Eczema in children: the basics every parent should know

If your baby’s cheeks are red and rough, or your toddler scratches behind the knees until they bleed, you’re probably looking at eczema. It’s one of the most common reasons parents bring a child to the doctor, and it’s frightening the first time you see it. The good news is that eczema is well understood, it’s manageable, and most children get better as they grow. Here’s what’s actually going on in that skin.

What is eczema, and what is atopic dermatitis?

“Eczema” is a family name for several conditions that make skin inflamed, dry and itchy. When a child has eczema, it’s almost always the member of the family called atopic dermatitis: “atopic” means the person has an inherited tendency toward eczema, asthma and hay fever, and “dermatitis” just means inflamed skin.

Atopic dermatitis is long-term and comes in waves. There are flares, when the skin is angry and itchy, and quieter periods when it looks nearly normal. It’s not contagious, and it’s not caused by poor hygiene or by something you fed your child.

How common is it in Canadian kids?

Very. The Canadian Dermatology Association estimates that up to 17% of Canadians will have atopic dermatitis at some point in their lives, and the Eczema Society of Canada puts it at about 15% of children and 4% of adults in Canada, with most cases mild to moderate.

It usually starts early. The Canadian Dermatology Association notes that atopic dermatitis almost always begins in infancy or before age five, and DermNet reports that about 80% of cases start before age six. So if your child’s eczema showed up in the first year, that’s typical, not a sign of something unusual.

Where does it show up at each age?

The pattern moves around as children grow, which can be confusing when the rash you learned to recognize on your baby turns up somewhere else at three.

• Babies (under about one year): cheeks, forehead and scalp are the classic spots, along with the outer arms and legs and the trunk. The diaper area is usually spared, because it’s kept moist. Babies can’t scratch well, so they rub their face on the sheets or squirm against your shoulder.
• Toddlers and school-age children: the rash tends to settle into the skin folds, especially the creases of the elbows and behind the knees, plus the wrists, ankles and neck. Instead of a weepy rash, older children often get small, itchy bumps and, with repeated scratching, patches of thickened, leathery skin.
• Teens: the folds are still common, and the hands, eyelids and the area around the eyes join in.

On lighter skin, eczema looks red or pink. On darker skin, it can look brown, purple, grey or ashy, and patches may end up lighter or darker than the surrounding skin for months after a flare. That’s a normal part of healing, not scarring.

Why does it happen? The barrier and the immune system

Two things go wrong at once in atopic dermatitis, and they feed each other.

The first is the skin barrier, the outermost layer of skin that works like a brick wall: skin cells are the bricks, and natural fats are the mortar. In many children with eczema, the wall is built with less “mortar” than it should have, partly because of genes involved in barrier proteins. A leaky wall lets water out, so skin dries fast, and lets irritants, allergens and germs in.

The second is the immune system. In atopic skin, immune cells overreact to things that cross the leaky barrier, releasing chemical messengers that cause redness, swelling and itch. Some of those messengers also weaken the barrier further. Then scratching tears the wall a little more, more irritants get in, and the cycle turns again.

That’s why the foundation of care is boring and repetitive: moisturize the wall every day, calm inflammation when it flares, and keep the skin away from what triggers it. A 2022 review in the Canadian Medical Association Journal found that any type of emollient (the medical word for a moisturizing lotion, cream, gel or ointment) applied twice daily helps manage atopic dermatitis and prevent flares, and that the best moisturizer is simply the one you’ll actually use. If you want to compare fragrance-free options, the moisturizers and baby care pages on this site list products whose claims have been reviewed.

What does the itch mean for a child?

Itch is the symptom that runs the show. It keeps babies fussy and wakes children at night, and a tired, itchy child is a miserable child, along with tired parents. The Eczema Society of Canada describes it as an itch-scratch cycle: scratching inflames the skin further, and more inflammation means more itch.

This matters beyond comfort. Broken skin is an open door for bacteria, and the same society notes that prolonged scratching can lead to infection. If your child’s eczema suddenly looks worse, with weeping, yellow crusts, painful areas or small blisters, that’s a reason to see a doctor promptly rather than wait it out.

What is the outlook?

Honest answer: it depends on the child, but the trend is toward improvement. DermNet cites follow-up data showing about 20% of children with atopic dermatitis still had it eight years later and fewer than 5% did after 20 years. Eczema that starts before age two tends to do better than eczema that starts later. Some children keep dry, easily irritated skin into adulthood even when the rash is gone, and a few have persistent, more severe disease.

There’s no cure yet, but as the Eczema Society of Canada puts it, most people with eczema can achieve excellent control and live comfortably. Treatment aims to relieve discomfort, prevent flares, prevent infection and stop the skin from thickening.

What should you do first?

Start simple. Keep baths short and lukewarm with a mild, fragrance-free cleanser. Moisturize every day, generously, and again after every bath. Notice what seems to set off flares: heat, sweat, wool, scented products, dry winter air. Keep fingernails short.

Then get a partner. Your family doctor, paediatrician or pharmacist can confirm it’s eczema (a few other rashes look similar in babies), suggest a prescription cream for flares and tell you what to expect. If the skin isn’t better after two weeks of regular care, if your child is losing sleep, if the rash is spreading widely, or if you see any sign of infection, don’t wait: book the visit.

Eczema is common, it isn’t your fault, and it usually eases with time. In the meantime, a leaky barrier and a jumpy immune system are the two things to keep in mind. Everything you do, from moisturizer to trigger-spotting to a doctor’s help when it’s needed, is about protecting that wall and calming that reaction.