Eczema (Atopic Dermatitis) Overview

EczemaThis article has been reviewed by Thanai Pongdee, MD, FAAAAI


Atopic eczema, also called atopic dermatitis,  is a common allergic skin disease that usually starts in early childhood. It can be associated with infection (bacteria, fungi, yeast and viruses) of the skin. Half of patients with moderate to severe eczema also suffer from asthma, hay fever (allergic rhinitis), and food allergies.  

The main symptom is itchy skin. Skin is also often dry. Scratching makes the skin red, chafed and thick.

eczema is now thought to be due to a “leaky” skin barrier. This allows water to leak out, making the skin dry. Leaky skin can be caused by genes inherited from parents or by factors in the environment:

•    Faults in the Filaggrin gene cause moderate to severe eczema in up to a third of people of North European and Eastern Asian descent.
•    Exposure to soaps, detergents, house dust mite, pollens, animal dander and some bacteria, which contain proteins called “proteases” can all flare eczema.  Proteases break the links between skin cells and make the skin barrier leaky.  

Moisturizers are used to improve the skin barrier. Clothing that covers the arms and legs can also help protect the skin from irritation. When there is a lot of redness, application of creams and ointments that dampen down the inflammation are often prescribed.    
 

Eczema Symptoms & Diagnosis

In infants and children the rash usually occurs on the scalp, knees, elbows and cheeks.

In adults the rash can occur on the creases of wrists, elbows, knees, ankles, face and neck.

The rash is usually itchy, red and scaly. Scratch marks often occur due to the itchy nature of the rash. If one has this rash for a long period of time the affected skin can become thicker.

The dry skin can worsen the itching and rash. An “itch-scratch cycle” can occur with rubbing or scratching the skin causing more irritation, and thus, additional itching.  

The rash can become worse after eating certain foods. In the case of eczema, this is usually a delayed reaction. However, other reactions to foods can occur more immediately, including hives (itchy welts) and swelling. Allergy testing, either by blood (blood draw) or allergy skin prick (“pricking” foods in a liquid form on the arms or back and waiting 10-15 minutes for an “itchy bump” to occur, indicating an allergy) may be performed by an allergist / immunologist to determine a possible presence of an immediate food allergy. Allergy tests are often positive even in patients who tolerate the food in their diet, and thus foods should not be removed from your diet solely based on the results of these tests.  

It is important to talk with an allergist / immunologist about your rash. Other types of rashes such as psoriasis and contact dermatitis (poison ivy) can look like the eczema rash. In addition, people with various other immune problems such as immune deficiencies (low immune system) and vitamin deficiencies (low vitamin levels) can have a similar rash. The ultimate diagnosis of eczema should be made by your allergist / immunologist.
 

Eczema Treatment & Management

The major goal of treatment is an improvement in your quality of life. You should be able to participate in your school, work, social, and family activities. You should feel healthy and satisfied with your skin’s appearance. There should be no social stigma attached with the condition. You should have little to no side effects from the treatments for eczema. In addition, sleep should be restful and undisturbed by the need to scratch the skin.

Avoidance of Possible Triggers
Irritants: Irritants such as chemicals, soaps, detergents, fragrances, certain fabrics, and smoke can further irritate the skin in patients with eczema.  

The following are steps to perform to reduce irritant exposures:
•    Wear comfortable clothing.
•    Wash all new clothes prior to wearing them.
•    Keep fingernails short and smooth to help prevent additional skin damage from scratching.
•    Use broad-spectrum ultraviolet (UV) protective sunscreen (UV-A and UV-B with an SPF of 15 or higher).
•    Bathe immediately after swimming to reduce and remove exposure to various chemicals found in swimming pools and beaches.

Inhaled Allergens: House dust mites are small, microscopic (you cannot see them with the naked eye) organisms. They are typically found indoors (mattresses, pillows, carpet), typically in areas of high humidity. These have been associated with eczema.

Foods: Common allergic foods have been associated with eczema. If you consistently notice worsening of your rash after ingesting certain foods, notify your allergist / immunologist for further evaluation. Of particular note, eliminating a variety of foods from the diet that you are not allergic to is rarely helpful in patients with eczema, so any evaluation of a possible food allergy should first be done with careful consultation with an allergist / immunologist.

Stress: Stress, including anger and frustration, can cause additional itching, thus potentially worsening the “itch-scratch cycle.”

Treatments
The following treatments may be used for both adults and children.

Basic Definitions
Topical Therapies: Topical means applying directly to your skin. There are many topical therapies:

Ointments: Tends to have more oil than water, usually is more thick and greasy. These are the most common types of moisturizers used to treat eczema.

Creams: A mix of oil and water, it usually looks white and smooth.

Solutions: This is a more liquid form, feels like water.

Lotions: This is thicker than a solution.

Topical Moisturizers
Dry skin tends to worsen the itching and rash. Various environmental issues, such as exposure to low humidity and wind can further dry the skin. Therefore, moisturizing (hydrating, or adding water) your skin is an important component to eczema care. After soaking your skin in a bath or shower, pat dry the skin gently (pat the excess droplets of water). Then, immediately apply a moisturizer on the slightly wet skin to “lock” in the water and thus, improve dryness.

It is important to know that moisturizers are NOT steroids. It is also important to tell the difference between steroids or other anti-inflammatory medications and moisturizers. Your allergist / immunologist can help you differentiate between them.

Topical Steroids
Topical steroids are anti-inflammatory medications that are used on the rash areas (the red and inflamed areas of the skin, not just dry areas) of the skin. The steroids used for eczema are different from other types of steroids, such as testosterone and estrogen. When used properly as advised by your physician, topical steroids are safe. One topical steroid may be stronger (more potent) than another, and thus, may improve the rash more effectively than a weaker topical steroid. However, the stronger steroid also has potentially more severe side effects including thinning of the skin, and thus potent steroids should not be used on certain areas, such as the underarms, groin area, and face. Usually, topical steroids found over-the-counter are less strong than prescription ones. Bring all topical medications (they come in various forms, including creams, lotions, and ointments) to your allergist / immunologist, so the physician can differentiate between the various steroids and other topical medications.
Steroid pills or steroid injections (shots) are much stronger than topical steroids and can therefore cause more side-effects (including weight gain and bone problems). In general, they should be avoided, particularly in children.  

Other Topical Anti-Inflammatory Medications
If topical steroids are not effective, other topical anti-inflammatory medications called topical immunomodulators might be tried. They are usually second-line agents used if steroids are unsuccessful. As they are not steroids, these medicines can be used on eyelid and other facial areas, as they do not normally thin the skin. As with any other medications, they have other potential side effects, so one must discuss them with an allergist / immunologist prior to use.

Wet-Wrap Therapy
Wet wrap therapy is usually used for people with severe and difficult to manage eczema. In this therapy, the skin is soaked in warm water for about 15-20 minutes and then, is patted dry. Topical medications (typically, steroids or other anti-inflammatory medications, as described above) are then placed on the “rash” areas of the skin. Then, a wet (not dripping) dressing (either gauze or clothing) is applied on top of the rash areas. This is followed by a dry wrap material, such as elastic bandage, pajamas, or sock, placed over the wet dressing. For patient comfort, a warm blanket may also be used. Wraps are used typically for 2-6 hours. The use of wet wrap therapy is individualized and should be performed under the close guidance of your allergist / immunologist.

Antihistamines
Oral, or pill, antihistamines do not reduce the itch associated with eczema, as it is not triggered by histamine. Sedative antihistamines are sometimes used to help encourage much needed sleep at night. However, there are potential side effects, including increased sleepiness, or sedation during the day, increased dryness, and difficulty urinating. Topical antihistamines should be avoided, as they may worsen your rash.  

Therapies for Associated Infections
If your allergist / immunologist diagnoses an associated infection with the rash, an antibiotic may be prescribed. Your skin may be infected if there is oozing, crusting, your clothes start to stick to your skin, or you have the development of cold sores or fever blisters.

Bathing Strategies Including Dilute Bleach Baths
Very dilute bleach baths (typically, one quarter to one half cup of bleach mixed with 40 gallons of water bath) once to twice weekly may help improve the rash and may decrease the need for antibiotics.

Stress-Relieving Therapies
Stress reduction techniques, such as biofeedback and other techniques may be used to improve mood and decrease anxiety associated with eczema.

Vitamins
There has been a recent increase in studies associating vitamin D deficiency with eczema. If you have been diagnosed with vitamin D deficiency (low Vitamin D level) by your physician, Vitamin D supplements may be prescribed.

Biologic Medicines
Biologic medications are newer anti-inflammatory medications that have been approved for other allergic diseases, such as asthma, as well as for other skin conditions, such as psoriasis.  

They have been studied in difficult to treat eczema patients, and one biologic agent has recently been approved for the treatment of very severe eczema. Your allergist / immunologist can discuss biological medications with you.

Probiotics
Despite a lot of media attention on probiotics, at present, there is no conclusive evidence showing that probiotic use improves or prevents eczema, and it is not currently recommended in routine eczema care.

Allergy Shots (Allergy Injections)
Allergy shots (giving injections of small doses of what you are allergic to, such as dust mites, under the skin in the arms) are currently approved for the treatment of asthma and allergic rhinitis (hay fever). Allergy shots can help some patients with eczema. Allergy shots are not the same as steroid shots, or steroid injections. Your allergist / immunologist can discuss whether allergy shots are appropriate for your eczema.   

In summary, eczema is usually manageable, regardless of your age. There are many treatments currently available and future therapies are on the way. With careful evaluation and follow up with your allergist / immunologist, you can have a very high quality of life and enjoy all your activities.

References
Lio P, Lee M, LeBovidge J, Timmons K, Schneider L.  Clinical Management of Atopic Dermatitis: Practical Highlights and Updates from the Atopic Dermatitis Practice Parameter 2012. J Allergy Clin Immunol Pract. 2014; 2: 361-9.

Nicol N, Boguniewicz M, Strand M, Klinnert M. Wet Wrap Therapy in Children with Moderate to Severe Atopic Dermatitis in a Multidisciplinary Treatment Program.  J Allergy Clin Immunol Pract. 2014; 2: 400-6.

Boguniewicz M and Leung D.  The ABC’s of managing patients with severe atopic dermatitis.  J Allergy Clin Immunol 2013; 132: 511-512e1-e5.

Understanding Atopic Dermatitis: An Educational Health Series from National Jewish. 2003: 1-16.

Facts: Atopic Dermatitis (Atopic Eczema): An Educational Health Series from National Jewish. 2003.

Facts: Key Therapy Points for Patients with Atopic Dermatitis (Atopic Eczema): An Educational Health Series from National Jewish. 2003.

Eczema: Topical Corticosteroids Myths and Facts, National Eczema Association 2013.

Therapeutic Principles in Dermatology.  ACP-MKSAP 17; 2016: 4.

Gray S, Anderson M, Dublin S, Hanlon J, Hubbard R, Walker R, Yu O, Crane P, Larson E.  Cumulative Use of Strong Anticholinergics and Incident Dementia.  JAMA Inter Med.  2014; 175: 401-7.

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