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THE PROBLEM OF ECZEMA IN INFANCYAND CHILDHOODBy REGINALD T. BRAIN, M.D., F.R.C.P.

Physician in Charge Skin Departments at the Royal Free Hospital and the Hospital for Sick Children, Great OrmondStreet; Physician, St. John's Hospital for Diseases of the Skin

The clinical picture of eczema as it appears ininfants and young children is sufficiently charac-teristic to be readily recognized. The earliestlesions consist of minute, pale pink papulo-vesicleswhich erupt in small groups and at first are set innon-inflamed skin, although the pale pink back-ground soon appears. The eruption is usuallysymmetrical and in infants most commonly firstarises on the cheeks just in front of the ears (Fig.i). Friction, or the application of irritants, suchas penicillin ointment or cream, usually quicklyaggravates the affected area of skin, and a brighterredness with some oedema indicates that a fric-tional or a contact dermatitis has been added tothe eruption. Secondary infection with pyogenicorganisms will also produce a similar picture ofdermatitis, but the pattern of the primaryeczematous eruption and the subsequent changes,to be described, clearly indicate that we are dealingwith a hypersensitive skin which presents thepeculiar pattern of reaction that is called eczema.

Because erythema, oedema and exudation arealmost constant factors in the eczematous reaction,and these are fundamentally inflammatory re-actions, the term 'dermatitis' can also be appliedto the eruption. However, for many dermatologiststhe term eczema does bring to mind a clinicalpicture as sharp in its definition as psoriasis orlichen planus, and it is felt that the term is almostuniversally adopted to designate the eruptionwhich is peculiar to a hypersensitive skin. Thishypersensitivity can be inherited or acquired, butin infants and young children there is good reasonto believe that the hypersensitivity is largely in-herited and familial cases are common.

PathologyA focal dilatation of capillaries in the papillae

of the dermis is the earliest histological feature ofeczema. A larger collection of lymph then collectsat the tip of the papillae and exudes through theepidermis, producing a moderate or marked inter-cellular oedema until it collects as microscopicvesicles under the stratum corneum. This ac-

FIG. I.-The early lesion.

counts for the clinical picture of red papulo-vesicles, the vesicular nature of which, if notvisible to the naked eye, is quickly revealed byslight scratching which removes the coveringhorny layer and leaves a moist, brighter red minutemacule which proceeds to dry up, to crust or toexude vigorously. Mild round-celled infiltrationmay be present in the papillae and in the upperpart of the dermis, and there is evidence thatsensitivity may be carried by the lymphocyteswhich are present in the infiltrate. Owing to afurther increase of the inflammatory reaction underthe stimuli of scratching, treatment or infection,all intensive studies of the histopathology merelylead one away from the more characteristic featuresof the early eruption into the common but moremarked changes of non-specific inflammation.

El

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166 POSTGRADUATE MEDICAL JOURNAL March 1952

AetiologyThe most accepted factor in the aetiology of

eczema at all ages is the inherited or acquiredhypersensitivity commonly called allergy, andmany observations have been made on the reactionof the skin to various allergens. This may be doneby intradermal injections or by scratching theclean surface of the forearm and rubbing in pre-pared solutions of food or other common allergens,but a simpler procedure is the use of the patchtest. To perform this test, i in. squares of adhesiveplaster are prepared with a centrally attacheddressing of a in. square of plain open meshbandage. On this central fabric a little powder orsolution of a suspected irritant is applied and thedressing is then affixed to the clean surface of theskin. A number marked on the outside of theplaster serves to record the nature of the allergenwhich is being tested. Some dermatologists usethis method to test a patient's reaction to anumber of common medicaments before they areused in treatment, and while this is a sensible pre-caution, experience usually enables one to decideupon a suitable bland preparation. It is some-times more speedy and equally satisfactory to treatseveral areas of the body with different medica-ments and note which produce the best clinicalresponse and which, if any, act as irritants. It is acurious fact that while many enthusiastic allergistsobtain evidence to support their thesis, an equallylarge number of practicing dermatologists almostentirely ignore the complicated ritual of the cult ofallergy and get equally good results by using thebland methods of local treatmrent which have beenevolved over the last half century.

Rarely an infant's eczema may be dependentupon offending substances applied to the skin,such as various types of soap, soda, the detergentsused in laundering, the perfumes of cosmeticpowders or certain ingredients of dusting powders,such as orris root, or even the metals which arepresent in the oxides used in powder bases. It iscertainly advisable to keep in mind the possibilityof a contact allergen being responsible for aneczematous eruption, but the matter should bereadily established by patch tests and, if thespecific allergen is avoided, the eczema shouldclear up quickly.A smaller number of practitioners believe that

treatment on more general lines with particularattention to consititutional and metabolic factors isof major importance in the treatment of eczema,while others put stress upon inherited qualities ofhypersensitivity and believe that the psychologicaladjustment of the individual to his or her maladyis of outstanding importance. It is probably faircomment to state that no school of thought has amonopoly of success in the treatment of this

troublesome complaint and that the best resultsare likely to ensue if consideration is given to everypoint of view.

Naturally endocrine preparations have beentried out in the treatment of various types ofeczema. As many cases of Besnier's prurigo havevery dry skins they seemed to offer an indicationfor thyroid treatment, but xeroderma of congenitalorigin is really due to a defect in the developmentof the sweat glands, and one cannot stimulateabsent glands by giving thyroid extract. Further,thyroid may make a reactive child more nervousand reactive and this hormone is of little use ininfantile eczema. Cortisone and ACTH have nowbeen used fairly extensively, and although there issome evidence that they diminish the sensitivity ofthe skin and in experimental animals diminish orinhibit the response to allergens, they of en fail toproduce any lasting benefit in the treatment ofeczema. Whether some more potent fraction willbe discovered remains to be seen, but at presentthere is no endocrine which has any constantspecific effect in the treatment of infantile eczema,so no rational indication for their use exists.Much thought has been given to dietetic factors.

In our experierce the incidence of eczema is justas common in breast fed babies as in those whoare bottle fed. Since mother's milk is far lesslikely to contain offending allergens than any otherfood it is obviously wiser to let the mother nursethe child as long as possible. One disadvantage,however, is the emotional bond which developsbetween mother and child more strongly, it issuspected, in the case of breast fed infants. If amother is emotional and easily distressed, as shemay well be by the appearance and discomfort ofher suffering infant, this distress may be conveyedto the baby at her breast. Some dermatologistsbelieve that this factor justifies the weaning of thechild, but this should be done with considerablereluctance after every other measure has been tried.Once an infant is put on cow's milk or;a pro-

prietary food one always wonders whether anoffending allergen is being introduced. It wouldseem that milk allergens are rarely important andthe various preparations of dried milk speciallymodified for allergic infants rarely producesufficient improvement to justify the expense oftheir continued use. This is not to say that a fewweeks' experience with a different brand of milk,or a modified milk, should not be given a thera-peutic trial, tut a mother should not be asked tobear the extra cost if the response is too indefiniteto be recognized. Probably the ordinary pooledmilk as supplied to the public is as satisfactory asany, and there is no particular merit in having T.T.milk, while Jersey milk is usually too rich and hasbeen known to be a factor in the eczema of fat babies.

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March 1952 BRAIN: The Problem of Eczema in Infancy and Childhood 167''he milk for a days' feed should be lightly boiled

for five minutes, then allowed to stand and theresu'ting film removed. This takes with it thelight foreign bodies which may have contaminatedthe milk before it was boiled. Although cane sugaror lactose may be added to the feeds in normalbabies, or to those with mild eczema, in the moresevere cases it is probably better to add glucosewith or without vitamin D, one teaspoonful toeach feed. This sugar is less likely to producegastro-intestinal disturbance because cane sugar issplit into dextrose and laevulose. It is known thatthe liver has more difficulty in dealing with thelatter, and as the liver is the great detoxifying organof the body it is well to make its task as light aspossible in an allergic subject. In some cases theaddition of i gr. of sodium citrate to each ounce ofundiluted milk, or the addition of one tablespoon-ful of lime water to the feed or, more rarely, theaddition of 5 to io m. of hydrochloric acid toeach feed, modifies the clotting or facilitates thegastric digestion of the milk and appears tobenefit the infant.The usual vitamin supplements may be given

but sometimes vitamins A and D are better givenas i minim of halibut oil instead of 60 minims ofcod liver oil, because the larger amount of thelatter introduces a greater amount of the fishallergens and, in some children, produces fattydyspepsia. It may be better in some cases to avoidthe fish oil altogether and give the syntheticvitamins. Cases have been reported in whichorange juice appeared to be an offending allergen,so that a trial should be made with other sources ofnatural vitamin C and occasionally ascorbic acidmay be added in 5 or io mg. doses to each bottle.As many of the patients are reactive and nervousit is thought that there is an indication for extravitamin B complex and the most economicalsource of it is undoubtedly dried brewers' yeastpowder. As this is often too granular to be suckedthrough a teat, it is better to mix the dried powder,which may be obtained from a crushed tablet, in aspoonful of milk, interrupting the feed to give it.When exudation is marked feature of an infant'seczema, it is possible that extra vitamin K may behelpful by increasing the viscosity of the plasma.At this stage of the review of vitamin therapy ineczema, it is well to note that the most extensiveuse of vitamins has so far produced so littleresponse in eczema that many clinicians remaincontent with the routine supplements of thenormal diet.With the introduction of the antihistamine group

of drugs it was hoped that the vascular dilatationand exudation, which are prominent features ofeczema, would be controlled as effectively as insome cases of urticaria. No doubt every anti-

histamine preparation has now been extensivelyused with this hope but rarely with evidence ofany specific action. It seems doubtful whetherhistamine is in this case the trigger which releasesthe eczematous eruption. Fortunately many ofthese drugs have a narcotic or anti-pruritic action,and if one hits upon the right preparation it mayconsiderably relieve the intense itching which doesso much, through the resulting scratching, toaggravate and extend the first localized eruption ofeczema. Occasionally an antihistamine drug willensure sound sleep when the ordinary sedativeshave failed.More recently considerable attention, particu-

larly in the matter of proprietary preparations, hasbeen given to the use of oils containing unsaturatedfatty acids. While there can be little doubt thatthese acids are an essential part of a well-balanceddiet, and they are probably necessary in lipoidmetabolism, there is little evidence that an or-dinary diet is deficient in this respect. It has beenshown that some dry skins, especially if associatedwith scaly follicular papules, suggestive of a mildphrynoderma, may be improved much more bygiving oils rich in unsaturated fatty acids than bygiving extra vitamin A, which was once thought tobe responsible for follicular dyskeratosis. Codliver oil and arachis oil, which are in common useinternally and externally, are good sources of theunsaturated fatty acids, and arachis oil is the usualsubstitute for olive oil in the manufacture ofcreams and oily lotions. If a child is not reactiveto fish or its products and is not obese and sebor-rhoeic it may be advantageous to give full doses ofcod liver oil by mouth and when the skin lesionsare dry and scaly to use creams and pastes mademore emollient by the addition of cod liver oilor arachis oil. Apart from such modifications weare unconvinced that the unsaturated fatty acidshave any specific effect in the treatment or controlof infantile eczema.

It will be noted that the preceding review of theaetiology of eczema gives no clue to a specific factorin causation with the rare exception of an oc-casional discovery of a specific allergy. Becauseof this one becomes increasingly convinced thatmany of these infants inherit a hypersensitiveskin which is intolerant of the ordinary environ-mental factors which do not affect the normalchild. There is nothing particularly novel aboutthis concept because we are familiar with othercases of inherited hypersensitivity. For instance,in epidermolysis bullosa the infant's skin will nottolerate ordinary degrees of injury without pro-ducing large bullae, and in xeroderma pigmentosathe child is unable to tolerate exposure to brightlight without severe reactions ending in freckling,atrophy and actinic keratoses which have a

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i68 POSTGRADUATE lMEl)ICAL JOUtRNAL, M.arch I952tendency to become malignant. Many cases ofeczema have a familial incidence and this is par-ticularly marked in cases of Besnier's prurigowhich, in severe instances, is associated with thewell-known congenital ectodermal defect of xero-derma. In xeroderma there is a demonstrablestructural defect of the epidermis seen as a relativeabsence of sweat and sebaceous follicles. As-sociated with it is a marked instability of the skin,manifest by severe irritation of the flexural sur-faces. Many patients with Besnier's prurigo alsosuffer from asthma or hay fever and these subjectsare regarded as conspicuous examples of allergy orof atopic dermatitis. In these cases the significanceof the inherited hypersensitivity is surely mademore credible by the association with a congenitalstructural defect.

Considering these facts it is reasonable to believethat an infant with eczema simply has a skin soreactive to the common metabolic and environ-mental factors that nothing more can be done thanto protect the skin from every possible externalhazard and to control the symptoms while thechild is reared in a sensible and unemotionalmanner.

Clinical TypesThe commonest type of infantile eczema first

appears as groups of minute papulo-vesicles arisingon the sides of the face, and may aptly be termedthe facial type, although in severe cases the erup-tion rapidly involves the whole of the face, neck,limbs and, later, the body. A second variety maybe termed the flexural type, and the most obstinateand impressive cases in this group have alreadybeen described as Besnier's prurigo. In manycases of eczema, however, the eruption arises inthe flexures or ultimately persists there when otherlesions have disappeared. In severe cases ofBesnier's prurigo associated with a very dry skin(xeroderma) the characteristic eruption of eczemamay be lacking and one sees areas of thickened and

excoriated skin (Fig. z) which are tle result ofscratching because of intolerable itching. Thethird type of infantile eczema is that associatedwith a scurfy scalp and seborrhoeic dermatitiswhich produces areas of scaly inflamed skin inthe scalp, behind the ears, in the folds of a fatneck and on the other moist flexural surfaces of thebody (Fig. 3). Eczematous lesions are very proneto erupt through these areas of seborrhoeicdermatitis, and it is thought that the mild infection

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March 1952 BRAIN: The Problem of Ezcema in Infancy and Childhood 169

is the provocative factor in many cases. Suchcases are not uncommon and unless attention isgiven to control the scurfy condition of the scalpprogress is unsatisfactory.The chief complications of infantile eczema are

pyogenic infections and, very rarely, a primaryinfection with the virus of herpes or vacciniawhich produces the dramatic picture of Kaposi'svaricelliform eruption. This latter complication isassociated with pyrexia and the sudden appearanceof a varioliform eruption, so that those unfamiliarwith it readily mistake the disease for smallpox orvery severe chickenpox.

In the later stages the eczematous areas becomecrusted with plasma or persist for some time asscaly pink patches or, if much scratched, theaffected areas of skin become thickened and showexaggerated lines which are the features describedas lichenification.Treatment of Infantile EczemaMuch space has been given to the aetiological

factors of eczema because it is upon a knowledge ofthese that the principles of treatment are based.It is probably unnecessary to say anything moreabout diet, whilst general treatment consists mainlyin the psychological management of a hyper-sensitive patient and the control of distressingsymptoms by adequate sedatives which may besaid to include some of the antihistamine drugs.In the irritable phases the little patients suffergreatly, and it is important to ensure sound sleepat night at any cost for the sake of the mother asmuch as for the child. A tired, emotional parentis the worst possible nurse for an infant or childwith eczema, so that full doses of chloral, bromideor a barbiturate should be given. It is strange howoften phenobarbitone fails as a sedative in infancy,but in older children it is a more useful drug forcontrolling the irritation and scratch reflex.

Local TreatmentThe most common mistake in treating cases of

infantile eczema is the prohibition of bathing.While plain water obviously irritates a broken andexuding skin, normal saline is almost invariablywell tolerated and daily bathing is a very con-venient method of cleansing the skin and removingcrusts and exudate. When the skin is very dry,as a temporary measure it is useful to cream i oz.of the emulsifying ointment B.P. in a jug of warmwater and tip this into the bath to make a thinemulsion. A trace of a bland soap may usually beused without ill effect, and by trial and error onesoon determines the best procedure to follow.After bathing, the skin should be dabbed dry witha soft towel because any friction is apt to light upirritation which might otherwise have been dis-persed by the bath. In most phases bland lotions,such as calamine, liquor proflavine or i per cent.of crystal violet in water may be used to dry theskin and control secondary infection.

Later the emollient creams, such as that of zincoxide and castor oil or of the oily calamine lotion,may be used with or without the addition of 2per cent. of solution of coal tar or of ichthyol.Alternatively, one may use the plain zinc paste,and this may be modified by the addition of 2 percent. salicylic acid or 2 per cent. yellow oxide ofmercury, if infection is present, and 3 or 4 percent. of the tar solution may be added to the plainpaste or to its modifications. The lichenized areaswhich are so common in Besnier's prurigo some-times respond better to a stronger tar paste andthat commonly used is pasta picis carbonis. Themain purpose of local treatment is to soothe andprotect the skin, and it is often necessary to useloose splints or restraining bandages until theirritation has been controlled. If the little patientcan be diverted by toys and cheerful playmates itis often possible to do without sedatives or re-straining splints. The progress in each case de-pends upon the strength of inherited qualities andupon the parents' understanding and co-operationin dealing with their sensitive child.

RUTHIN CASTLE,NORTH WALESA Clinic for the diagnosis and treatment of Internal Diseases (except Mental or Infectious Diseases). The

Clinic is provided with a staff of doctors, technicians and nurses.The surroundings are beautiful. The climate is mild. There is central heating throughout. The annual

rainfall is 30.5 inches, that is, less than the average for England.The Fees are inclusive and vary according to the room occupied.

For particulars apply to THE SECRETARY, Ruthin Castle, North Wales.Telegrams: Castle, Ruthin. Telephone: Ruthin 66.

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