Is Itching An Emergency?

It is discouraging when a parent checks their child into the Emergency Department for a rash.  Rashes are rarely an emergency and should be seen by the child’s regular doctor.  I often go into these patient’s rooms feeling grumpy:  I feel like this parent is misusing the system, coming to the Emergency Department for convenience rather than being patient and waiting to see their doctor.  However, when I see the child covered with rash and scratching away, I get more sympathetic.  I too have sensitive skin, and itching drives me absolutely nuts.  I imagine this little 2 year old guy trying to sleep at night, but his skin is on fire and he is tearing himself up with scratching. 

Rashes are rarely emergencies, but on the other hand itching is quite miserable.  Itching is particularly bad at night, when the air is dry, and there are no day-time distractions to take the kid’s mind off his itch.  The child is trying to sleep, but the itch won’t let him.  And this is the purpose of this blog: to give parents tools to take care of these problems at home and avoid a time-consuming and expensive Emergency Department visit.  

The most common reason for kids coming to see me for itching is eczema.  Eczema is a condition where skin is extra-sensitive.  Extra sensitive skin easily itches when irritated.  When it itches, kids scratch.  When they scratch, they make a rash.  Eczema if often called the itch that rashes, rather than the rash that itches. 

Eczema is partly genetic.  These kids are born with skin that is extra sensitive, and breaks down more easily.  Then that sensitive skin gets irritated.  Many things irritate eczema skin, like dry winter air or air-conditioned air.  Dusty conditions are drying and irritating too.  Some soaps are hard on eczema skin, like Zest, Ivory, Irish Spring, and Dial.  These soaps are so strong that they wash away the natural oils that skin makes to protect itself.  Finally, skin can be irritated by abrasive things like washcloths, synthetic clothes, and things that chafe like jewelry or wet and tight clothing. 

These things that cause eczema to flare do two things: they dry, or they rub.  And these are the clues to eczema treatment: moisturize, and protect.  The first step in moisturizing is to use a moisturizing soap rather than a drying soap.  Good soaps are Dove, Caress, and Lever.  The next step is using a moisturizing lotion.  This should be smeared all over the child’s itchy dry skin three times daily.  It is especially important that one of those times to put it on is right after the kid takes a bath and dries off.  This ”locks in” the moisture the child’s skin gets from the tub or shower. 

To avoid rubbing injury to eczematous skin, have your kid wear only loose fitting, 100% cotton clothes.  That way the clothes don’t collect sweat and stay wet, and don’t rub too much.  Washcloths often irritate skin too.  They scrub at the skin, which damages sensitive skin.  Kids with eczema should soap up with their hands or a very soft sponge.  Toweling scrubs skin too.  Kids with sensitive skin should be patted dry with the towel, not scrubbed.   

Eczema is often helped by medicines like steroid creams.  Steroids are anti-inflammation medicines, and can calm down inflamed, itchy skin.  Steroid creams come in many strengths.  The mildest is over-the-counter hydrocortisone.  Hydrocortisone will calm down most minor, itchy patches.  Medium and high-strength steroids can only be had by a doctor’s prescription.  I prescribe medium-strength steroids, which are pretty strong but do not have the potential to damage skin.  High strength steroids should only be prescribed by dermatologists, since they can harm skin if used improperly.

Other good medicines for itching are medicines like tylenol, ibuprofen, and benadryl.  Tylenol and ibuprofen take away pain, and itching is actually a minor type of pain.  Since eczema is an allergy-related sensitivity, benadryl can help with that itch too.

So when your child with itchy skin starts scratching and whining at night, try these things to calm and protect the skin.  It that does not work, call your doctor.  Eczema is a chronic condition, and chronic conditions should be seen by the same doctor who knows what has worked and what has not.  Don’t go to the Emergency Department or a walk-in clinic, because you might see different doctors every time, who won’t know your child’s condition.  It is your doctor who will go the extra mile to help your kid with his emergency itching.

The Itch That Rashes

Very few rashes belong in the Emergency Department.  Just about all rashes can wait until the next day to see the doctor.  Parents bring their kids in anyway, often because they are afraid: afraid of infection, allergy, contagiousness, or the rash just plain looks weird.   As we often say here in this blog, it is not an emergency if the child is breathing well, drinking well, alert, and smiling. 

This time of year we are seeing a lot of eczema, and the moms bring in the kids because of the ferocious itching.  Eczema is a medical term for very sensitive, dry skin.  It is often called the itch that rashes, because that sensitive dry skin itches first, then the kid scratches the heck out of it until it gets red, cracked, bleeding, and weepy. 

What makes sensitive skin so bad this time of year?  First, the  air conditioning we all live in now is drying, because A/C extracts water from the air when it cools the air.  The colder it is, the dryer it is.  When you see water dripping out of the bottom of an A/C unit, that is the water that should be in the air moisturizing your skin. 

Secondly, kids get dirtier now that they are out playing more.  Then the soaps they wash with are often too strong, and can wash out the natural oils their skin makes to protect itself.  Examples of drying soaps are Zest, Ivory, Irish Spring, or Dial.  Scrubbing skin with washcloths, and scrubbing dry with towels can damage skin too.

Finally, much of eczema is genetic.  Some people are born with sensitive skin, some more sensitive than others.  Some have eczema so bad that even dermatologists and strong medicines barely control the cracking and scarring.  Here is what you can do to make your kid with dry, itchy skin happier until you see their doctor.

Turn your A/C unit to 75 degrees.  That should be comfortable for you in shorts and t shirts in the house and a sheet only in bed at night.  Switch to moisturizing soaps like Dove, Caress, or Lever 2000.  Apply moisturizing lotion three times daily, especially after the bath.  Use your hand instead of a wash cloth when bathing your child, and pat dry with the towel instead of scrubbing dry.  Keep your kid’s fingernails trimmed- long, sharp fingernails are better at tearing skin and making itching and infection worse.

Finally, for bad dry patches that just won’t heal with this care, see your doctor about medium-strength steroid ointments.  You only need a small ball of ointment (a little bigger than the size of a BB) for each bad patch.  Ibuprofen or acetaminophen (Tylenol) take the edge off itching, just like they take away pain.  High strength steroid creams, steroid pills or liquids, or other medications should be prescribed only by dermatologists for severe cases.  

 So next time you or your child get a bad itchy rash, try the above things to make skin better.  Before you go to the Emergency Department for a rash, call your doctor.  Unless your doctor says otherwise, rashes can wait for the next appointment.   And find those fingernail clippers!