Eczema

See also: contact dermatitis, discoid eczema, seborrhoeic dermatitis and other eczema leaflets.

What is 'atopic' eczema?

‘Atopy’ is the term used for the tendency to develop eczema, asthma and/or hay fever.
Atopic eczema is a dry, itchy inflammation of the skin. The words ‘eczema’ and ‘dermatitis’ are interchangeable and mean the same thing. Atopic eczema, therefore, is the same thing as atopic dermatitis. For simplicity we shall stick to the word ‘eczema’ here.

Atopic eczema can affect any part of the skin, including the face, but the areas most commonly affected are the bends of the elbows, around the knees, and around the wrists and neck. These are known as ‘flexural’ areas. It affects both sexes equally and usually starts in the first weeks or months of life. It is most common in children, affecting at least 10% of infants, although it can carry on into adult life or come back in the teenage or early adult years.

What causes atopic eczema?

This is still not fully understood. Atopy runs in families (see below) and is part of your genetic make-up. Atopic people have an overactive immune system and their skin easily becomes inflamed (red and sore). Their skin ‘barrier’ does not work well, so that their skin may become dry and prone to infection. Atopic eczema is not catching.

What makes atopic eczema flare up? 

Many ‘external’ factors can make eczema worse. These include:

• Heat, dust, and contact with irritants such as soap or detergents.
• Being unwell: for example having a cold can make eczema flare.
• Infections with bacteria or viruses can make eczema worse. Bacterial infections make the skin yellow, crusty and inflamed, and may need treatment with antibiotics. A viral infection with the herpes simplex virus can cause a painful flare of eczema, and may need treatment with antiviral tablets.
• Dryness of the skin.
• Stress may also trigger flare ups.

 Is atopic eczema hereditary?

Yes - atopic eczema (as well as asthma and hay fever) tends to run in families. If one or both parents suffer from eczema, asthma, or hay fever, it is more likely that their children will suffer from them too. In addition, there is a tendency for these conditions to run true to type within each family: in other words, in some families most of the affected members will have eczema, in others, asthma or hay fever will predominate.

What are the symptoms of atopic eczema?

The main symptom is itch. Scratching in response to this may be responsible for many of the changes seen on the skin. Itching can be bad enough to interfere with sleep.

What does atopic eczema look like?

If you have eczema, it is likely your skin will be red and dry. When the eczema is very active (during a ‘flare-up’) you may develop small water blisters on the hands and feet or your skin may become wet and weepy. In areas that are repeatedly scratched, the skin may thicken in response - a process known as lichenification.

How is atopic eczema diagnosed?

It is usually easy for health care professionals, such as health visitors, practice nurses and general practitioners, to make the diagnosis when they look at the skin. However, sometimes the pattern of eczema patches in older children and adults is different, and the help of a hospital specialist may be needed. Blood tests and skin tests are usually not necessary. Occasionally the skin may need to be swabbed (by rubbing a sterile cotton bud on it) to check for bacterial or viral infections.

Can atopic eczema be cured?

No, it cannot be cured, but there are many ways of controlling it. Most children with atopic eczema improve as they get older (75% clear by their teens). However, many of those who have had eczema continue to have dry skin and need to avoid irritants such as soaps or bubble baths. Eczema may persist in adults it but should be controllable with the right treatment.

How can atopic eczema be treated?

You will need the advice of a health care professional on the best treatment for your eczema and on how long this should continue. The treatments used most often are moisturisers, and topical steroid creams or ointments.

• Moisturisers (emollients) should be applied every day to stop your skin becoming dry. Many are available, and it is important that you choose one you like to use.
  
• Topical steroid creams or ointments will settle the redness and itching of your eczema when it is active. They come in different strengths (potencies), and your doctor will advise you which type needs to be used where, and for how long. Topical steroids should be used in combination with moisturisers in a skin care ‘regime’.
  Topical steroids are safe as long as they are used in the right way - using the right strength to improve a flare up and stopping them or reducing their strength once things have improved. Stopping topical steroids abruptly may allow the eczema to flare up again, and it may be helpful to go on using them on 2 consecutive days a week for a few weeks after a flare of eczema has settled.
  Skin thinning from topical steroid preparations should not be a problem if they are used properly. It usually arises only when too strong a steroid has been used for too long, or in a ‘delicate’ area where the skin is thin. Weaker topical steroids should be used where the skin is particularly thin, such as on the face, eyelids, and armpits: stronger steroids can be used at other sites. Steroids are classed as mild, moderate, potent and very potent; and it is sometimes recommended to have a range of suitable creams of different strengths and to move up and down through different strengths like a ladder, depending on how the skin is flaring up. In this way stronger creams may be used while your skin is flaring up, and milder ones as your eczema settles.

• Antibiotics. If your eczema becomes wet and weepy, it may mean that it is infected and that antibiotics are needed.

• Topical immunosuppressants, Some people benefit from the newly introduced non-steroid creams, tacrolimus (Protopic) and pimecrolimus (Elidel), which can reduce inflammation in the skin. They are effective treatments for atopic eczema. They do not thin the skin or cause the side effects associated with topical steroids. The commonest side effect is stinging on application and they may increase risk of skin infections. They should not be applied to sun-exposed sites in the long term, or used at the same time as ultraviolet light treatment. Although, theoretically, they might increase the risk of skin cancer they have been safe in use for up to 4 years.

• Antihistamines, particularly the so-called ‘non-sedating’ types used to treat hay fever, are of no benefit to people with eczema. The only antihistamines that may help control atopic eczema are those that make people sleepy. They are less effective if used in the long term.

• Bandaging can sometimes help, particularly for the arms and legs. ‘Wet wraps’ are cooling bandages that are sometimes helpful for short periods in treating children.

• Ultraviolet light. Some people with chronic eczema benefit from ultraviolet light treatment, which is usually given in a specialist hospital department and supervised by a dermatologist. There are three types of ultraviolet light treatment, narrow band UVB, UVA and PUVA.

• Stronger treatments. People with severe or widespread eczema sometimes need stronger treatments, which will usually be given under the close supervision of a health care professional. Oral steroids (usually prednisolone) are sometimes used for a very short time if the eczema has flared badly. They work well but cannot be used in the long term as they may cause side effects. More severe forms of eczema may need longer courses of other tablets that calm down the immune system, such as azathioprine or ciclosporin. They too have side effects that need to be monitored with regular blood tests and visits to the hospital.

• Chinese herbs are an alternative therapy that some people report can be effective. Most doctors would not recommend their use, as their ingredients are not regulated. Potential side effects are therefore unpredictable. Liver problems have been known to occur with Chinese herbs, and patients taking them should be monitored for side effects.
  

Dealing with allergies

Atopic people often have immediate allergies, for example to cats, dogs, pollen, grass, or the house dust mite. Contact with these normally causes hay fever or asthma. However nettle rash (urticaria) can occur after contact, and this may then cause eczema to flare.

The house dust mite: The most common allergy shown by people with atopic eczema is to the house dust mite. Decreasing the amount of house dust and its mites, especially in living rooms and bedrooms may help to control eczema. Similar allergies can occur with pollen and animal fur.

Food allergies: Atopic people are more prone to food allergy. If such an allergy is present, the symptoms are usually obvious to the patient. The lips may swell, or there may be an irritation inside the mouth immediately on eating the particular food (usually eggs, fish, milk (diary products), nuts or wheat) to which there is an allergy. It is rare for these allergies to cause eczema. Tests for food allergy are therefore not performed routinely. In a few children, the avoidance of some foods can help to control eczema. However, it highly important for people with eczema to have a healthy, well balanced diet.

'Contact’ allergy to creams and ointments can occur. Let your doctor know if treatments seem to be making your skin worse (see the Information Leaflet on Contact dermatitis)

Latex (rubber) allergy is more common in people who are atopic. The symptoms include itching of the skin immediately or soon after contact with rubber. This can happen in many ways: for example when you put on rubber gloves, or when a dentist examines your mouth, or when you are blowing up balloons or from contact with latex condoms. Latex allergy can sometimes occur with allergy to foods such as kiwi fruit, bananas, potatoes or tomatoes. Latex allergy is very important – mention it to your doctor if you think you have it after contact, and this may then cause eczema to flare.

Treatments that are not recommended.      

These include:

'Natural' herbal creams, as they can cause irritation and allergic reactions. Their use on broken and inflamed skin is therefore not recommended.
Evening primrose tablets are no longer recommended, as they have shown no proven benefit.

What can I do?  

• Moisturise your skin as often as possible – maybe as often as 6 times per day. A bland, non-perfumed moisturiser is best. This is the most important part of your skin care.
• Wash with a soap substitute. Try to avoid using soap, bubble baths, shower gels and detergents.
• Wear gloves to protect your hands if they are likely to come into contact with irritants.
• Shower well after swimming, and apply plenty of your moisturiser after drying.
• Wear comfortable clothes made of materials such as cotton, and avoid wearing wool next to your skin.
• Avoid scratching if you can. It may relieve your itch briefly, but it will make your skin itchier in the long term.
• Avoid close contact with anyone who has an active cold sore.
• Do not keep pets to which there is an obvious allergy.

While every effort has been made to ensure that the information given in this leaflet is accurate, not every treatment will be suitable or effective for every person. Please consult your doctor if you have any concerns about your skin health. He or she will be able to advise in greater detail.