If a pediatrician will pay some attention to eczema he can treat it quite well, and will not often need to send these patients to a dermatologist. Let him first be sure, however, that he is dealing with eczema, and not with some less common skin disease of which he probably knows nothing, such as lichen planus, psoriasis, or dermatitis herpetiformis. If there is any suspicion in his mind that such may be the case, let him send the patient to a dermatologist and save himself much embarrassment. I often do this, and am usually glad I did; some of the more uncommon skin diseases are far beyond the diag­nostic and therapeutic ability of pedi­atricians or allergists.

It is not necessary to do skin tests on all children with eczema, and some dermatologists think that scratch or intracutaneous tests are of no value for any child with eczema. I do not quite agree with this, and believe that often valuable information may be obtained by scratch and intracutane­ous tests, and also by patch tests, when used in the appropriate pa­tients. However, if it seems clear from the history and from inspection that the eczema is not of allergic ori­gin, skin testing is not indicated.

Skin testing will be discussed more fully in the section dealing with atopic and contact eczema.

No child with eczema should be vaccinated nor should he be exposed to a child who has been recently vaccinated. The virus of cowpox is extraordinarily contagious if the skin is broken, and most of the cases of eczema vaccinatum that I have seen have been acquired from a sibling. Direct contact is not necessary-the virus has been found in dust, and on clothes, towels, and bedclothes, and may live for two months.

If the mother has herpes of the lip and her baby has eczema, the baby will probably acquire Kaposi’s varicelli-form eruption from her, which clini­cally closely resembles eczema vac­cinatum. If possible, mother and child should be separated until she is over the herpes: Kaposi ’s eruption is no light matter.

Other Immunizations.-A baby with eczema is no more likely to be upset by tetanus, diphtheria, and pertussis immunization than is any other child. However, if the eczema is severe, it is wiser to wait until it is better than to run the risk of adding insult to injury. Immunization with influenza vaccine should not be done to any child who is sensitive to egg white.

1. Hospitalization.-There are two advantages to hospitalization; these are usually outweighed by the dis­advantages and I hospitalize only a small proportion of my eczema pa­tients. The first advantage is that the patient can be seen every day, and treatment can therefore be fol­lowed more efficiently than if he is seen at longer intervals in the office. The second advantage is that the mother gets a much-needed rest. Few people have nursemaids now, and the strain on the mother is no light mat­ter when she is continually occupied during the day with a fretful, itching eczematous baby, and often up a good part of the night with him as well. Often these poor women are ex­hausted. They must have a rest: hospitalization of the baby provides it.

The disadvantages of hospitaliza­tion are two:

A. Infection: Babies with eczema are unduly susceptible to respiratory infection; they are more likely to acquire this in a hospital than at home. This is particularly true of babies with atopic erythroderma; not a few of these die from pyogenic respiratory and blood stream infec­tion.

B. Expense: There is no use in hospitalizing a child with eczema for a few days. If any good is to come of it he needs to stay for several weeks. The expense is too much for most people, and a good part of the time is not justified by the results. If it were certain that the child could be entirely cured by hospitalization, almost any expense would be justi­fied. This is not so, however, and it is common, particularly with older children where environmental aller­gens are likely to be involved, for them to be discharged from the hos­pital nearly or entirely free from eczema, and the whole thing comes back as bad as ever before they have been home a week.

As a rule, a young couple with an eczematous child can spend their money to better advantage on a good woman, or even a high school girl, to take charge of the child part of each day in order to relieve the mother than they can by letting the hospital have it. There may be, of course, circumstances which make hospitali­zation imperative, no matter what the expense.

2. Nutrition.-Although sometimes removal of certain foods from the diet helps babies with eczema, this prac­tice should not be carried to a foolish extreme, which is too often done. The child must have an adequate, well-balanced diet, no matter whether he has eczema from it or not. If a baby with eczema is too thin (which is not usual), he should be made fatter; if he is too fat (which is common), he should be prevented from getting any fatter.

The more rapidly a baby gains in weight, the more active is his eczema likely to be, and I think that a good many cases of eczema (particularly seborrheic dermatitis) are due more to eating too much food in general than to any specific food sensitivity. You are often between the devil and the deep sea in feeding a large, thriving and vigorous baby with eczema-he wants to eat more than his skin can handle. If he eats as much as he wants, his eczema is worse; if he is not fed as much as he wants, he cries all night.

3. Itching.-Seborrheic dermatitis and monilia infections often itch but little; atopic, contact, and nummular eczema itches a great deal. From the mother’s point of view, the most im­portant thing in treatment is to stop the itching. It is not possible to do this entirely. The local applications which have the most antipruritic effect are phenol, camphor, menthol, coal tar, and benzocaine. Of these, benzocaine is probably the best. If itching in an adult is con­fined to some small area, as it often is, it is possible to do a good deal for it with various local applications.

The trouble is that in most babies and children with eczema, the eczema, and consequently the itching, is diffusely scattered, and so in order to control it, it would often be necessary to cover the child’s whole body with an anti-itch preparation. Another trouble is that menthol, phenol, and camphor sting a good deal when first applied unless the skin is entirely un­broken, which is rarely the case in ec­zema.

Crude coal tar is moderately antipruritic, and if the state of the eczema is such that tar is indicated for local treatment, this may relieve the itching. The trouble with benzocaine is that it is a strong sensitizer; also it is not desirable to use it over large areas. The various antihistamine salves, which a few years ago were so often recommended for the treat­ment of itching, most of the time do no good. I do not usually expect to accomplish a great deal by the local treatment of itching, but probably accomplish more by the use of various tar ointments on the arms and legs and by bandaging these parts than in any other way. For small areas it has seemed to me that “Caligesic”* ointment, which contains 3 per cent benzocaine, works as well as any­thing ; and I think that babies and children are less likely to become sensitized to benzocaine than are adults.

If there is itching with unbroken skin, as there sometimes is if the itching is due to “dry” skin, or sometimes to food sensitivity or to urticaria, the following prescription, which is clean and easy to apply, often works fairly well.

Liquor carbonis detergens   (N.F.)   3 iv

Phenol 3 ss

Menthol gr. x

Powdered tragacanth q.s.

“Neobase” ii

Camphor water ad  viii

S. Shake well before using.

Itching at night is better controlled by a sedative given internally than by any local application, but this is often not very satisfactory either. The trouble is that many children are stimulated rather than quieted by the barbiturates, and that others, in order to be put to sleep, need a dose which is close to the danger mark. If it were a question of doing this only occasionally, there would not be much objection to it, but it has to be done every night over a considerable period.

However, the barbiturate drugs are by no means without value; the ones to use are phenobarbital, Seconal, and Nembutal. Phenobarbital is slow in action-it takes aboiit an hour before it begins to work, and the sedative effect, if it does work, is prolonged. The elixir of phenobarbital (U.S.P.) contains about Ys grain phenobarbital to the teaspoonful.

Seconal and Nembutal work more quickly, in about twenty minutes, but the duration of sedation is much less than with phenobarbital. The elixirs of these contain 1/4 grain of the drug to the teaspoonful. There are also suppositories of each, in 1/2 and 1 grain strengths. A good plan is to give the baby 6 to 8 months old a dose of phenobarbital of % grain about an hour before he is to be put to bed, and ^l/2 grain of Nembutal or Seconal if he does not go to sleep or if he wakes up and fusses after he does go to sleep. Sometimes the barbiturates, when given in this way, work pretty well-more often they are not much good. Many times I have seen eczem-atous babies in the hospital kept by the resident in a continual state of coma by large doses of phenobarbital given “round the clock.” True enough, the baby is quite comfortable, and is put out of circulation to the extent that he cannot even raise a finger, let alone scratch with it, but such treatment certainly should not be kept up for long, and should not be used in the home at all.

In about one case in twenty Benadryl will make a baby so sleepy that he will not scratch. “When this works it is the best means of controlling the itching; most of the time it is no good. The dose is 1 teaspoonful (10 grains) of the elixir two or three times during

the day if needed, and twice at night, for a 6- to 12-month-old baby, with four hours between doses. The dos­age that I have usually seen given is smaller than this, and is not enough.

Taking everything into considera­tion, it has seemed to me that chloral hydrate is the best sedative for these babies. I have used Noctee [Squibb's   chloral   hydrate   preparation], and start with % teaspoonful. If this does no good, the next night the dose is raised to I teaspoonful (7 1/2 grains chloral), for a baby 1 year old. This is a pretty good sized dose of chloral for a baby. I have seen it do no harm. Less than this will not do much good.

4. Restraint.-A large amount of the skin trouble on any baby or child with eczema is caused by what he does to himself. No skin can heal when it is continually scratched and rubbed. In many hospitals the baby is “spreadeagled,” that is, his wrists and ankles are wound with sheet wadding and then tied by tapes to the sides of the crib. This can rarely be done at home-the mother will not do it, and I do not much blame her. I no longer recommend it. I once saw a baby about 1 year old with severe atopic erythroderma, whose arms had been kept tied to the crib for several months. Every minute he was awake he was struggling against his bonds, and he used his arm muscles so much that his biceps became as hard and stuck out as much as those of a prize fighter. It is as well to make up one’s mind that it is not possible to prevent entirely a baby from scratching and rubbing, no matter what is done. However, a good deal of it can be prevented. It has seemed to me that

the use of elbow splints probably accomplishes more than anything else.* Elbow splints prevent the baby from scratching his face, and if his legs and arms are bandaged (see be­low), and the rest of him is kept well covered by clothes, he cannot do a great deal of scratching. It is also a good idea to put little cotton cloth bags over the hands or to put the hands in the toe of a small white cot­ton stocking and then to pin the other end of the stocking to the shirt, so that even if the baby does get his hands into contact with his skin, he cannot dig it with his fingernails. It is not possible to prevent rubbing of the face on the shoulder, but it can be seen to that what it is rubbed on is soft cotton and not wool.

5. Bandaging.-Bandaging the arms and legs is of the utmost importance, and does so much good that I would not think of treating an arm or leg eczema of any moment without it. Eczema of the popliteal or anticubital spaces, or of the wrists or ankles of older children, should always be bandaged. It is impossible to prevent outside trauma if this is not done, and good results can never be ob­tained in the treatment of any eczema if there is continual picking, rubbing, and scratching. To put the skin at rest and to give it a chance to heal is the first principle of local treatment. It is surprising to me to see how many people pay no attention to this. They seem to think that removal of some food from the diet or the use of a salve is enough. It never is.

The details of bandaging are im­portant. Whatever salve is being used is applied, then a soft piece of white cotton cloth (never gauze), then a 2-inch Ace elastic bandage goes over this. When applying the band­age to a leg it is well to start it under the foot-it stays on better than if started at the ankle. In the same way, if bandaging the arm, the bandage should be started between the thumb and forefinger, then carried up around the wrist. The bandages should be considered part of the child’s clothes, and are put on every day just as the clothes are, but are to be off only once in twenty-four hours to put on new salve. When bandages are taken off it is best to take off only one at a time, apply the salve, and put the bandage on again before taking off another one, so that the child cannot get at himself during the bandaging process. One minute of scratching can undo the improvement of weeks.

6. Ultraviolet Light.- This may occasionally help older children who have what I call “winter skins” (thick and dry), and who are nearly free from eczema in the summer, and begin to have it in the fall “as soon as the heat is turned on.” These children are usually at their worst in the early spring. I have had by no means a large experience with ultraviolet light. I use it sometimes when I am at my wits’ end and do not know what else to do and I think the parents need treatment, which they usually do. Ultraviolet light treatment is good medicine for the parents-it makes them feel that they are really doing something. Furthermore, it may actu­ally help the child, particularly his itching. An ultraviolet light* is used, which can be bought for about $10.00.

It is put into a “bridge lamp” stand and kept at a distance of 30 inches from the patient. Treatment is started with an exposure of 1/2 minute to the front (the child is naked), and i/₂ minute to the back. The time of ex­posure is increased a minute each day up to 20 minutes for the front, and 20 minutes for the back.

The best discussion of light treat­ment I know of is in that splendid little monograph of Nexmand’s, Clinical Studies of Besnier’s Prurigo. This was published in Copenhagen in 1948, but is written in English.*

Nexmand worked at the Finsen Institute and treated fifty-seven pa­tient’s with atopic dermatitis (mostly children). The light baths were given in the outpatient department every other day. If the patient tolerated the treatment, the baths were given in a series of thirty to forty, the num­ber of treatments depending on the skin condition. Of fifty-seven pa­tients treated, thirty-three were con­siderably improved.

7. Bathing.-It is sometimes said that babies with eczema should never be washed with water. I do not entirely agree with this. If there are many breaks in the skin the baby is likely to cry when put into water- it stings him. For such babies tub baths should not be used, but sponge baths of the diaper region, axillae, and groins can be given. If there is eczema of the arms and legs and bandages are being used, it is best to keep these parts dry. Some babies with eczema like to be put into the tub, some do not. The best thing to do is to try it and see what happens. If water irritates neither the baby nor his skin, there is no harm to it.

*It could be obtained (when I got it) from Walter J. Johnson, 125 Bast 23rd St., New York (dealer in foreign medical books), and I recommend it highly to anyone who is seriously interested in atopic dermatitis.

8. Soap.-It is true that if a woman has eczema of the hands and does much dishwashing with soap, her eczema will be worse or, in some women, eczema may be actually caused in this way. I am pretty sure that I have never seen eczema in a baby or child caused by any mild soap, and I have seen no harm done to eczematous children with it unless it is used on acute, very tender areas. If it is found that soap does irritate the skin it is best to use “pHisoderm,” or “pHisoHex,” if any infection is pres­ent.*

*Soap substitutes made by Winthrop-Stearns, Inc., New York.

Classification. In order to treat eczema intelligently, it is first desir­able, if possible, to find out by the history, the appearance and distribu­tion of the lesions, the symptoms, and, possibly by skin tests and other laboratory procedures, what sort of eczema it is, for eczema is an inflam­mation of the skin under which are grouped a number of entities of vari­ous causation.

It is true, however, that about 75 per cent of the “eczema” that is seen in infants and children is atopic dermatitis, that is, the sort of eczema which often occurs with asthma or hay fever, and to which there is a certain amount of hereditary predis­position. Other forms of eczema that may be seen in the young are sebor-rheic dermatitis, infectious eczema-toid dermatitis, nummular eczema, contact eczema, and rarely eczematoid fungus infections.

History.-The first step in treat­ment is a detailed history: this is of the utmost importance. Some of the things that you want to know are as follows:

1. Do the father, mother, or any of the siblings have eczema, asthma, or hay fever? What any less closely connected relatives have or may have had is, in my opinion, of little import. If the father or mother has hay fever, the chances are that what the child has is atopic dermatitis.

2. How old was the child when the eczema began? Atopic dermatitis can begin at any age, but not com­monly before the third month. “Eczema” before this age is likely to be seborrheic dermatitis, or, if in the newborn period, possibly a monilia infection. If the eczema began sud­denly and the child is over 2 years old, it is often due to contact with something from the outside.

3. Upon what part of the body did it begin? Atopic dermatitis in early infancy commonly starts on the face. In children over one year old it is more likely to begin in front of the elbows and back of the knees. If it does begin in these places, it is prob­ably due to environmental allergens rather than to foods. Monilia in­fections are likely to have their origin around the anus. Contact eruptions may start on any part of the body, according to what contact is causing the trouble. Seborrheic dermatitis often begins with cradle cap, and intertrigo in the axillae, groins, and around the navel.

4. What was the diet when the eczema began? What foods have been omitted from time to time? Did the removal of these foods do any good? Is the mother sure from what she has seen herself, and not from what some doctor has told her, that any food makes the eczema worse?

5. Does the child sleep on a feather pillow? Is there a dog, cat, or bird in the house? Is there a barn or hen house on the place, and if so, how near is it to the house, and how many horses or cows or sheep are there in the barn, and how many hens in the hen house? How much does the child go into either place? What is the father’s occupation? Does anybody in the household ride horseback? I have seen atopic dermatitis in a young child aggravated by contact with the riding clothes of an older sister.

Does con­tact with wool make the eczema worse? Did it begin shortly after the wearing of any new clothing? Does the child creep? Creeping, and the resulting contact with rough wool in the rugs, possibly dyes, and possibly inhalation of and contact with dust, when close to the floor, often aggravates or causes eczema. If by the appearance and distribution of the eczema (especially in babies) a contact eruption is sus­pected, what detergents or bleaching powders have been used in laundering the underclothes and diapers? Have plastic diaper protectors been used?

6. Is the itching very severe, or slight, or is there no itching? Atopic and contact dermatitis always itch; in seborrheic dermatitis there is often no itching.

7. What local applications have been used in treatment? Has any salve or lotion been used which has made the eczema worse? (See sec­tion on contact dermatitis.)

8. Has cortisone been used, and, if so, in what dosage, and for how long?

9. Does the baby keep the mother awake all night, and is she “on the verge of a nervous breakdown”? If so, what sedatives have been given the baby and with what result? Prom a practical point of view these ques­tions are very important, for in many cases treatment of the mother is as necessary as treatment of the baby, and if she is about at the end of her rope, it may be necessary to hos­pitalize the baby or to use cortisone for a while.

10. If the trouble suggests moniliasis, did the mother have a vaginal discharge during her pregnancy or did the baby have thrush in his mouth while in the hospital?

11. In older children who have had eczema for several years, it is of con­siderable importance to find out if there is any seasonal variation in its severity. This may point the way to the cause (possibly wool or dust in the winter, pollen in the summer).

12. Is the child having difficulty with schoolwork, or any other psycho­logical trouble?

Inspection of the Skin.-The next step is a careful inspection of the skin. A trained dermatologist ob­serves the distribution of the lesions, which may be of great importance in diagnosis, their kind, whether papu­lar, macular, crusted, scaling, erythem-atous, pustular, or sharp margined, and especially the characteristics of the primary lesions, which may mean a great deal to him, and the stage of the dermatitis-acute, subacute, or chronic. Evidences of infection are particularly important to look for, and one small pustule, a subsiding paronychia, or any skin infection on the mother’s face, arms, or hands may tell a good deal about the nature of the trouble in the child. All these questions go through the mind of a dermatologist automatically as he makes a diagnosis and plans treatment.

The pediatrician should train himself to do likewise. If he makes a practice of setting down on the child’s record some of these details, such observation will soon become as automatic for him as it is for the dermatologist.

From the history and from inspec­tion of the skin a fairly accurate idea of the type of eczema present can usually be obtained.