Eczema

ECZEMA - a patient's guide
Dr Stephen Helander - Dermatologist

WHAT IS IT?

Eczema is the most common inflammatory disorder of the skin. It appears as a red, itchy, scaly and sometimes blistering rash. Dermatitis is another term for eczema.

Although not an indication of poor health, eczema causes much misery and suffering. Hand eczema is a huge cause of lost time at work. There is no cure for eczema but there is much that can be done to treat it. Severe or difficult cases should ideally be reviewed by a dermatologist

TYPES OF ECZEMA:

There are 2 main types of eczema, but it is not uncommon to have a mixture of both:

1. Exogenous (Environmental) Eczema

External contact factors induce the eczema. This is usually caused by irritants such as soaps, detergents or solvents. Everyone's skin can develop an irritant dermatitis, but the resistance to irritation varies a lot. For example anyone that uses oven cleaner without gloves will develop irritant dermatitis, but it may take much less irritation to trigger it in others. Another type of contact eczema is allergic in nature. Here the immune system is sensitised or "vaccinated" against a specific substance, so that contact with even minute quantities can trigger dermatitis. Examples of this include plant dermatitis and nickel dermatitis.

2. Endogenous Eczema

Here there seems to be a problem with the skin itself. Three main types are seen:

Atopic eczema - is often genetically inherited and can be associated with asthma and hay fever.

Ninety percent of cases present in childhood, usually infancy on the face and subsequently the creases of arms, legs, neck and face. The skin is often very dry. Ninety percent of children will have outgrown their eczema by the time they reach adulthood.

Seborrhoeic eczema - appears as severe scalp dandruff with a greasy scaly rash in the T zone of the face (eyebrows, central cheeks and sides nose) and sometimes the central chest, armpits and groin. It usually starts at puberty.

Discoid eczema - starts as itchy weepy scaly circular sores especially on the arms and legs. It can appear at any age.

Infection:

Eczematous skin is more prone to infection with bacteria and viruses. This is particularly so for atopic eczema. These infections can really flare the eczema. The most common bacteria that infects eczema is Staphylococcus aureus. This bacteria is very common around the human environment. It can cause impetigo and boils. When eczema becomes infected it becomes sore, weepy and crusted.

Herpes simplex or cold sore virus can infect atopic eczema and causes serious flares that can recur. As mentioned atopics have reduced resistance to skin viruses.

TREATMENT OF ECZEMA

General measures

Regardless of cause there are a number of simple measures that can make a big difference:

Dry skin: This is particularly a problem in atopic eczema. Soaps and detergents aggravate the problem. Excessive washing should be avoided. Try to avoid long showers. Use of a soap substitute such as Aqueous Cream can help. Moisturisers should be applied frequently. There are many good proprietary products. Generally eczema sufferers should use simple products without perfume or additives and the moisturiser should be a cream or ointment as these moisturise better than lotions. Aqueous and Oily Creams are good and cheap moisturisers that are very unlikely to irritate sensitive skin.

Heat and sweating: Getting hot will aggravate any itch. Avoiding warm clothes, hot bedding and hot baths is important. Exercise also aggravates eczema and should be reduced during bad flares.

Clothing: Wool and nylon against the skin aggravate eczema. Cotton is best.

Stress: There is no doubt that stress can flare some people's eczema. Tackling this stress can be very helpful.

Sun exposure: Some careful sun exposure can help in many cases.

Diet: This is a controversial area of eczema management. Properly controlled studies suggest dietary elimination of foods such as dairy foods can help but only in about 10-15% cases. Eczema can vary so much itself that simple observation of short term improvements with dietary elimination are unreliable. If you do wish to pursue this treatment, foods should be totally eliminated one at a time for 6 weeks and reintroduced as a challenge. Allergy testing is not a reliable predictor for which foods affect eczema.

Infection: is indicated by weeping and crusting. It will need specific treatment as outlined below. If this is frequently a problem, putting half a capful of Janola in the bath twice a week can help. At this concentration it will not irritate skin while other household antiseptics may.

It is important to avoid contact with active cold sores, e.g. relatives with cold sores kissing children with eczema.

Contact factors: the home and work environment should be studied for irritant or potential allergy inducing factors. Gloves should be used to avoid contact with detergents soaps and other irritants. Barrier creams do not work well. If a specific allergic contact factor is suspected, a dermatologist can perform allergy patch testing to investigate this.

SPECIFIC TREATMENT

Specific treatment will depend on the individual case and should be determined in consultation with your doctor, but some basic principles apply: There should be a clear specific plan in place.

Moisturisers: (Emollients) to include a soap substitute and moisturiser as mentioned above. The moisturiser should ideally be applied several times a day.

Steroid creams and ointments: These will need to be prescribed by your doctor and are an essential part of successfully managing eczema. There is much fear of steroids and yet they are safe if used properly. Strong steroids (e.g. Dermovate, Betnovate) applied to large areas of the body can be absorbed and have internal side effects similar to those seen with prenisone. This is not a problem for small areas of application and for weaker steroids. If strong steroids are applied to the same areas of skin for more than 2-3 weeks without a break, atrophy (thinning) of the skin may occur. This is a particular problem on the face and in the groin. There is no good evidence that using steroids more than once daily is of benefit. Ointments are generally preferable to creams because the skin is generally dry.

I give my patients a clear outline of how long and on what parts of the body to use their steroids. Generally I would start with a stronger steroid for 1-2 weeks and then change to a weaker one.

Infection: If the eczema becomes weepy or crusted then antibiotics are needed. Small areas can be treated with Bactroban which is available without prescription but oral antibiotics should be used if the infection is extensive. The antiviral drug Acyclovir can be prescribed if there is herpes simplex infection.

Antihistamines may help some sufferers. They work by blocking release of histamine in the skin and are most effective in urticaria (hives). The itch of eczema is not primarily caused by histamine release and thus antihistamines are typically not effective. Sedating antihistamines e.g. Phenergan largely work by providing some nighttime sedation.

Prednisone and Cyclosporin are powerful drugs reserved for severe unresponsive eczema. Prednisone is an oral steroid that is very effective for severe flares. It should not be used frequently or for prolonged periods due to side effects. Cyclosporin is an immune suppressant drug initially developed for organ transplantation that can be dramatically effective in severe intractable eczema.

SUMMARY

Eczema is a common problem with the potential to cause much misery and disability. Much can be done to relieve the problem both in terms of self-help and medical treatments.

Eczema appears as an itchy scaly at times blistering rash, as seen here:

Atopic eczema typically affects the flexural creases of the limbs:

Sudden flares with crusting and erosions may indicate herpes simplex virus.