Battling the Baby Eczema Blues

Summer is over, autumn leaves have fallen from the trees and winter has arrived. Winter is a challenging time for families. Not only do you worry about making sure everyone is keeping warm, avoiding the sniffles and trying to find activities for those wet and windy days. But trying to manage your family’s skin as well? Especially if any of you suffer from dry skin, eczema or dermatitis. 

Having a baby or toddler who suffers from eczema trumps it all. Seeing their dry scaly skin, often with inflamed patches, and knowing they are suffering is distressing. It’s frustrating figuring out how to manage your baby’s skin problems, and how to do it fast. While most babies will eventually grow out of skin issues by age 5 you still need to find ways to take care of their skin now.

Baby Skin
So why do so many babies develop eczema? Well, when babies are born their skin is innately different to an adults. All skin is composed of an epidermis, dermis and sub-epidermis. However babies have a thinner epidermis and stratum corneum (SC), the outermost part of the epidermis, than adults.1,2  This makes their skin more sensitive and less effective as a barrier. Composed of saturated free fatty acids, such as palmitic acid, stearic acid and oleic acid, and other fatty acids, such as poly unsaturated linoleic acid, the cells of the epidermis are tightly arranged in a layer. 3 Each layer hardens and flattens as they move from the bottom of the epidermis to the SC at the top. 
Babies skin have a higher rate of moisture loss, referred to as trans-epidermal water loss (TEWL), which means their skin dries out quickly. This is because their skin is adjusting from the wet uterine environment inside mum’s belly to the dry environment outside. It’s really common to see a newborn’s skin peeling in the first few weeks of life, and this is due to their skin having a higher pH than an adults. 
 
The pH of skin is actually a really important factor in skin health and why so many companies market their products as being ‘pH neutral’. Skin in good health has a low pH, meaning it is slightly acidic. You may have heard it called the ‘acid mantle’. The mantle has three main roles;  to protect the skin from nasty microbes that cause infection, to regulate enzymes in the skin that control how permeable the skin is and how well the skin cells stick together to form a barrier.4 Once the pH of the skin is put out of balance then it can become infected with nasty bacteria, the skin barrier becomes defective and not only is moisture lost but the skin becomes inflamed and irritated. 

During the first 3 months of a newborn’s life their skin experiences many changes. The pH of their skin lowers to that of an adults. This makes their skin healthier and a nicer environment for the microbiome to develop. There is also a decrease in moisture loss as there is less TEWL, which leads to an increase in skin hydration. And finally the skin produces water binding Natural Moisturising Factor (NMF). The NMF is a soup of different substances produced by the skin such as free fatty acids, organic acids (lactic acid, carboxylic acid etc.), peptides, sugars, urea, citrate and glycerol. The role of NMF is to bind water to the skin, retaining hydration and promoting skin elasticity. It has a role in helping the skin to shed dead cells naturally and keeping the pH of the skin low which supports the barrier function of the epidermis. 

The microbes that reside on the skin, called the ‘microbiome’, also have an important job in maintaining the skin barrier. Taking up to baby’s first birthday to fully develop the microbiome is a delicate balance of resistant commensal microorganisms and transient microorganisms. These microbes are able to active the innate immune system of the skin. By policing the skin they can alert the immune system when nasty bacteria such as S. aureus or MRSA start to grow. Thus preventing skin conditions and infection.  While every patch of skin has its own microbiome, not one is the same. All skin has a unique ecosystem that relies on skin pH, SC integrity, microbiome development and NMF production.

Developing Eczema
When your baby develops eczema or atopic dermatitis (AD) their skin will be dry and inflamed. It may also be itchy. In some cases there may be weeping of the skin, formation of crusts and blisters. All of which are painful. As the skin is broken skin infections are common, making the skin more painful and harder to treat. 
In babies up to one years old you often see patches on the cheeks, arms, legs and the body. In toddlers from one to three years old AD is more commonly seen on the face, neck, inside of elbows, back of knees, wrists and ankles. Though AD can occur anywhere.

So why does your baby develop AD? Simply, it is a complex skin condition with many contributing elements.5 Both immunological and genetic factors play a part in whether a child develops AD. However other external factors are also important. These can include allergenic triggers such as foods, dust or pet dander, as well as stress, infections, detergents and heat. 
There is a strong association between AD and food allergies. Commonly dairy or gluten are suspected but other foods such as nuts (peanuts or tree nuts), eggs, fish or soy can also be triggers. If you are breastfeeding it can be challenging to limit your diet over a number of weeks to see the effects. However you should be relieved to know that breastfeeding is associated with lower AD rates (up to 46%).5

While foods may trigger flare ups it is unlikely that they are the sole cause. In fact AD is considered to be the first indicator of developing a future food allergy. Thought to be the first stage in the ‘Atopic March’ from AD to asthma, food allergy and rhinitis, good management of AD may delay or prevent development of food allergies.6
While you can see the distressing physical changes in your baby’s skin there are a number of physiological changes you can’t see. And although it is unclear what happens first, or what causes the initial trigger, in the development of AD we do know that the skin’s ecosystem is totally disrupted.

Skin pH
The pH of the skin is raised towards alkaline, removing the acid mantle function. As a result skin permeability is increased so it becomes ‘leaky’ and moisture is lost easily. Higher levels of TEWL making skin drier which contributes to skin cracking and further breakdown of the skin barrier. 

Microbiome
The microbiome is affected as there is a monopoly of growth of bad bacteria. As the commensal and transient bacteria need an acidic pH to grow well. Infection of the skin causes further inflammation and makes the initial AD more difficult to treat. 

Skin Barrier
Disrupted by dryness and an increase in pH the skin is unable to produce NMF as efficiently. Skin cells do not mature properly and the barrier is broken down. This allows further moisture loss and the entry of allergens into the skin. Contributing to inflammation and increasing potential allergenic reactions and triggers. 
It is a vicious circle of barrier disruption, inflammation and dryness in your baby’s skin. So how can we help to treat and prevent your baby’s skin from getting worse? There are a number of medicated creams for AD, most of which are not long-term solutions. And considering your little one you probably don’t want to be smothering them in steroid creams or antibiotic lotions if you can help it. Thankfully studies have found that there are some simple early interventions that are natural and safe to use to help you manage AD in your baby.

Natural Eczema Treatments and Preventions

Bathing
Bathing with water is good for the skin! While bleach baths are often recommended for moderate-severe cases of AD, a number of studies have found no significant benefit over water. This also includes ‘moisturising’ bath additives. 789. 

Avoid Soaps. Usually no soap or detergent is needed but soap is especially bad for AD. As an alkaline substance, soap will dry the skin and worsen symptoms of AD. Choose natural-based synthetic detergents instead.4 Or use a natural cleanser like Oats or Oatmeal. 

The use of oats and oatmeal for their anti-inflammatory properties has been known since the Romans and they have a beneficial effect when placed into bathwater.10 You can soak a handful in the bath (in some old tights) or find natural bath products with oats.

Moisturising

Whether AD is mild, moderate or severe, use of moisturisers has been highlighted. Using moisturisers on a daily basis has found to reduce the need for corticosteroids during flare ups by 40%.2 The use of moisturisers improves the skin barrier function by restoring hydration of the SC and reducing TEWL.

But not all moisturisers are considered equal. Studies have looked at the use of natural plant oils for their positive physical effects on the skin3,11–13. Most plant oils contain the same free fatty acids that are found in the skin which can help the skin restore the SC barrier. Water containing moisturisers and lotions may have the tendency to sting when applied on broken skin. The water content, along with fragrances or perfumes, can irritate the epidermis when the skin barrier is compromised.

Natural oil based moisturisers would be the better option, as they have been found to be effective in reducing AD and increasing skin condition.12 

Probiotics
If you follow the natural health trends you will know all about probiotics and how helpful they can be with many conditions. However a recent study looking at all the probiotic data found that while probiotics were shown to reduce severity of AD in toddlers over one years old there was no benefit to babies under one year. 14 In addition they found that probiotic treatments containing mixed bacterial species or Lactobacillus spp. were of more benefit than Bifidobacterium spp. alone.14 So it’s worth looking into as your baby gets older.

The best approach: 
The most recommended treatment and preventative is the ‘soak and smear’ approach. It’s super simple and most natural. But what really makes it so effective is consistency. Sticking to the regimen meant that AD flare ups were better controlled and occurred less frequently.

Soak and Smear: Bathe your baby daily, for 20 minutes. Pat them dry as opposed to rubbing and apply a moisturiser within 3 minutes of leaving the bath. This is to lock-in the water content to the skin.3,7–9,15

Having a baby is hard work, having one who has skin problems is extra tough. Like most parenting challenges helping your baby through painful AD involves lots of cuddles and a consistent approach. Build caring for your baby’s skin into your daily routine, perhaps making the daily moisturisation into a baby massage to maximise bonding with your baby. 

To help you chose the best way to care for your baby’s skin we have included a list of recommended natural oils and baby-safe essential oils that help with managing AD. Remember to always dilute essential oils for babies at 0.1% (1 drop in 1 tbsp oil), or choose products that contain these oils or essential oils already diluted.

A note about Pregnancy and AD
While still needing further research, scientists are finding that what mums eat and take during pregnancy can affect the development rates of AD in their babies. Calcium rich foods like cheese and yogurt have been identified as possibly reducing infant AD, though there is no direct correlation. It does, however, highlight that perhaps healthier eating during pregnancy may have an effect.16 Conversely the same study found that higher levels of Vitamin D (from supplementation) where associated with higher rates of infant AD.

Interestingly, a large analysis of 19 studies has found that the use of oral probiotics during late pregnancy was associated with reduced infant AD. In addition it found that 6 studies suggested fish oil supplementation during pregnancy and lactation was associated with reduced egg allergy in children. These trials show that mum’s diet during pregnancy and lactation may influence her child’s risk of developing allergies.17

Natural Oils to manage AD
Jojoba oil – Repairing, anti-inflammatory and wound healing. Penetrates skin and readily absorbed
Grapeseed oil – Anti-microbial, anti-inflammatory and wound healing. Penetrates the skin well
Coconut Oil – Improves skin barrier, reduces TEWL, wound healing, anti-inflammatory, anti-microbial, anti-viral and anti-fungal. Some reports of causing dermatitis with continuous use.5 Takes time to sink into skin
Sesame Oil – Anti-inflammatory, pain-relieving, maintains skin barrier 
Rose Hip Oil – Anti-inflammatory and repairs damaged skin
Shea Butter – Anti-inflammatory, repairs skin barrier by filling in holes of SC, restores skin moisture and removes dead cells
Sunflower oil – Restores skin barrier, anti-inflammatory, maintains skin barrier. Light oil for delicate skin
Baby Safe Essential Oils for AD
Lavender – Pain-relieving, healing and antimicrobial 
Chamomile Roman – Pain-relieving, healing and antiseptic
Cedarwood Atlas – Antiseptic, fungicidal and tones the skin
Geranium – Anti-inflammatory, antiseptic, healing
Patchouli – Anti-inflammatory, antimicrobial, antiviral, healing and fungicidal. 

References
1.    Ludriksone, L., Garcia Bartels, N., Kanti, V., Blume-Peytavi, U. & Kottner, J. Skin barrier function in infancy: A systematic review. Arch. Dermatol. Res. 306, 591–599 (2014).
2.    Blume-Peytavi, U. et al. Fragility of epidermis in newborns, children and adolescents. J. Eur. Acad. Dermatology Venereol. 30, 3–56 (2016).
3.    Lin, T.-K., Zhong, L. & Santiago, J. Anti-Inflammatory and Skin Barrier Repair Effects of Topical Application of Some Plant Oils. Int. J. Mol. Sci. 19, 70 (2017).
4.    Ali, S. M. & Yosipovitch, G. Skin pH: From basic science to basic skin care. Acta Derm. Venereol. 93, 261–267 (2013).
5.    Sayaseng, K. Y. & Vernon, P. Pathophysiology and Management of Mild to Moderate Pediatric Atopic Dermatitis. J. Pediatr. Heal. Care 32, S2–S12 (2018).
6.    Bantz, S. K., Zhu, Z. & Zheng, T. Journal of Clinical & Cellular The Atopic March : Progression from Atopic Dermatitis to Allergic Rhinitis and Asthma. (2014). doi:10.4172/2155-9899.1000202
7.    Chopra, R., Vakharia, P. P., Sacotte, R. & Silverberg, J. I. Efficacy of bleach baths in reducing severity of atopic dermatitis: A systematic review and meta-analysis. Ann. Allergy. Asthma Immunol. 119, 435–440 (2017).
8.    Santer, M. et al. Emollient bath additives for the treatment of childhood eczema ( BATHE ): multicentre pragmatic parallel group randomised controlled trial of clinical and cost e ff ectiveness. 1–8 (2018). doi:10.1136/bmj.k1332
9.    M., S. et al. Bath additives for the treatment of childhood eczema (BATHE): Protocol for multicentre parallel group randomised trial. BMJ Open 5, no pagination (2015).
10.    European Medecines Agency. Assessment Report on Avena Sativa L., Herba and Avena Sativa L., Fructus. 1–21 (2008).
11.    Nangia, S., Paul, V., Chawla, D. & Deorari, a. Topical coconut oil application reduces transepidermal water loss in preterm very low birth weight neonates : a randomized clinical trial Sushma Nangia , Vinod Paul , Deepak Chawla and Ashok Deorari The online version of this article , along with updated. Pediatrics 121, S139–S139 (2008).
12.    Verallo-Rowell, V. M., Katalbas, S. S. & Pangasinan, J. P. Natural (Mineral, Vegetable, Coconut, Essential) Oils and Contact Dermatitis. Curr. Allergy Asthma Rep. 16, (2016).
13.    Evangelista, M., Casintahan, F. & Villafuerte, L. The effect of topical virgin coconut oil on scorad, transepidermal water loss and skin capacitance in mild to moderate pediatric atopic dermatitis: A randomized, double-blind clinical trial. Int. J. Dermatol. 53, 100–108 (2014).
14.    Kim, S.-O. et al. Effects of probiotics for the treatment of atopic dermatitis: a meta-analysis of randomized controlled trials. Ann. Allergy, Asthma Immunol. 113, 217–226 (2014).
15.    Cardona, I. D., Stillman, L. & Jain, N. Does bathing frequency matter in pediatric atopic dermatitis? Ann. Allergy, Asthma Immunol. 117, 9–13 (2016).
16.    Miyake, Y., Tanaka, K., Okubo, H., Sasaki, S. & Arakawa, M. Maternal consumption of dairy products, calcium, and vitamin D during pregnancy and infantile allergic disorders. Ann. Allergy, Asthma Immunol. 113, 82–87 (2014).
17.    Garcia-larsen, V. et al. Diet during pregnancy and infancy and risk of allergic or autoimmune disease : A systematic review and meta-analysis. 125, 1–25 (2018).