Eczema (Dermatitis)

What is it?

Eczema is a condition that causes skin inflammation leading to dryness, itching and redness. The protective barrier function of the skin is reduced allowing increased water loss out of the skin leading to dryness.

Any area of the skin can be affected, although the most commonly affected areas are the backs of knees, elbow and wrist creases and the neck. In babies the face is commonly affected.

There are 2 types of eczema

  • Atopic eczema is caused by a problem within the body where you are born with a tendency to develop the condition. Atopic refers to individuals who have an allergic tendency and who may also suffer from hay fever and/or asthma. Mostly this type of eczema develops in children under the age of 5, and in around 70% of people, resolves by the mid teens.
  • Contact dermatitis is caused by a substance from outside the body, such as cleaning detergents, nickel, rubber products, hair dyes etc, which causes skin inflammation when in contact with the skin. If the substance is avoided, the skin inflammation should resolve.

What causes Atopic Eczema?

There is no single proven cause but many factors are thought to play a part. The release of inflammatory chemicals by the body’s immune system causes redness and dryness in the skin, although it is not clearly understood why this happens. In some people, hereditary factors play a part and it is common for children to be affected when one or both of the parents have the condition.

The condition is becoming more common and there are many theories to explain this eg increasing pollution, climate changes and house dust mite, among others.

What should I avoid?

  • Scratching will provoke more inflammation and dryness, which in turn causes more itchiness. It helps to keep your nails short and rub your skin with your fingers instead when your skin feels itchy, and if possible re-apply your eczema moisturiser at the same time. The more moist your skin is, the less itchy it will be.
  • Soaps, shower gels, bubble baths and handwashes dry out the skin. Use a soap substitute instead ( see treatment section).
  • Biological soaps and fabric conditioners can irritate the skin.
  • Wool may irritate the skin; try and wear cotton undergarments in any area where clothing is in contact with the skin.
  • Extreme temperatures may provoke your eczema, hot or cold.
  • Perfumes, preservatives and alcohol in cosmetics and creams can aggravate symptoms.
  • House dust mite may be a trigger in some cases. These are tiny insects that cannot be seen with the naked eye. We all have them in the soft furnishings in our homes, and they are impossible to eradicate completely. However, if your eczema is severe, regular vacuuming of soft furnishings like sofas, cushions and mattresses may help.
  • Food allergies may exacerbate atopic eczema. This is usually in young children who may have a food sensitivity. The most common foods which may trigger symptoms are cows’ milk, eggs, soya, wheat, fish and nuts. It may be helpful to keep a diary of everything that is eaten and drunk for 4 weeks to identify the suspect food(s). If food allergy is suspected, it should be confirmed by a specialist. They may recommend a diet without this food if the eczema is severe and difficult to control by other means.

How long will it last?

There is no cure for eczema, but you may find that you go between quiet periods where you have very few symptoms, and flare-ups where your skin becomes dryer and itchier. A flare-up can also be triggered when your eczema becomes infected and feels weepy and wet.

Flare-ups are variable from person to person as is the severity with which people with eczema are affected.

Treatment

Emollients

Eczema moisturisers or emollients are used daily to keep symptoms at bay. Do not stop using these when your eczema symptoms are quiet. This is a common mistake.

They are to be used liberally and applied in the direction of hair growth to prevent a possible risk of infection in the hair follicle.

When your skin flares-up try and use these at least four times a day.

There are various types of creams which vary in how heavy and greasy they feel. Some people prefer the lighter creams as they are easier to apply and less messy but these will need to be applied more frequently.

There are eczema shower creams and bath oils which may not foam up but clean adequately well. These should be used instead of soaps, shower gels and bubble bath. Pat yourself dry after bathing to retain some of the oil on your skin, but do also apply your emollient after drying. It is absorbed very well in moist skin.

Handwash should be substituted for an emollient cream preferably in a pump dispenser to avoid germs being harboured in the cream.

Steroid creams or ointments are used for flare-ups. These are available on prescription from your doctor.

Topical steroids (steroid creams and ointments)

Steroid creams work by reducing inflammation in the skin, and are used short term in the treatment of flare-ups. They are available in different strengths which will be tailored to the severity and site of your eczema. In most cases 1-2 weeks of treatment is usually adequate. Some people who have frequent flare-ups may need to use steroid treatment to keep symptoms under control by using it just at the weekends routinely, for example.

Creams are best on wet, weepy areas and ointments are better on dry or thickened skin. They are applied by rubbing a small even amount thinly over the affected areas until it disappears. Squeezing out the cream and running it from the tip of an adult index fingertip to the first crease is called 1 Finger Tip Unit (FTU). 1 FTU should cover an area of skin equal to 2 adult palms with the fingers held together.

Remember to continue using your emollients even when requiring steroids. If possible, apply steroid cream 1 hour after the emollient, but if this is not practical 15 minutes will be fine.

Side effects of steroid creams and ointments

Short courses are safe and usually cause no side effects, as is the case with mild steroids. If strong steroids are used for long periods or repeated often then some skin thinning may occur. Spidery blood vessels, bruising and striae, which look like stretch marks, can also occur.

Steroids can also make some skin conditions like rosacea, perioral dermatitis and acne worse. Please check with your doctor before applying steroids on these areas.

Small amounts of topical steroids are absorbed into the bloodstream and can affect growth. Growth should be monitored in children who require frequent strong steroids.

Infected eczema patches

If your skin becomes wet and weepy, with infected skin lumps or small blisters, then it will not respond well to the above treatment until the infection has been treated. This is usually with an antibiotic cream alone or in combination with a steroid, or with antibiotic tablets.

Why treatment fails

  • You may not be applying emollients often enough to keep the skin moist.
  • The strength of the steroid used may need to be increased.
  • The skin is infected and is not responding to the normal treatment until the infection has been treated.
  • You have developed a sensitivity to an ingredient in the cream such as a preservative. This may provoke the inflammation.

Other treatments

Tacrolimus and Pimecrolimus creams are available on prescription only from your doctor. They are useful in eczema not responding to steroids. They are not steroids and do not have the same side effects. They may cause a tingling or burning sensation when first applied but this tends to resolve. They should not be used on infected skin.

Steroid tablets can sometimes be used if the topical creams are not helping and if your eczema is severe.

Antihistamine tablets are sometimes useful to relieve the itch and help with sleep, especially in those where sleep is affected by the itching.

Your doctor will refer you to see a specialist, if other hospital-based treatments are to be considered.

Further help and information

National Eczema Society
Hill House, Highgate Hill, London, N19 5NA
Tel (Helpline): 0800 089 1122
www.eczema.org

References

Patient UK
British Association of Dermatologists
Primary Care Dermatology Society