Eczema
Eczema
What is atopic eczema?
Atopic eczema is a common skin condition. It can happen at any age, but it usually starts in childhood. About 1 in 5 children in the UK develop eczema.
The word ‘atopic’ is used to describe conditions linked to strong reactions of the body’s immune system. These include asthma, eczema and hay fever.
‘Eczema’ is a term which is used to describe red, dry, itchy skin. Sometimes the skin can crack, weep, blister, or become scaly, crusty and thick.
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What causes atopic eczema?
Atopic eczema is a complicated skin condition. It can be caused by a number of things, including your genes and the environment around you.
One important gene is called filaggrin. It helps control a protein important for keeping the skin barrier strong and healthy. If this gene does not work properly, the skin barrier becomes weaker, and the affected person can develop eczema.
A weak skin barrier makes it easy for bacteria and viruses to enter the skin and cause skin infections. It also allows irritating substances to enter the skin, making it inflamed and itchy.
Things that can irritate the skin include allergens (for example, pollen and dust), soaps, detergents and other chemicals.
Atopic eczema often runs in families, especially if other family members have asthma or hay fever. But it is important to know that eczema is not contagious – you cannot catch it from someone else.
Is atopic eczema hereditary?
Yes, atopic eczema tends to run in families. If one or both parents have eczema, their children are more likely to develop it too.
Around 1 in 3 children with atopic eczema will also develop asthma and/or hay fever. Atopic eczema affects both males and females equally.
What does atopic eczema feel and look like?
The main symptom of atopic eczema is itching (pruritus). This can be very uncomfortable and lead to scratching that can make the skin look and feel worse. The itch can be so strong that it affects sleep, causing tiredness and irritability.
Atopic eczema often comes and goes in flare ups – times when the skin gets worse. Sometimes flare-ups have a clear cause, but often there is no obvious reason.
Atopic eczema can appear anywhere on the body, including the face. Most commonly it appears on the creases of the joints at the elbows, knees, wrists and neck (known as a flexural pattern). It can also appear as coin-sized areas of inflammation (a discoid pattern), or as many small bumps around the hair follicles (a follicular pattern).
The skin usually feels dry, itchy and sore. Scratching can cause marks, and sometimes the skin may bleed.
During a flare-up, the skin feels warm and looks red. On brown or black skin, the redness may be harder to see, but the area may also become darker or lighter than the surrounding unaffected skin. This is called post-inflammatory hyperpigmentation (darker) or hypopigmentation (lighter).
Sometimes, the skin can also become wet and weepy. In some cases, small water blisters develop, especially on the hands and feet. This is called pompholyx. If the skin is scratched repeatedly over time, it can become thicker. This is known as lichenification.
How is atopic eczema diagnosed?
A healthcare professional can usually recognise atopic eczema just by looking at the skin. Blood tests and skin tests are usually unnecessary.
What makes atopic eczema flare-up?
Many things in a person’s environment can make atopic eczema worse and cause a flare up. These include:
- Irritants such as soaps, detergents and other chemicals, heat, dust, woollen clothing, and pets.
- Being unwell, such as having a common cold
- Skin infections caused by bacteria or viruses:
- Bacterial infection (usually with a type of bacteria called Staphylococcus) makes the affected skin yellow, crusty and inflamed, and may need specific treatment.
- An infection with the cold sore virus (herpes simplex) in the skin affected by eczema can cause a sudden painful widespread flare-up of atopic eczema, with weeping small sores. This condition is called eczema herpeticum. This condition can be very serious if not treated quickly.
- Dryness of the skin
- Teething in babies
- Food allergens, which can trigger eczema in some people.
- Stress, which can make symptoms worse.
Can atopic eczema be cured?
Atopic eczema cannot be cured, but there are many ways of controlling it. Most children affected by it will see improvements as they get older, with 4 out of 5 clear of it by their teens.
Many people continue to have dry skin in adulthood. It is important to use moisturisers on a regular basis and avoid irritants such as soaps, detergents and bubble baths.
Atopic eczema may be troublesome for people in certain jobs that involve contact with irritant materials, such as catering, hairdressing, cleaning, or healthcare work. In later life, atopic eczema can present as hand dermatitis. Therefore, exposure to irritants and allergens should be avoided both in the home and at work.
Can atopic eczema be prevented?
Currently, there is no proven way to stop eczema from developing.
Some people think that breastfeeding might help prevent eczema in babies. However, there’s no strong evidence that it works.
There is also no clear proof that eating organic food or taking fish oil during pregnancy lowers the risk of eczema in children.
Can someone with atopic eczema lead a normal life?
Yes, people with eczema can lead a full life which can include participating in sports, swimming and travel. They may need to make minor changes such as keeping moisturiser with them at school, work or when away from home.
How can atopic eczema be treated?
There are many treatments that can help manage atopic eczema and reduce flare-ups. Treatment depends on how severe the eczema is.
Moisturisers (emollients)
Moisturisers (emollients): Keeping the skin moisturised is one of the most important parts of eczema care. This is called complete emollient therapy. It means:
- Using moisturiser several times a day.
- Using moisturiser instead of soap when washing (called a soap substitute).
Moisturisers help stop the skin from drying out, reduce itching, and protect the skin from irritants. There are many types – some are greasier than others. The best moisturiser is the one you are happy to use regularly.
Topical steroid creams (TCS)
These are creams and ointments that reduce inflammation. They come in different strengths called potencies. Your healthcare professional will advise which one to use, where to use it, and for how long. Sometimes, your healthcare professional may suggest slowly reducing how often the topical steroid is applied or reducing its strength. This is known as weaning.
Topical calcineurin inhibitors
These include tacrolimus ointment and pimecrolimus cream. They may be used if steroids do not work well or are not suitable. Topical calcineurin inhibitors can help prevent flare-ups when used regularly. They might sting at first, but this usually goes away. These creams can make your skin more sensitive to sunlight, so it is important to use sunscreen (SPF 30 or higher) during the day.
Antihistamines
Antihistamines that make people sleepy can be helpful when taken at night to reduce sleep disruption. They are not recommended as a long–term treatment for atopic eczema, however; short–term use can help to reduce itch during flare ups.
Bandaging (dressings)
Cotton bandages and clothing can be worn on top of creams to stop them from rubbing off and help prevent scratching the skin directly. Sometimes wet wraps are used for a short time. Wet wraps may upset babies and young children because they can become too cold. Some people may use medicated paste bandages, which are soothing and provide a physical barrier against scratching. It is important to use the dressings correctly –your health professional will advise you about bandages and dressings that are suitable for you.
Oral or injected treatments
For severe or widespread atopic eczema that does not get better with topical treatments, stronger treatments may be needed. These are taken by mouth or given as injections and are usually prescribed by a dermatologist (skin specialist). They work by calming down the immune system. Options include:
- Oral steroids (for example, prednisolone)
- Janus Kinase inhibitors (JAKi’s): abrocitinib, baricitinib, upadacitinib
- Injection treatments: dupilumab, tralokinumab, lebrikizumab.
Antibiotics and antiseptics
If the skin becomes wet, weepy and crusted, it may be infected. In that case, antibiotics may be needed. Antiseptics can help prevent infection, but they should be applied to the skin alone or as part of a moisturising preparation. However, using them incorrectly can irritate the skin and worsen eczema. Antiseptics should not be used continuously, as this can result in excessive drying of the skin.
Ultraviolet (UV) light
Some people affected by chronic eczema benefit from ultraviolet light treatment. This is usually given in a specialist hospital department. This is not usually recommended for children. Commercial sunbeds should not be used to treat eczema.
Mental health support
Many people affected by eczema can benefit from mental health support, such as habit reversal therapy for scratching. These techniques are used alongside topical treatment. Speak to your healthcare professional about this.
Alternative treatments
Chinese herbal treatment: This is a complementary therapy that has been reported to benefit some patients, but healthcare professionals do not generally recommend these. These treatments can cause serious side effects, such as inflammation of the liver.
‘Natural’ creams: People affected by eczema should avoid ‘natural’ herbal creams. Some can cause allergic reactions or skin irritation. Some have even been found to contain strong steroids or harmful bacteria, including MRSA, which can be life-threatening.
Self care (What can I do?)
Taking care of your skin daily can make a big difference. Here are some tips to help manage atopic eczema:
- Moisturise the skin often – at least 2-3 times a day. Use a moisturiser you like and feel comfortable using regularly. Apply it in the direction of hair growth. To keep the moisturiser clean, use a spoon or spatula to take out the amount you need. Then put it on a piece of kitchen roll before applying to the skin. This stops bacteria from getting into the container and contaminating it. Contaminated moisturiser can be a source of infection, which will then transfer back onto your skin.
- Wash with a moisturiser instead of soap – avoid soaps, bubble baths, shower gels and detergents.
- Treat flare-ups early – the sooner you treat the eczema, the easier it is to control.
- Protect your hands – wear non-powdered, non-rubber gloves (for example, vinyl gloves) to protect your hands when doing housework and using cleaning products.
- After swimming care – rinse off well and apply plenty of moisturiser after drying your skin. Make sure the shower at the swimming pool contains fresh water and not chlorinated water from the pool.
- Wear comfortable clothes made of materials such as cotton and silk and avoid wearing wool next to your skin.
- Try not to scratch. Scratching can feel good briefly, but it will make the skin itchier and worse in the long term. Instead, apply moisturiser to soothe the skin.
- Avoid skin contact with active cold sores. If someone has a cold sore, do not kiss or touch the area. People affected by eczema are at higher risk of getting a widespread infection from the cold sore virus.
- Do not keep pets to which you are allergic.
- Stay cool. Getting too hot (overheating) can make the skin itch more.
- Use a double-rinse cycle to remove laundry detergent residues when washing clothes. Avoid using fabric softeners, if you think they might irritate your skin.
Images DermNetNZ.