Infant Eczema Diagnosis
Filed under: 1 - Principles Of TreatmentClassification. 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.
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