Pediatric Eczema in India

Pediatric eczema (atopic dermatitis) is a chronic, inflammatory skin condition characterized by dry, itchy skin and recurrent rashes. It affects approximately 15-20% of children in India, with prevalence varying by region and urban-rural setting. This common childhood condition typically begins in infancy, with 60% of cases appearing within the first year of life. In Indian children, eczema often presents with increased hyperpigmentation compared to Western populations. The condition is part of the "atopic march," where children develop eczema first, followed by food allergies, allergic rhinitis, and asthma. While genetics play a significant role, environmental factors like climate, pollution, and dietary habits also influence disease expression. Studies from major Indian cities show increasing prevalence, especially in urban areas with higher pollution levels. Though not contagious, eczema significantly impacts quality of life through sleep disturbance, social stigma, and psychological distress. With proper management following culturally appropriate protocols, most children experience improvement with age.

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Causes

Genetic predisposition - Family history of eczema, asthma, or allergies significantly increases risk, with research in Indian families showing stronger maternal inheritance patterns
Skin barrier dysfunction - Defects in filaggrin and other proteins that maintain skin barrier integrity allow moisture loss and allergen entry
Immune system dysregulation - Overactive immune responses, particularly involving Th2 cells and inflammatory cytokines, trigger skin inflammation
Environmental triggers - Dust mites, pollen, mold, and animal dander often exacerbate symptoms, with house dust mites being particularly problematic in humid Indian climates
Climate factors - Hot, humid conditions common across much of India can worsen sweating and eczema flares; conversely, winter dryness also triggers symptoms in northern regions
Air pollution - Higher rates of eczema in Indian urban centers correlate with increased air pollution, particularly PM2.5 particles
Food allergens - Certain foods may trigger flares in some children, with studies in Indian populations showing egg, milk, and peanut as common culprits
Irritants - Harsh soaps, detergents, synthetic fabrics, and wool can irritate sensitive skin
Stress - Emotional stress exacerbates symptoms through neuroimmunomodulatory pathways
Microbial imbalance - Staphylococcus aureus colonization is more common on eczematous skin and contributes to inflammation and infection

Signs and Symptoms

Intensely itchy skin - The hallmark symptom, often worse at night, disrupting sleep
Dry, scaly patches - May appear red on lighter skin tones or darker brown/purple on darker skin common in Indian children
Location-specific rashes - In infants: cheeks, scalp, and extensor surfaces; in older children: flexural areas like neck, wrists, ankles, and behind knees/elbows
Skin thickening (lichenification) - From chronic scratching, more visible as darkened areas in darker skin tones
Post-inflammatory hyperpigmentation - More pronounced in Indian children with darker skin, causing persistent dark patches after inflammation subsides
Frequent skin infections - Due to scratching and compromised skin barrier, with increased risk of bacterial, viral, and fungal infections
Small, fluid-filled bumps - That may ooze and crust, especially during flares
Facial features - Increased infraorbital folds (Dennie-Morgan lines) and darkening around eyes
Hyperlinear palms - Increased palm and sole creases, particularly visible in South Asian children
Xerosis - Extremely dry skin even in non-eczematous areas
Follicular accentuation - Small bumps at hair follicles, more noticeable in darker skin
Heat intolerance - Sweating triggers itching and discomfort, particularly challenging in India's warm climate
Variable presentation - Symptoms may flare and remit, with periods of relative improvement followed by exacerbations

Diagnosis

Clinical Evaluation and History

Following Indian Academy of Pediatrics (IAP) guidelines, diagnosis primarily relies on a thorough examination and detailed history. Dermatologists assess the distribution and appearance of skin lesions, which in Indian children often show more pronounced hyperpigmentation and follicular accentuation compared to Western populations. The doctor will inquire about symptom onset, pattern of flares, aggravating factors, family history of atopic conditions, and previous treatments. The history includes questions about potential triggers in the home environment specific to Indian households, such as types of cooking fuels, living conditions, and local environmental factors.

Diagnostic Criteria Application

Standardized criteria like the UK Working Party diagnostic criteria or the Hanifin and Rajka criteria are adapted for Indian skin characteristics. The essential features include pruritus (itching), typical morphology and distribution based on age, chronic or relapsing course, and personal or family history of atopic conditions. In darker skin tones common in Indian children, erythema (redness) may be difficult to appreciate, so doctors look for warmth, edema, and alterations in pigmentation to assess inflammation. Recent IAP recommendations highlight the importance of recognizing these skin tone-specific presentations to avoid delayed diagnosis.

Allergy Testing

When specific triggers are suspected, particularly foods, allergen testing may be performed. Skin prick tests or blood tests (specific IgE) can identify potential allergens, though these must be interpreted cautiously as positive tests don't always correlate with clinical reactivity. In Indian medical centers, patch testing is sometimes used to identify contact allergens, particularly when contact dermatitis is suspected. Specialized centers in major Indian cities may offer component-resolved diagnostics for more precise allergen identification, though this is not routinely required for diagnosis.

Exclusion of Differential Diagnoses

Other conditions that can resemble eczema must be ruled out. In the Indian context, these importantly include scabies, which is relatively common in some regions, seborrheic dermatitis, fungal infections like tinea corporis (ringworm), and nutritional deficiency dermatoses. Contact dermatitis from traditional medicines, cosmetics, or jewelry (particularly those containing nickel or kumkum) must also be considered. When the presentation is atypical or treatment-resistant, skin scrapings, cultures, or occasionally skin biopsies may be performed to exclude other conditions.

Evaluation for Complications and Comorbidities

Children with suspected eczema are evaluated for signs of secondary infection (bacterial, viral, or fungal) and other atopic conditions like asthma and allergic rhinitis. Growth parameters are monitored as severe eczema and associated sleep disturbance can affect growth. In the Indian context, where social stigma around skin conditions can be significant, psychological assessment may be included, particularly for older children experiencing bullying or social isolation due to visible skin lesions.

Severity Assessment

Tools like the SCORAD (Scoring Atopic Dermatitis) index or EASI (Eczema Area and Severity Index) help quantify disease severity and monitor treatment response. These standardized measures assess extent, intensity, and subjective symptoms. For Indian children, where post-inflammatory hyperpigmentation is more prominent, the modified versions of these scales that account for pigmentary changes may be used. Severity assessment guides treatment decisions and helps monitor disease progression over time.

Treatment Options

Specialized Skincare Regimen

The foundation of pediatric eczema management is proper skincare, following guidelines adapted for Indian climatic conditions and locally available products. This includes daily bathing with lukewarm water and gentle, soap-free cleansers, followed by immediate application of moisturizers to lock in hydration. In India's humid climate, lighter moisturizers may be preferred in summer, switching to more emollient formulations during drier winter months. The "soak and seal" method is often recommended—patting skin partially dry after bathing, then applying medication (if prescribed) followed by thick moisturizer within 3 minutes. For hyperpigmentation common in Indian children with eczema, specific moisturizers may be recommended that address both dryness and pigmentary changes. Parents are educated about appropriate products available locally, with emphasis on fragrance-free formulations and those suitable for sensitive skin.

Topical Anti-inflammatory Medications

Prescription topical corticosteroids remain the mainstay of treatment for flares, with potency selected based on age, body site, and severity. Following Indian pediatric dermatology guidelines, lower potency steroids are used for facial and flexural areas, while moderate potency may be needed for limbs and trunk. For maintenance therapy, topical calcineurin inhibitors (tacrolimus, pimecrolimus) are often prescribed, particularly for sensitive areas where steroid side effects are concerning. These medications are generally applied once or twice daily to affected areas during flares, with frequency reduced during maintenance phases. Given the risk of hypopigmentation being more visible in darker skin tones, judicious use of topical steroids under medical supervision is emphasized to Indian parents, addressing common concerns about steroid side effects while ensuring adequate treatment.

Infection Management

Secondary bacterial infections, commonly with Staphylococcus aureus, frequently complicate eczema in Indian children, particularly in hot, humid conditions. Signs include increased redness, oozing, yellow crusting, or failure to respond to usual treatments. Management may include antiseptic baths (potassium permanganate or diluted bleach baths), topical antibiotics for limited infections, or oral antibiotics for more extensive involvement. Antiseptic washes containing chlorhexidine or triclosan may be recommended for regular use to reduce bacterial colonization. Herpes simplex virus infections (eczema herpeticum) require prompt recognition and antiviral treatment, while fungal infections are managed with appropriate antifungal agents. Preventive strategies include proper wound care, keeping fingernails short, and avoiding sharing of personal items.

Trigger Identification and Avoidance

Identifying and avoiding triggers is crucial for long-term management. Common triggers in Indian households include dust mites (particularly problematic in humid climates), seasonal pollen, mold (especially during monsoon season), and certain fabrics like wool or synthetic materials. Environmental modifications may include using allergen-proof covers for mattresses and pillows, frequent washing of bedding in hot water, keeping indoor humidity below 50%, and using air purifiers in urban areas with high pollution. Food triggers are individually identified, with elimination diets conducted under medical supervision when food allergies are suspected. Irritant avoidance includes using fragrance-free products, wearing loose cotton clothing (preferably white or light-colored and washed before first use), and avoiding extreme temperature changes when possible.

Systemic Therapy for Severe Cases

For severe or refractory cases not responding to topical treatments, systemic therapies may be considered under specialist care. Short courses of oral corticosteroids may be used for acute severe flares, though long-term use is avoided due to side effects. Other options include cyclosporine, azathioprine, or methotrexate for severe cases, though these require careful monitoring. In tertiary centers in major Indian cities, biologics like dupilumab (which targets interleukin-4 and interleukin-13 pathways) may be available for adolescents with severe eczema, though cost considerations often limit access. Phototherapy (narrowband UVB) is sometimes used for older children with widespread eczema but requires specialized equipment available only at advanced centers. The decision to use systemic therapy weighs benefits against potential risks and is made in consultation with pediatric dermatologists.

Integrative Traditional and Modern Approaches

In India, many families seek traditional medicine approaches alongside conventional treatments. When appropriately integrated under medical supervision, certain Ayurvedic treatments may complement conventional therapy. These might include specific herbs with anti-inflammatory properties such as turmeric (Curcuma longa), neem (Azadirachta indica), or sandalwood preparations formulated for sensitive skin. Traditional practices may also include dietary adjustments based on dosha balance, though these should not replace nutritionally complete diets. Ayurvedic oils like coconut oil or customized medicated oils may be used as moisturizers. Modern approaches are integrated with these traditional practices, with emphasis on evidence-based treatments first, supplemented by traditional approaches that align with basic principles of good skincare and trigger avoidance. Any traditional treatments should be discussed with healthcare providers to ensure they don't interfere with prescribed medications.

Psychological Support and Education

The visible nature of eczema can lead to significant psychological impact, including social isolation, bullying, sleep disturbance, and reduced quality of life. In the Indian context, where skin conditions may carry particular stigma, psychological support is essential. This includes age-appropriate education about the condition, counseling when needed, and school-based interventions to prevent bullying and promote understanding among peers and teachers. Parent education focuses on eczema management, realistic expectations, and addressing parental anxiety which can affect the child. Support groups connecting families dealing with eczema provide emotional support and practical advice. Techniques for itch management, including distraction strategies and relaxation techniques adapted for children, help break the itch-scratch cycle. For adolescents, addressing body image concerns and building self-confidence despite visible skin differences is particularly important.

Home Remedies

Wet Wrap Therapy for Severe Flares

For intense flares, wet wrap therapy can provide significant relief. After bathing, apply prescribed medication to affected areas, then moisturizer to the rest of the body. Dampen a clean cotton garment or gauze in warm water, wring until damp (not dripping), and apply to the affected area. Cover with a dry layer of clothing. Leave in place for 2-3 hours or overnight for severe cases. This increases medication penetration and skin hydration while providing a physical barrier against scratching. In the Indian context, thin cotton clothing works well for this purpose, and during hot weather, wraps can be applied for shorter periods in air-conditioned environments or cooler evening hours. For localized areas, cotton bandages or clean cotton cloths can be used instead of full garments.

Natural Moisturizing Options

While commercial moisturizers are effective, some natural options may be integrated into care routines, particularly in areas where commercial products are less accessible or affordable. Cold-pressed coconut oil, traditionally used in many Indian households, has mild antimicrobial properties and is well-tolerated by many children with eczema. Sunflower seed oil is another option with barrier-repair properties. These should be applied to slightly damp skin after bathing for best results. For older children with less severe eczema, aloe vera gel (pure, without alcohols or fragrances) can provide cooling relief in hot weather. These natural options work best when used consistently as part of a comprehensive skincare routine and should be tested on a small area first to ensure no irritation occurs.

Itch Relief Strategies

Managing itch is crucial for breaking the itch-scratch cycle. Cold compresses can provide immediate relief—wrap ice in a soft cloth or use a clean cloth soaked in cold water and apply to itchy areas for 5-10 minutes. For nighttime itching, keeping the bedroom cool (around 18-20°C if possible) and using cotton bedding helps. Fingernails should be kept short and clean, and cotton gloves may be worn during sleep for children who scratch unconsciously. Distraction techniques like engaging activities or gentle pressure instead of scratching can be taught to older children. In hot weather common across India, cooling sprays of plain water kept in the refrigerator can provide relief when used throughout the day. For infants who cannot control scratching, cotton mittens or socks over hands may be used temporarily.

Dietary Approaches

While food allergies affect only a subset of children with eczema, dietary modifications may help some children. Rather than eliminating foods without professional guidance (which risks nutritional deficiencies), work with healthcare providers to identify specific triggers. Common triggers in Indian children include egg, milk, peanuts, and tree nuts, though individual responses vary greatly. For general skin health, a balanced diet rich in omega-3 fatty acids (found in flaxseeds, walnuts, and fatty fish), zinc (legumes, nuts, whole grains), and antioxidants (colorful fruits and vegetables) supports skin barrier function. Probiotics from yogurt (dahi) and fermented foods may benefit some children by supporting gut microbiome health, which can influence immune responses, though research shows variable results. Adequate hydration is essential, particularly in hot weather, with water being the best choice.

Clothing and Laundry Practices

Clothing choices significantly impact eczema comfort. In India's climate, loose-fitting, 100% cotton garments are ideal, allowing skin to breathe while avoiding friction. Light colors are preferable to dark dyes, which may contain irritating chemicals. New clothes should always be washed before wearing to remove manufacturing chemicals and sizing agents. For laundry, use mild, fragrance-free detergents specifically formulated for sensitive skin, avoid fabric softeners and dryer sheets, and rinse clothes thoroughly (consider an extra rinse cycle). Traditional Indian practices like sun-drying clothes can be beneficial—UV exposure helps kill dust mites and bacteria, though during high pollen seasons, indoor drying may be better for highly allergic children. Bedding should be changed and washed frequently, ideally weekly in hot water if tolerated by the fabric.

Creating an Eczema-Friendly Home Environment

Home modifications can significantly reduce eczema triggers. In Indian homes, dust mite control is particularly important—use allergen-proof covers for mattresses and pillows, wash bedding weekly in hot water, and reduce dust-collecting items like stuffed toys and heavy drapes. During cleaning, the affected child should be in another room, and damp dusting rather than dry methods prevents allergen dispersal. In areas using biomass cooking fuels, ensure proper ventilation to reduce irritant exposure. During monsoon season, use dehumidifiers or air conditioning if available to maintain humidity below 50%, preventing mold growth. For homes in highly polluted urban areas, HEPA air purifiers in the child's bedroom can reduce irritant exposure. Remove carpeting if possible, especially in the child's bedroom, and opt for easily cleaned flooring. Smoking should never be allowed inside the home, and exposure to incense, strong cleaning products, and fragrant cosmetics should be minimized.

Preventive Care

Maintain a consistent daily skincare routine with gentle cleansers and regular moisturizing, even when the skin looks clear, to prevent flares
Identify and avoid individual triggers, keeping a symptom diary to track flares in relation to exposures, activities, foods, and environmental changes
Dress children in loose, cotton clothing appropriate for the climate, with layers that can be removed to prevent overheating and sweating
Control home environment by minimizing dust, mold, and pet dander; in Indian urban settings, consider air purifiers to reduce pollution exposure
During seasonal changes, particularly from winter to summer or during monsoon season, proactively adjust skincare routines and environmental controls
Begin treatment at the first sign of a flare to prevent escalation—early intervention reduces the intensity and duration of symptoms
Ensure children stay well-hydrated, particularly important in India's hot climate where dehydration can worsen skin dryness
Manage stress through age-appropriate techniques like deep breathing, storytelling, or gentle yoga, as emotional factors can trigger eczema flares
Keep fingernails short and clean to minimize damage and infection from scratching; consider cotton gloves during sleep for children who scratch unconsciously
After swimming in chlorinated pools or the ocean, rinse immediately with fresh water and apply moisturizer to prevent drying and irritation
Ensure regular medical follow-up to monitor the condition and adjust treatment plans as the child grows and seasons change
Educate caregivers, school staff, and family members about the child's condition to ensure consistent management across all environments

Surgical Options

Non-Surgical Condition

Pediatric eczema (atopic dermatitis) is primarily managed with non-surgical approaches including specialized skincare, topical medications, systemic therapies when indicated, and lifestyle modifications. There are no specific surgical interventions for treating eczema itself.

Procedures for Complications

In rare cases where severe bacterial infections have developed as a complication of eczema, minor procedures might be needed to drain abscesses or treat extensive infections. However, these are not treatments for the eczema itself but for its complications. Such procedures are uncommon and would only be performed when absolutely necessary in pediatric patients.

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