Eczema (atopic dermatitis) is a chronic and recurring inflammation of the skin that usually starts in early childhood. It typically appears as dry patches of skin that can be extremely itchy and uncomfortable. Eczema can appear on any part of the body. In babies, it often starts on the face. In toddlers, it moves to the forearms and shins. In older children, it typically shows up in front of the elbows and behind the knees. If eczema persists into adulthood, the face, eyelids and hands are frequently affected. Eczema affects probably 10-15% of the population and is becoming more common for reasons that are not well understood. The frequency is variable throughout the world. Eczema is a condition that is easily recognized by dermatologists. Three quarters of the time, eczema presents itself in the first six months of life. The condition comes and goes over the years with frequent flare-ups. In Greek, eczema means to” boil over” and this refers to the weeping stage of acute eczema. Eczema, hay fever and asthma are grouped together in a complex known as atopy. The psychological impact of this disease is significant, especially feelings of embarrassment. Sleep disruption is common (80%) and 60% report the condition affects their daily activities.
Common features of eczema include:
Dryness: Skin affected by eczema looks and feels very dry and scaly. The skin of eczema is unable to provide adequate “waterproofing” so there is an increased evaporation of moisture from the skin’s surface, which leads to further dryness.Inflammation and Redness: There is no eczema without inflammation. This is likely due to the immunological response. Inflammation produces redness on the skin. In severe cases, it may be generalized so that all of the skin is involved. The redness is associated with swelling of the upper part of the skin in both the epidermis and the upper dermis.
Itchiness: Itching can be severe at times, and often leads to discomfort, agitation and frequent interruption or loss of sleep. Constant itching may also lead an individual to seek relief by scratching the affected area. Unfortunately scratching will not only irritate the skin, but further damage the skin barrier and provoke the release of pro-inflammatory mediators such as cytokines, which can prolong and intensify itching.
Thickening of Skin: Repeated rubbing of the skin due to irritation and itching may cause the skin to thicken over time. Thickening of the epidermis will often produce skin markings, called lichenifications. They commonly appear as a criss-cross pattern on the thickened skin, and are commonly seen in front of the elbows and behind the knees.
Infection: Bacterial infection is almost inevitable in atopic eczema. Most patients with active eczema will carry Staphylococcus aureus on the skin, which can often cause flare-ups of itching and inflammation. Sometimes yellow crusting is seen, but more frequently the skin only shows erosions.
The cause of eczema is not entirely understood. In eczema, an overreaction in the immune system and a problem with the barrier function of the skin limits its ability to retain water, and also allows irritants and potential allergens to penetrate the skin stimulating an immune response. This causes the skin to become dry, inflamed and itchy.Skin affected by eczema can also act if it is immune suppressed, therefore becoming more susceptible to infection. Although, there are no specific tests available to confirm the diagnosis, the majority of cases show an increase in immunological activity. Some with eczema will have a defect in the production of filaggrin, which is important in the regulation of the skin barrier. Not all individuals with eczema have a filaggrin defect.
Because eczema tends to be chronic, treatment strategies must be practical and sustainable.Learn to recognize and diagnose the condition promptly and initiate treatment. Eczema sufferers have a predisposition for developing other atopic conditions, such as asthma and hay fever.Maintaining a diary to track flare-ups, the use of medications, moisturizers, and cleansers can help to guide therapeutic decision-making by treating physicians. Identify and eliminate relevant triggers (e.g., irritants, aeroallergens) and seek ways to reduce stress. The regimented use of emollients can partially repair and restore the skin barrier and reduce infections and allergic reactions. Body washes incorporating non-irritating surfactants, emollients and humectants can replenish barrier lipids. Lukewarm baths (5-10 minutes in duration) are recommended over showers. Creams and ointments are more effective for eczema. Ceramide-based barrier repair products have a significant place in eczema care. Generously and regularly apply moisturizers 3-5 minutes after bathing and throughout the day.
The most effective way to combat eczema is good skin care and hydration.If you have eczema you should avoid soaps, especially bar soaps, as they will cause dry skin and may damage the skin barrier. Only mild soap-free cleansers, preferably liquid, should be used. These cleansers will gently remove dirt, excess oil, bacteria and cosmetics without damaging the skin barrier.Moisturizers are extremely helpful to restore and maintain the skin’s natural moisture levels. Frequent application of moisturizing creams can help soothe dry and itchy spots.Make sure to avoid any allergens that may irritate the skin and trigger a flare-up. Look for skin care products that are fragrance-free and hypoallergenic.
When flare-ups occur, begin immediate treatment to break the itch-scratch cycle and limit severity. Consider increasing the use of emollients to reduce itch intensity.Over-the-counter preparations that include a topical corticosteroid (such as clobetasone butyrate and hydrocortisone) can control inflammation and restore the skin barrier. The intensive use of emollient-based products can reduce the need for topical steroids.
A doctor may prescribe topical steroids, which have been extensively used for over 40 years to treat various inflammatory skin conditions. There are a large number of topical steroids available. These quick-acting agents are the mainstay of therapy for eczema because they are effective for reducing inflammation and itch.Intermittent use of tacrolimus, pimecrolimus or calcinurin inhibitors, can be used for flare prevention. There is some evidence that calcinurin inhibitors may be less damaging to the barrier function of the skin compared with topical corticosteroids.Topical steroids are available as creams, lotions, gels and ointments; some products can also provide moisturization. These medications can be used effectively and safely while under the care of an experienced physician. The use of oral antibiotics to reduce bacteria is also helpful in difficult cases, even though there may be no obvious signs of infection.Topical antibiotics such as Bactroban or Fucidin have shown some benefit but are not as easy to use compared with the systemic approach when the eczema is extensive. Cloxacillin, erythromycin or cephalosporins may be needed for a few weeks.Oral antihistamines have also been helpful in reducing itching, mostly through sedation. These are usually used at bedtime. Hydroxyzine has been used with good effect.
In some cases medical procedures may be used. Phototherapy is especially useful in cases of stubborn, chronic atopic dermatitis.