Everything Eczema

What is eczema or dermatitis?
The terms Eczema or dermatitis can be used interchangeably and are used to describe an inflammation of the skin – the suffix “-itis” means inflammation.
Another example is “arthritis” which means inflammation of a joint.

Atopic eczema is the most common type of eczema that affects up to 30% of children and 10% of adults. Rarely, one can develop eczema for the first time even after the age of 60. Atopy means a genetic predisposition to develop eczema, asthma and hayfever and we find that these conditions run in families, children also have a greater risk of developing eczema if one of their parents have had it.

A few other common types of eczema are:

Seborrhoeic eczema – a mild form of eczema occurring most commonly on the scalp, ears, face and mid chest and  ‘Cradle cap’ is a variant of seborrhoeic eczema which affects babies. Malassezia yeasts are thought to contribute to the cause of seborrhoeic eczema.

Allergic contact eczema is a variant of eczema that occurs from contact with chemical substances that the skin is allergic to.
A common example is contact allergy to nickel in earrings and clothing studs leading to an eczema around the area of contact.
People may also develop allergies to various other allergens including plant materials (eg poison ivy), hair dyes and ingredients in personal care products.

Asteatotic eczema occurs mostly in elderly patients and starts with a very dry skin that cracks and becomes red and inflamed. This kind of eczema occurs mostly on the lower limbs and flanks.

Stasis dermatitis occurs particularly on the lower limbs in patients with varicose veins and is due to the pooling of the circulation beneath the skin.

What does eczema look like?
The inflamed skin of eczema can look red, wet and weeping if the eczema is acute and severe.
The skin is leathery with varying redness, scaling and crusting if the eczema is subacute, or thickened and nodular if the eczema is chronic.
The distribution of eczema may vary with age.
Babies generally have eczema on the face, neck and scalp, outer arms and front of the legs.
Childhood eczema is typically in the folds of the elbows and knees, the wrists, ankles hands and feet, we call this flexural eczema.

The distribution may alter yet again in adults who have a higher incidence of hand eczema. It is important to exclude allergic contact eczema in adults with hand eczema.

What causes Eczema?
As with most disease there is a genetic predisposition and contributing environmental factors. These vary with different types of eczema.

The skin in Atopic eczema has an impaired skin barrier function and a defective immune response.
Mutations in a gene called fillagrin is a strong predisposing factor which weakens the skin barrier and allows allergens to penetrate and trigger the immune response.

There are multiple potential environmental triggers; irritants like detergents, soaps and fragrances contribute to weaken the skin barrier, as well as synthetic fabrics and wool which irritate the skin and worsen itching and scratching.
Allergens like house dust mite, pollen and animal hair have also been shown to trigger atopic eczema.

Is eczema contagious?
No. You will not get eczema from touching an area of eczema on another person. Similarly you can’t make your eczema ‘spread’ over your own skin by touching it.

Can you outgrow eczema?
Yes. As many as 50-60% of sufferers can outgrow their eczema around puberty.
Regular moisturizing of the skin can control asteatotic eczema. Avoidance of the offending substance in allergic contact allergy may resolve this condition.

What are the treatment options?
Treatment consists of maintenance treatment and treatment of the acute flare up.
Maintenance is exceptionally important as it can help keep the eczema in remission for prolonged periods of time and reduce the need for topical steroids .
Avoid soap on the skin as it has an ingredient called sodium laurel sulphate which weakens the skin barrier, also avoid perfumed products, bubble baths and other environmental triggers.
Use soap free products to wash with and a suitable emollient to moisturise the entire skin at least twice a day.

Topical treatments
The first line treatment for the ‘acute flare-up’ of eczema are topical corticosteroids which range in strength or potency. There is much controversy regarding the use of ‘steroids’ leading to ‘steroid phobia’ in patients with eczema. Topical corticosteroids remain the most potent anti-inflammatory agent for a condition that is characterized by varying levels of inflammation.
As a dermatologist I am constantly educating my patients on the correct and responsible use of steroids to prevent occurrence of known steroid side effects.

Topical calcineurin inhibitors pimecrolimus and tacrolimus are used in ongoing maintenance of atopic eczema. They may sometimes be used as first line treatment in suitable patients.

A new topical therapy for atopic eczema, crisaborole has recently been approved by the United States food and drug administration.

Systemic treatments
These include oral steroids, steroid injections, and oral immuno-suppressive drugs which include include azathioprine, cyclosporine and methotrexate. These treatments are indicated for severe flare-ups of eczema, or eczema that cannot be managed with topical treatment.

A new biologic injectable drug called dipilumab was recently approved by the United States Food and Drug Administration and has shown promising results in clinical trials.

Phototherapy (light therapy)
Light therapy with narrow band UVB light has been shown to improve inflammation in eczema and the associated itch. Light therapy is generally combined with other treatment options.

Are there certain foods I need to avoid if I have eczema?
Food avoidance is only recommended if there is a proven food allergy.
Atopic eczema, food allergy, asthma and hay fever are genetically linked. If you have one of these conditions, then you may be predisposed to develop any of the others. However it does not necessarily mean that avoiding certain foods will have any effect on the eczema. If you believe that a certain food is worsening your eczema, keep a food diary to establish whether this is consistent. Food allergies can be investigated and tested by an allergologist. This will prevent you avoiding food that you are not actually allergic to.

Does stress worsen eczema?
Yes. Psychological factors including emotional stress can certainly trigger worsening of eczema. Flare ups of eczema are commonly seen in students around exam time.
Another reported example of stress triggering eczema, is the occurrence of first onset of atopic eczema in pregnant women.

Can I use sunscreen if I have eczema?
There are sunscreens suitable for sensitive eczema-prone skin. These are usually the physical or mineral sunscreens and those that are free of perfumes and fragrance.

Dermatitis or eczema can be a frustrating condition to live with particularly if it is chronic.
It’s also difficult to accept the first onset of a chronic skin condition later in life and with such a wide variety of washes and emollients available, patients are often overwhelmed for choice.  It’s always best to contact your dermatologist if you are suffering with eczema or feel you may be developing a similar skin condition.