Eczema

What is Eczema?

Eczema, also called atopic eczema and atopic dermatitis, is an inflammatory skin disease. The condition is recurring, and most cases are mild. Eczema commonly occurs in children and adults. The disease tends to gradually improve with age, and most eczema in childhood has resolved by adulthood. Eczema is not contagious and requires treatment to prevent a poor quality of life. The word 'atopic' means that there is an increased chance of getting other allergic conditions, particularly asthma and allergic rhinitis (hay fever).

Getting Treatment

The Online Clinic provides free consultations for patients with suspected eczema. Private prescriptions are also available via this service from £29.95. The service is available for patients 18 and over only.

Who gets Eczema?

Eczema is estimated to affect about 10%–30% of children and 2%–10% of adults. Around 45% of cases start before 6 months of age, 60%–65% develop in the first year of life, 70%–90% of cases occur up to the age of 5 years, and up to 30% of cases first occur in adulthood. Eczema more commonly develops in people who live in urban areas than those in rural areas.

What causes Eczema?

The cause of eczema is complex, with genetic, immune system, and environmental components involved in its development. Eczema is also the result of a defect in a gene (the filaggrin gene). A gene mutation results in the protective outer layer of skin becoming 'leaky', thereby allowing water loss from the skin and the entry of harmful irritants, allergens, and microbes. People with eczema also have fewer proteins in the skin that defend the body from microbes (bacteria, fungi, and viruses) causing infection.

Regarding involvement of the immune system and environment, irritants and microbes can cause an inflammation, while allergens can cause both the immune system to become very sensitive and trigger allergic reactions.

What triggers Eczema?

Eczema can be made worse by many different factors.

• Commonly, exposure to perfumed cosmetics and lotions, soaps, detergents, and cleaning products, as well as metals and latex (rubber) can be irritant allergens and act as triggers.
• Allergens that are inhaled may include dander from animals, house-dust mites, pollens, and moulds.
• Some people react to fabrics (e.g., wool and synthetic fibres) that irritate the skin or prevent air circulation.
• Skin infections can trigger eczema since the microbes tigger an immune response, which then causes worsening of the condition.
• Women may find their eczema worsens with the hormonal changes that occur during the menstrual cycle (usually before a period) and pregnancy. Similarly, stress and anxiety can also make eczema worse, due to the release of the stress hormone cortisol that increases inflammation.
• Infections can affect eczema symptoms.
• Lack of sleep can trigger eczema symptoms by affecting the skin's barrier function, since it interferes with the healing of damaged skin that occurs during the night.
• Extremes of temperature, and changes in climate affect people with eczema, since the condition tends to be better in summer and worse in winter - particularly in cold dry winters. Additionally, sweat due to heat or exercising can be an eczema trigger, especially if left to dry on the skin, since it leaves a salty deposit that acts as an irritant.
• Eating certain foods may trigger a flare up although not everyone has reactions to the same foods. Common foods that trigger eczema flare ups are milk, eggs, peanuts, tree nuts, wheat, soy, shellfish, and fish.

What are the signs and symptoms of Eczema?

Eczema appears as red, dry patches of skin that are intensely itchy. The condition can lead to a cycle of itching and scratching, whereby the itch leads to scratching and rubbing, which results in worse irritation. Typically, patches of oozing and crusty blisters firstly appear, followed by the patches developing into red, dry, scaly areas of skin; continuous scratching of these patches then results in skin thickening. Eczema typically fluctuates between periods of flare (worsening) and remission (improvement).

The appearance of the rash and sites affected vary with age, becoming more localised with age. In infants, an oozing red scaly rash is widely distributed on the body and occurs on the face and neck, while in children and adults, a scaly dry rash tends to occur in the elbow bends, behind knees, and on the wrists and ankles.

How is Eczema diagnosed?

A diagnosis of eczema is usually based on medical history and examination of the rash. The key symptom is itch. Other investigations are not usually necessary unless the doctor needs to exclude similar skin conditions or a food allergy. In that case, then blood tests for the antibody immunoglobulin E, skin-prick testing, and/or rarely a skin biopsy may be arranged.

How is Eczema treated?

Eczema management and treatment depends on the severity of the condition, which varies considerably between individuals. Eczema can usually be controlled with treatment, but if poorly controlled it can greatly affect a person's well-being. Skin hydration with emollients and management with topical anti-inflammatory medicines are key.

Hydration of the skin is critical irrespective of disease severity to improve the poor skin barrier. Daily skin moisturising using a fragrance-free emollient (moisturiser) is essential, as well as washing with a moisturiser (soap substitute) and bath oil. Moisturiser should be used at least twice daily, depending on the skin's dryness. Ointments are preferred to creams, as they remain on the skin's surface for longer and therefore provide a better barrier to water loss and infection.

Individuals should identify and avoid any triggers. Foods that cause reactions should be eliminated from the diet, following advice from a doctor and a positive skin prick test. Development of food allergies may be prevented in new-born babies by exclusive breast feeding until aged 4–6 months.

Control of flares and itch generally requires treatment with topical anti-inflammatory medicines, usually corticosteroids, until the flare has subsided. Topical corticosteroids may be used intermittently over the long term for control of areas of skin that frequently flare. Topical calcineurin inhibitors may be considered for flares and long-term use instead of topical corticosteroids, particularly where the eczema affects sensitive skin areas (face, under arms, groin, and under skin folds).

When eczema cannot be controlled effectively with topical treatments (even though the treatment regimen has been strictly followed), and the eczema is moderate-to-severe, systemic treatment with medicines that are anti-inflammatory (e.g., oral corticosteroids) and suppress the immune system can be used. These medicines are generally used on the advice of a specialist, and not all are recommended for use in children.

Other treatments may include:

• In cases where oozing and sore skin patches cannot tolerate topical treatment, 'wet wraps' may be applied until oozing stops. Dry bandages may also prevent scratching and creams from transferring to clothes. Their suitability and correct use require advice from specialist nurses.
• A course of antibiotics may be required to prevent worsening of eczema where oozing and crusted skin patches become infected.
• While medicines will relieve the intense itch caused by eczema, but some people need additional antihistamine therapy where the itch is severe. Antihistamines may help in some cases, particularly where itching affects sleep, and the antihistamine causes drowsiness.
• Phototherapy may improve itch, affected skin, and sleeplessness, and may be given in combination with other eczema treatments.

How can a person with eczema help themselves?

Generally, doctors will provide information about eczema, self-care, and how to look after the skin and reduce the risk of flare. Self-help includes:

• Seek advice and treatment as soon as signs and symptoms that might be eczema appear.
• Strictly follow the treatment regimen to avoid the condition worsening.
• Moisturise the skin at least twice each day with an oily, non-fragrant moisturiser.
• Wash with moisturising soap substitutes and use a bath oil.
• Do not scratch, moisturise.
• Do not keep a pet with fur if allergic to their animal dander.
• Wear non-rubber gloves when using cleaning and washing products, and any known irritants.
• Wear smooth, non-itchy, comfortable clothes and rinse them well after washing.
• Avoid getting too hot and sweating; it worsens the itch.

References

Avena-Woods C. Overview of atopic dermatitis. Am J Manage Care 2917;23:S115 - S123.

National Institute for Health and Clinical Excellence. Eczema - atopic. April 2023.
Available at: https://cks.nice.org.uk/topics/eczema-atopic/

Nemeth V, Evans J. Eczema. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
Available from: https://www.ncbi.nlm.nih.gov/books/NBK538209/

Wollenberg A, Barbarot S, Bieber T, et al. Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part I. J Eur Acad Dermatol Venereol. 2018;32(5):657-682. doi: 10.1111/jdv.14891.

Wollenberg A, Barbarot S, Bieber T, et al. Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part II. J Eur Acad Dermatol Venereol. 2018;32(6):850-878. doi: 10.1111/jdv.14888.