Irritated skin can be caused by a variety of factors. These include immune system disorders, medications and infections. When an allergen is responsible for triggering an immune system response in the skin, then it is an allergic skin condition.
Atopic Dermatitis (Eczema)
Eczema is the most common skin condition, especially in children. It affects one in five infants but only 10% of adults. One explanation for eczema is thought to be due to “leakiness” of the skin barrier, which causes it to dry out and become prone to irritation and inflammation by many environmental factors. Also, some young children with eczema can flare with a particular food. In about half of patients with severe atopic dermatitis, the disease is due to inheritance of a faulty gene in their skin called filaggrin, although this is affected by your race and ethnicity. Unlike with urticaria (hives), histamine is not the only cause of the itch of eczema so anti-histamines may not control the symptoms. Eczema is often linked with asthma, allergic rhinitis (hay fever) or food allergy. This order of progression is called the atopic march.
Allergic Contact Dermatitis
Allergic contact dermatitis occurs when your skin comes in direct contact with an allergen. For instance, if you have a nickel allergy and your skin comes in contact with jewelry made with even a very small amount of nickel, you may develop red, bumpy, scaly, itchy or swollen skin at the point of contact.
Coming in contact with poison ivy, poison oak and poison sumac can also cause allergic contact dermatitis. The red, itchy rash is caused by an oily coating covering these plants. The allergic reaction can come from actually touching the plant, or by touching clothing, pets or even gardening tools that have come in contact with the oil.
Hives are an inflammation of the skin triggered when the immune system releases histamine. This causes small blood vessels to leak, which leads to swelling and itching. Swelling without itching in deep layers of the skin is called angioedema. There are two kinds of urticaria, acute and chronic. Acute urticaria occurs at times after eating a particular food or coming in contact with a particular trigger. It can also be triggered by non-allergic causes such as heat or exercise, as well as medications, foods, insect bites or infections. Chronic urticaria is rarely caused by specific triggers and so allergy tests are usually not helpful. However, in rare hereditary diseases that cause chronic urticaria, genetic tests are helpful. Chronic urticaria can last for many months or years. Although they are often uncomfortable and sometimes painful, hives are not contagious.
Angioedema is swelling without itching in the deep layers of the skin. It is often seen together with urticaria (hives). Angioedema many times occurs in soft tissues such as the eyelids, mouth or genitals. Angioedema is called "acute" if the condition lasts only a short time such as minutes to hours. Acute angioedema is commonly caused by an allergic reaction to medications or foods. Chronic recurrent angioedema is when the condition returns over a long period of time, with each episode lasting hours to several days. Most cases do not have an identifiable cause.
Hereditary angiodema (HAE)
Hereditary angiodema (HAE) is a rare, but serious genetic condition involving swelling in various body parts including the hands, feet, face, intestinal wall and airways. It does not respond to typical angioedema treatment with antihistamines or adrenaline so it is important to see a specialist to screen for HAE and other genetic conditions.
Skin conditions are one of the most common forms of allergy treated and managed by an allergist / immunologist, a physician with specialized training and expertise to accurately diagnose your condition and provide relief for your symptoms.
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Itching, redness and swelling are common to most skin allergies. Yet there are some differences that help in the diagnosis of specific conditions.
Atopic Dermatitis (Eczema)
Itchy, red or dry skin. It may “weep” or leak fluid that crusts over when scratched, which means that it is also infected.
In infants, eczema often appears on the face. Children are prone to have the rash at the bends of the elbow joint, wrists, behind the knees and behind the ears. Adolescents and young adults typically have the rash in the same locations as children, as well as on the hands and feet.
Patients with the faulty filaggrin gene often have hand eczema with excessive little lines on the skin of their palms.
In many children, the exact cause of the eczema is not clear and treatment depends on regular use of moisturizer and topical medicines to dampen down the inflammation. One such treatment is topical steroids. In children where the skin is oozing, crusting and painful, an infection that needs treatment with antibiotics may be the primary trigger.
Infants and young children with more severe eczema should be evaluated for food allergy. It’s important to see an allergist / immunologist for diagnosis and management. Often input from a dietitian is needed as well.
Food allergies causing eczema are much less common in older children and adults. If you are suspected of having eczema that is caused by a food allergy, a confirmed diagnosis requires avoiding the trigger food for about four weeks with the help of a dietitian before doing a food challenge under your doctor’s supervision to confirm that the food was actually causing the flare.
Urticaria (Hives) and Angioedema
Urticaria consists of itchy, red and white raised bumps or welts that range in size and can appear anywhere on the body. The welts disappear in minutes to hours and typically heal without scarring. Acute urticaria can last up to six weeks. Chronic hives last more than six weeks and can last months or even years. Angioedema is swelling without itch and often appears on the face around the eyes, cheeks or lips. This deeper layer of swelling can also occur on hands, feet, genitals, or inside the bowels or throat. In acute urticaria, the welts disappear within minutes to a few weeks. Chronic hives last for months or even years.
In the majority of chronic cases the exact cause cannot be determined. Some rare diseases that cause chronic hives may require genetic testing. Routine testing such as general blood counts or screens are not cost-effective, nor do these tests make a difference in treatment strategies to relieve the symptoms. There are certain instances when allergy testing is helpful, especially when eating a particular food or coming in contact with a particular substance triggers symptoms of acute hives. Food allergy is rarely, if ever, a cause of chronic hives
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Atopic Dermatitis (Eczema)
Eczema is sometimes described as an “itch which rashes.” The more the patient scratches, the more severe the rash will be. This is why it’s important to avoid scratching.
The most effective way to treat eczema is to use appropriate skin care measures to rehydrate the skin and repair the skin barrier. The use of trilipid creams, other moisturizers and topical ointments that reduce inflammation are all important. Topical medications to reduce inflammation include topical steroids, calcineurin inhibitors, phosphodiesterase 4 inhibitors and topical JAK inhibitors. The itch is not relieved by antihistamines, although these are sometimes used at night to help people with eczema sleep.
There are several newer therapies approved for treatment of atopic dermatitis that is otherwise difficult to control. Dupilumab, a monoclonal antibody blocking interleukin-4 and interleukin-13, is an injectable biologic therapy that is used to treat adults and children 6 months of age and older with moderate-to-severe atopic dermatitis. Tralokinumab, a monoclonal antibody blocking interleukin-13, is another injectable biologic recently approved to treat adults age 18 and older with moderate- to-severe atopic dermatitis. Two oral JAK/STAT inhibitors have recently been approved for the treatment of moderate to severe atopic dermatitis. Upadacitinib is approved for age 12 and older and abrocitinib is approved for age 18 and older.
Antibiotics may be prescribed if a skin bacterial infection is suspected as a trigger for your eczema flare-up. Symptoms include crusting, oozing and pain. If a secondary fungal infection is suspected, it should be treated with antifungals. Oral steroids should be avoided, as although they are effective the eczema usually returns when the medicine is stopped. Oral steroids can also cause serious side-effects if taken for long periods of time.
Sometimes cotton undergarments and body suits help protect the skin from irritants and from scratching. Avoid using soap products that contain sodium laurel sulfate and any triggers that cause a reaction. Your allergist will be able to help determine whether there is a trigger that can be avoided.
These skin allergy treatment and management strategies can relieve social challenges as well. People with eczema, especially children, are sometimes ignored or singled out by others who believe the rash is contagious.
Atopic Dermatitis Personalized Management Plan
Urticaria (Hives) and Angioedema
If the cause of your hives can be identified, you can manage the condition by avoiding that trigger. Triggers for hives are more likely to be identified if your hives have been present for a shorter period of time. Treating hives or angioedema is often successful with oral antihistamines that control the itch and recurrence of the rash.
If the rash is not controlled with a standard dose of the antihistamine, your doctor may suggest increasing the dose for better control of your symptoms. If antihistamines do not control the rash, or if it leaves bruises, then it is important that your doctor rules out other causes which may need alternative therapies. Sometimes chronic hives without a known cause may be resistant to antihistamine treatment. Omalizumab, an injectable IgE antibody biologic therapy approved for individuals 12 and older with chronic spontaneous urticaria, may be useful in such cases.
If you are on certain blood pressure medicines (ACE inhibitors) and develop angioedema, it is important to consult your doctor. Changing to another blood pressure medicine may help the angioedema go away.