add water to the air during the dry months. If your air conditioner is running you shouldn't need (or want) to add humidity. If your heat is on, you might have an attached humidifier, which is great. You can also buy a room humidifier or vaporizer to add water to the air. When there's more water in the air, the skin will have less evaporation.
• Use wet water cloths on dry patches. This can help get a child through an itchy time with a cool compress. It also helps hydrate the skin. Since it might remove the moisturizer, re-apply moisturizer when the wet cloth is removed. Some kids benefit from wet wraps (see link). This is time intensive, but very effective, so worth trying for more severe eczema patches. 
• If your child just can't stop itching, be sure nails are clipped to help avoid scratching. Sleeping with socks or mittens helps the inadvertent scratching during sleep. Many kids remove these, so sewing an old pair of socks onto the arms of long sleeve PJs can help. (Don't forget to put moisturizer on first!)
• If your child drools or sucks a finger, wipe the saliva off regularly and protect the skin with petrolatum jelly.

At times prescription medicines are needed. These can include steroids, immune modulators, and antibiotics. If your doctor recommends them, don't be afraid to use them. Many parents under utilize medical treatments out of fear of side effects. Yes, there are risks to all medicines, but there are also risks to having eczema untreated. Discuss fears with your doctor to come up with a good plan that you both agree with. Don't just not use the prescriptions.

Get control of your child's eczema. If you can't seem to do it alone, schedule an appointment with your pediatrician to see what else can be done.

For more information, see the American Academy of Pediatrics clinical report on eczema management and the American Academy of Dermatology's Guidelines.

Lip Licker's Dermatitis: AKA Chapped Lips

photo source: Wikipedia Commons

As the leaves fall and the wind blows, I know that I will start seeing kids with smiles bigger than life due to red swollen chapped lips. Parents frequently bring kids in year after year with this "recurrent rash" that comes every dry season and goes away (or at least improves) in the Spring.

Dry lips are a problem that tends to worsen with the treatment that comes most naturally: licking your lips. Saliva contains enzymes that break down food you eat -- or the lips you are licking. It also damages regular skin, so the skin around the lips dries if licked, the skin on the neck and chest are affected in droolers,  and thumbs or fingers can get really chapped if they are sucked this time of year. The same theories discussed below can be used to treat other dry skin worsened by saliva.

What can help?

First, stop licking your lips! I know that's easier said than done, especially for kids with a strong licking habit. If you catch them licking, offer a lip balm or suggest that they drink some water. Remember to praise them if they make a choice to do anything other than lick!

Adding humidity to the air helps and doesn't require child participation (since they resist so much of what we do). Even if you have a whole-home humidifier, add a vaporizer or humidifier to the bedrooms each night. Be sure to keep it clean and out of reach of little hands.

Everyone should drink plenty of water throughout the day.

Seal in moisture with a lip balm or ointment. Ingredients such as shea butter, lanolin, petrolatum, sunflower seed oil, squalane, and vitamin E are common. Products with glycerin, hyaluronic acid, or sodium PCA also have been shown to help. The more often they are applied, the better they work, so try to keep them available throughout the day. (This might require talking to teachers to allow it to be freely available at school.) Waxes are good to avoid dry lips, but don't help as much as a moisturizing product once the lips are already dry. Avoid products with eucalyptus, menthol, or camphor because they can increase dryness and irritation. Since flavored lip products might encourage licking lips, I suggest you avoid them. Use one with sunscreen when outdoors. Keep the balm handy throughout the day and be sure to apply after brushing teeth before bed. To avoid sharing germs, everyone should have his own, and I prefer sticks versus anything you dip your fingers into.  It is okay to apply the balm or ointment to the skin surrounding the lips if needed-- for those kids who have a wide area they lick around the lips!

Many parents ask if their kids will become addicted to the lip balm. Simple answer: No. They might use it more frequently as they get used to the idea of using it instead of licking their lips when they feel dry, but that is a good habit, not an addictive behavior. As soon as the weather warms up, we don't feel our lips being as dry, so we use the balm less often.


Avoid evaporation. Mouth breathing dries the lips, so try to get kids to breathe through their nose. Keep the wind off the lips with a scarf. The wind increases the evaporation of water from the skin, drying it out.