What is Eczema? What causes Eczema?
Eczema is also known as atopic dermatitis, or atopic eczema (the most common form of eczema). Atopic eczema mainly affects children, but it can continue into adulthood or start later in life. The word eczema comes from the Greek word ekzein meaning “to boil out”; the Greek word ek means “out”, while the Greek word zema means boiling.
Eczema is a chronic skin condition in which the skin becomes itchy, reddened, cracked and dry. Approximately 30% of all skin-related GP visits in Western Europe result in a diagnosis of atopic eczema. It affects both males and females equally, as well as people from different ethnic backgrounds. Most GPs (general practitioners, primary care physicians) in Western Europe, North America and Australia say the number of people diagnosed each year with eczema is has been rising in recent years.
Atopy is the hereditary predisposition toward developing some hypersensitivity reactions, such as hay fever, asthma, chronic urticaria, and some types of eczema. Atopic eczema, therefore, means a form of eczema characterized by atopy – in other words, inherited eczema.
Approximately 80% of atopic eczema cases start before the age of 5, and a sizeable number develops it during their first year of life.
What are the symptoms of eczema?
As atopic eczema is a chronic disease symptoms are generally present all the time. A chronic disease is a long-term one; one that persists for a long time. However, during a flare-up symptoms will worsen and the patient will probably require more intense treatment.
Below are some common symptoms of atopic eczema (without flare-up):
The skin may be broken in places.
Some areas of the skin are cracked.
The skin usually feels dry.
Many areas of skin are itchy, and sometimes raw if scratched a lot.
Itching usually worse at night.
Scratching may also result in areas of thickened skin.
Some areas of skin become red and inflamed.
Some inflamed areas develop blisters and weep (ooze liquid).
The skin has red to brownish-gray colored patches.
Areas of skin may have small, raised bumps.
Although the patches may occur in any part of the body’s skin, they tend to appear on the hands, feet, arms, behind the knees, ankles, wrists, face, neck, and upper chest. Some patients have symptoms around the eyes, including the eyelids. Scratching around the eyes may eventually lead to noticeable loss of eyebrow and eyelash hairs. Babies tend to show symptoms on the face.
When there is a flare-up the previous symptoms still exist, plus some of the ones below:
The skin will be much more itchy.
Itchiness and scratching will make the skin redder, raw and very sensitive.
Many of the affected areas will feel hot.
The skin will be much more scaly and drier.
The raised bumps will be more pronounced and may leak fluid.
Blisters will appear.
The affected areas may be infected with bacteria.
Flare ups can last from a day or two to several weeks.
Patients with mild atopic eczema will generally have only small areas of dry skin which may itch sometimes. When symptoms are severe large areas of skin become very dry and the itching is constant. Many areas will ooze fluid.
A vicious circle can set in. It starts with unpleasant itching, then scratching which makes the itching worse, which makes the patient scratch more – eventually the skin can bleed. Children who get into this cycle can suffer serious sleep disruption and may find concentrating at school extremely challenging.
The following may worsen the symptoms of atopic eczema:
Prolonged hot showers or baths.
Allowing the skin to stay dry.
Rapid temperature changes.
Certain fabrics for clothing, such as wool.
Some soaps, solvents, or detergents
A Swedish study found that linalool, the most common fragrance ingredient used in shampoos, conditioners and soap is a powerful allergen for a significant number of people.
What are the causes of atopic eczema?
Experts say that people with eczema are born with it – it is a genetically inherited condition. It can be worsened with exposure to external or environmental factors such as pollen or pet fur, and internal factors such as hormone levels and stress.
In 2006, scientists from the University of Dundee, with collaborators in Dublin, Glasgow, Seattle and Copenhagen, discovered the gene that causes dry, scaly skin and predisposes individuals to eczema.
In 2009 a study carried out by scientists at the University of Edinburgh concluded that the defects in a particular gene known as the filaggrin gene are linked to a considerably amplified risk of developing allergic disorders such as eczema, rhinitis, and asthma.
The oily (lipid) barrier of skin is usually reduced in people with atopic eczema, compared to other people. The lipid barrier helps prevent water loss. If your barrier is reduced you will lose water faster and your skin will be drier. Several studies have been confirming this, including this one.
The immune system cells of people with atopic eczema release chemicals under the skin’s surface which may cause inflammation. Experts are not 100% sure why this happens. They just know that it is an immune system overreaction.
Even though scientists are fairly sure genetics are the primary cause, they do not yet know what the exact genetic cause is. The above-mentioned studies are giving us a better idea – but a great deal of further research is needed. 60% of children with atopic eczema have one parent with the same condition. Studies have shown that children run an 80% risk of developing eczema if both their parents have the condition.
Eczema linked to gut bacteria in children – children who have eczema have a wider range of bacteria in their gut compared to kids without the condition, researchers from the University of Turku, Finland, reported in the journal BMC Microbiology. The scientists noticed that the bacteria in the gut of children with eczema were more like those found in adults than other kids.
Recent studies are starting to reveal a picture of early life lifestyle habits that may reduce the risk of developing eczema later on, either during early childhood or later on in life. An infant diet that includes fish before the age of 9 months curbs the risk of developing eczema, a Swedish study reported.
Environmental factors that make atopic eczema symptoms worse
Some scientists say that environmental factors are the ones causing the number of recent eczema cases in the developing world to rise. They argue that it is highly unlikely that genetic factors would change in such a short time.
Environmental factors are also known as allergens – they cause the body’s immune system to overreact; an allergic reaction.
The three most common allergens for atopic eczema are:
House dust mites (bed bugs)
Children who are exposed to cats soon after birth may have an increased risk of developing eczema, according to a study carried out by researchers at the University of Arizona in Tucson, USA.
These three allergens are also the main ones that trigger asthma and hay fever.
Several scientists have suggested that hard water may be bad for people with eczema. Scientists from the University of Portsmouth, England, are carrying out a study to find out whether installing a water-softener in the home might improve the symptoms of children with eczema. Results of their study should appear around the end of 2009.
Foods that may make atopic eczema symptoms worse
These are foods that typically cause allergic reactions in people with sensitive immune systems. These include:
About 10% of children with atopic eczema are affected by food allergens. Foods rarely affect the symptoms of adults with eczema.
Hormones can worsen symptoms
A significant proportion of women with eczema report that their symptoms worsen during their menstrual cycle. 30% of women have flare ups during the days preceding their menstrual period. 50% of women with eczema say their symptoms got worse when they were pregnant. These are all periods when a woman’s hormone levels change.
Mental stress can make eczema symptoms worse
Doctors are not sure what exactly it is that causes a worsening of symptoms during mental stress. Atopic eczema patients commonly report that their symptoms are likely to get worse when they are mentally stressed. It is possible that a vicious cycle could develop – the symptoms of eczema stress the patient, the resulting stress exacerbates the symptoms, etc.
Winter is usually worse than summer
Most patient who do not live near the equator find that their symptoms are worse in the winter than the summer, even though pollen is an important trigger.
Diagnosis of eczema
No laboratory test or skin test currently exists which can diagnose atopic eczema.
A GP is able to diagnose atopic eczema after examining the patient and asking some questions about his/her symptoms and medical history – this will include questions about the presence of eczema in close family relative. The doctor will also ask about some other allergy-related conditions, such as asthma and hay fever.
A number of diagnostic criteria to confirm diagnosis
A doctor in the UK will assess the patient’s skin against a number of diagnostic criteria in order to confirm an eczema diagnosis. The criteria include:
A long period with itchy skin – the patient has had itchy skin for the last 12 months.
Plus at least three of the criteria below:
Itching and irritation – itchiness and irritation in skin creases, such as the front of elbows, behind the knees, front of ankles, around the neck, or around the eyes.
Asthma or hay fever – the patient either has asthma or hay fever or has had them in the past. If the child is under four, the doctor will ask whether a close relative (brother, sister, mother, father) has asthma or hay fever.
Dry skin – the patient’s skin has been dry for the last 12 months.
When it started – the condition started when the patient was two years old, or less. (If the patient is under four years of age this criterion is not used).
Joints – eczema is present either where skin covers the joints or the parts of the body that flex, such as wrists, knees, or elbows.
If the patient meets these criteria (the first, plus at least three of the others) the UK doctor will not usually have to carry out any further testing to confirm diagnosis.
Identifying trigger factors during diagnosis
The doctor will try to find out what triggers worsen the patient’s symptoms. He/she will ask the patient questions about lifestyle, soaps and detergents used, diet, home environment, pets, where exactly the house is, etc.
Some doctors will ask the patient to keep a diary – the patient will note down such data as eating habits, clothes worn, what time of day symptoms are better or worse and where the patient was during those times, etc. The aim here is to identify as many trigger factors as possible.
What is the treatment for atopic eczema?
There is currently no cure for atopic eczema – there is no treatment that gets rid of it for good, as might be the case with surgery to cure blindness caused by cataracts. However, there are a variety of treatments which focus on the symptoms, as well as strategies to avoid triggers, and may improve the patient’s quality of life considerably.
A significant proportion of children with atopic eczema will find that their symptoms will improve as they get older.
Self-care – What the patient can do
Itchiness is a common part of eczema, and scratching is a natural reaction to deal with itching. Unfortunately, scratching will invariably further aggravate the skin and make symptoms worse. Scratching also raises the risk of infection.
Getting an adult to control his/her scratching is hard enough – it is even harder for children. Children will often not be able to control the urge to scratch. It is important that nails are kept short and clean. Babies may benefit from anti-scratch mittens.
Avoid trigger factors
A good doctor will have established a list of factors that trigger eczema flares. The patient should try to avoid them as much as possible. Parents/guardians need to remind children of triggers and help them devise strategies to avoid them – younger children may need to be reminded frequently.
People with atopic eczema usually avoid clothes made of synthetic fibers and opt for natural materials, such as cotton.
We know that dust mites are likely triggers for many people. However, most studies have shown that trying to eradicate them from your home is very time consuming and does not seem to be very effective in reducing the frequency and severity of flare-ups. Several patients have written into Medical News Today saying that when they get up in the morning they pull their sheets right back and do not make their beds for several hours, allowing the bed to be ventilated – this has helped them (bear in mind this information is not a study, and must be taken as anecdotal).
It is important to check with your doctor before undergoing any large change in diet, especially if the patient is a child. Breastfeeding mothers whose babies have atopic eczema should check with their GP before embarking on any significant diet change. Milk, eggs, and nuts are common triggers. Researchers from King’s College London found no evidence that exclusive breastfeeding reduces the risk of a baby eventually developing eczema.
The German Institute for Quality and Efficiency in Health Care stresses that parents should be cautious about eliminating important foods like milk from their baby’s or child’s diet. In fact, their report says that avoiding foods may do more harm than good for children with atopic eczema, unless your child has a proven food allergy.
Regular fast-food consumption linked to eczema risk – children who consume fast foods at least three times a week are much more likely to have eczema as well as hay fever, researchers reported in the journal Thorax (January 2013 issue).
If you have identified the triggers you should avoid them. However, if a child’s trigger is milk he/she will need an alternative source of calcium. Always check with your doctor or a qualified nutritionist first before taking a major food source out of your or a child’s diet.
These are very popular among patients with atopic eczema. They include aromatherapy, massage, homeopathy, and some herbal remedies, to mention but a few. It is important to remember that although patients do report benefits, a lot of information one reads in books and on the internet is anecdotal. For therapy to be convincing, it should undergo proper clinical tests, usually carried out and compared to a placebo (dummy treatment). Before undergoing any complementary/alternative therapy, check it out carefully.
Researchers at Mount Sinai Hospital in New York reported that treatments consisting of Erka Shizheng Herbal Tea, a bath additive, creams and acupuncture, effectively treated patients with persistent atopic eczema. Their findings were presented at the 2009 Annual Meeting of the American Academy of Allergy, Asthma & Immunology.
Another study, carried out by Scientists at the Chinese University of Hong Kong, found that a traditional Chinese herbal concoction, consisting of Flos lonicerae (Japanese honeysuckle), Herba menthae (peppermint), Cortex moutan (root bark of peony tree), Atractylodes Rhizome (underground stem of the atractylodes herb) and Cortex phellodendri (Amur cork-tree bark) may help people with eczema and reduced their needs for medications.
Researchers from the Northwestern University Feinberg School of Medicine reported that bleach baths offer an effective treatment for kids’ chronic eczema.
An emollient is an agent that softens and smoothes the skin – it can be a cream, lotion or ointment. They keep the skin supple and moist. Emollients are an important part of atopic eczema treatment. The skin of people with eczema is usually dry; emollients help keep them moisturized, which helps prevent cracking and irritation.
Finding the right emollient may be a question of trial-and-error at first. The patient may have to try several different ones before hitting on a suitable one. Patients usually end up needing different types of emollients for different parts of their body.
Some emollients are specific for very dry skin, while others are aimed at less dry skin. Ointments are generally prescribed for drier skin, while creams and lotions are usually prescribed for other skin types.
It is not uncommon for patients to find that an emollient is not longer as effective as it used to be. Others may start experiencing skin irritation after long-term use. If either case happens to you or your child, you should see your GP.
Applying an emollient – apply smoothly to the skin, following the direction the hair grows. Do not rub it in as this may irritate the skin. Gently dry the skin after washing and apply the emollient as soon as the skin is dry. Emollients must not be shared.
Creams and lotions are generally used for red, inflamed areas.
Ointments are usually used for dry areas that are not inflamed.
Apply often – Frequency is the key for effective emollient use. Do not stop applying it when the skin seems to be clear. Frequent use on known affected areas will significantly reduce the number of flare-ups, as well as their severity. Patient’s whose skin is very dry should have repeat applications every two to three hours. During flare-ups frequency of use is paramount – this is when the skin needs the most moisture. Applications during a flare-up should be both frequent and generous.
If your child has atopic eczema it is important that you liaise with his/her school. In the UK it is common for a child to have emollient supplies at home and at school.
Emollient instead of soap – emollient treatments should be used in place of soap. Soap irritates the skin if you have atopic eczema. In many countries it is possible to purchase emollient bath and shower additives. This measure will make a significant difference in the patient’s frequency and severity of flare-ups.
Side effects of emollients – some patients may develop a rash with certain ingredients in a specific emollient. That is why people commonly have to try out different ones when they first start. Some emollients contain paraffin and can be a fire hazard – store them carefully and do not use them near a naked flame. Emollients may make the surface of the bath and the floor of the shower cubicle more slippery.
In medicine topical means “applied on to the skin”. Corticosteroids rapidly reduce inflammation. If the patient’s skin is very red and inflamed the doctor may prescribe a topical corticosteroid.
Many parents or adult patients react with alarm when the doctor utters any word with “steroid” in it. They imagine anabolic steroids that bodybuilders use. Corticosteroids are not anabolic steroids, and when used correctly, they are a safe and effective treatment for eczema.
Applying a corticosteroid – apply to the affected area sparingly. Follow the instructions on the leaflet carefully. You can also ask the doctor, and if you cannot remember, ask a qualified pharmacist.
Applying a corticosteroid during a flare-up – the corticosteroid should not be applied more than twice daily. Most patients will only require one application per day. After the flare-up has cleared up you should continue for another 48 hours.
If the patient is using corticosteroids on a long-term basis, he/she should check carefully with the doctor on how and when to apply it.
If you have tried corticosteroids and symptoms have not improved you should see your doctor.
Alitretinoin is used for patients with severe, chronic hand eczema who have not responded to other treatments. A specialist skin doctor (dermatologist) needs to supervise treatment with alitretinoin. Alitretinoin is a retinoid, a type of medication that helps lower levels of irritation and itchiness associated with eczema. Treatment usually consists of swallowing one tablet a day for 12 to 24 weeks.
Alitretinoin must NOT be taken by pregnant women or breastfeeding mothers. In most countries alitretinoin is not recommended for women of child-bearing age.
Side effects of alitretinoin include headaches, dry skin, flushed skin, joint pain, and muscle pain. The following extremely rare side-effects also exist: hair loss, blurred and distorted vision, and nose bleeds. Anybody who experiences blurred vision when taking this medication should contact the dermatologist immediately.
This type of medication stops the effects of histamine, which our body releases when in contact with an allergen. If the effects of histamine can be stopped or reduced, symptoms of eczema, hay fever, and some other allergic conditions are often significantly reduced.
Sedating antihistamines can make some people feel drowsy and are generally prescribed for itchiness at night – their drowsiness side-effect will help some patients get a good night’s sleep. Sedating antihistamines are not usually prescribed for more than a couple of weeks at a time. They should be taken about one hour before going to bed. Sometimes drowsiness is still present the following day – it is important that the child’s school knows this. If the patient is an adult and feels drowsy the following morning he/she should not drive or operate heavy machinery.
Non-sedating antihistamines may be used on a long-term basis. They will help ease itching but will not make the patient feel drowsy.
If the eczema becomes infected the patient will probably need an antibiotic.
Oral antibiotic – An oral antibiotic will be prescribed if symptoms are very severe and infection has affected a large area. The most commonly prescribed antibiotic is flucloxacillin, which should be taken for seven days. If you or your child are allergic to penicillin a different antibiotic will be prescribed, perhaps erythromycin or clarithomycin.
Topical antibiotic – if symptoms are not so severe and the infection does not cover a large area the patient will most likely be prescribed a topical antibiotic – one that is applied directly onto the affected area. This will usually be an ointment or a cream.
The doctor may prescribe new supplies of topical medications in case your current ones have become infected.
Patients who have areas which are prone to recurrent infection may be prescribed a topical antiseptic, which is applied directly onto the targeted area of skin. Examples include chlorhexidine and triclosan.
Light Therapy (Phototherapy)
This involves the use of natural or artificial light. In its most simple form, all the patient has to do is expose himself/herself to controlled amounts of natural sunlight.
Other forms of phototherapy include using artificial ultraviolet A (UVA) or ultraviolet B (UVD) light, either on its own or in combination with drugs.
Light therapy is very effective. It is important that it is done with a qualified health care professional. Exposure to sunlight has many beneficial effects, but it does, however, also have risks if not controlled properly. Examples of risks include premature skin aging and a higher risk of developing skin cancer.
When to see a specialist
The GP may refer a patient to a specialist skin doctor (dermatologist) if:
The patient has not responded to treatment.
The GP is uncertain about what is causing the eczema.
The patient insists the GP refers him/her or the child to a specialist.
The GP thinks the patient would benefit from specialist treatment, such as ultraviolet light exposure, bandaging treatments (wet wraps), or calcineurin inhibitors.
Complications of atopic eczema
If the skin becomes dry and cracked there will be an opportunity for bacteria to penetrate. The likelihood of this happening is greater for people with eczema. Scratching the eczema increases the risk of infection further.
A bacterium called Staphylococcus aureus (S. aureus) commonly infects people with eczema. An infection with S. aureus will make the eczema much worse, causing increased redness, oozing of fluid and crusting of the skin, making it virtually impossible for the skin to heal naturally (without antibiotics).
The mental stress of living with eczema can have a psychological impact on the sufferer, especially if it started very early in life. Children with atopic eczema are much more likely to have behavioral problems at school, compared to their peers who do not have it. Parents sometimes comment that their child with atopical eczema is much more clingy than their other children.
The stress can also come from other people. More than a quarter of patients with atopic eczema have been bullied or teased because of their skin condition, according to an international study.
Children with eczema frequently suffer from a lack of self-confidence. Family support and encouragement is a crucial factor in helping them overcome this. If your child’s self-confidence appears to be seriously undermined, talk to a health care professional, as well as the staff at his/her school.
The majority of children with atopic eczema have sleep-related problems. Lack of sleep can have an impact on the patient’s physical and mental health.