Eczema

Not just a childhood itch

Eczema, or atopic dermatitis is a chronic, itchy, blistered rash that can make its first appearance in infancy (sometimes called infantile eczema). About 5% of children have eczema. This condition is believed to be an immune system abnormality, and occurs most commonly in children who have asthma, hay fever, rhinitis, hives, or chronic sinus problems, or have relatives with these conditions. It generally appears in specific places such as the upper arms, in front of the elbows, and behind the knees. A child may have flare-ups of eczema throughout childhood, however, 90% of eczema sufferers see the condition clear up by the onset of puberty.

Acute atopic eczema is characterized by a red, bumpy, swollen rash that itches intensely. Persistent scratching can cause oozing and crusted lesions. The lesions can develop secondary infections.

Pronunciation

EK-ze-ma

Synonyms and Abbreviations

  • Disseminated neurodermatitis
  • Atopic eczema
  • Atopic neurodermatitis
  • Constitutional dermatitis
  • Besnier's prurigo
  • Atopic dermatitis

Detailed Description

Atopic eczema is quite itchy and scratching only makes it worse. It follows a fairly predictable pattern of appearance on the body as a child grows, starting with the face, abdomen, diaper area, lower back, and calves of infants. Later, the pattern shifts, starting on the fronts of elbows, thighs, shins, back of ankles, backs of knees, and backs of upper arms.

If that weren't bad enough, scratching can lead to secondary infections and permanent damage to the skin.

Allergies and eczema are often related, so you might find that certain foods or conditions cause flare-ups. A good part of eczema treatment is prevention, including learning to identify which foods or conditions precipitate a flare-up and avoiding them. Stress and changes in temperature and humidity are important factors.

There are two other common types of atopic dermatitis:

  • Nummular or discoid eczema is mainly an adult disorder. This persistent, itchy rash may come and go without any apparent reason, although many experts believe it is particularly reactive to changes in the environment. Small, round lesions marked by tiny blisters, scabs, and scales may ooze and form crusts. It is most commonly seen on the arms, legs, and buttocks, but it may also appear on the torso.
  • Steatotic eczema occurs mainly in elderly people. This condition causes the skin to become very dry and scaly.

How Common Is Eczema?

Eczema can affect people of all ages but is more common in infants and young adults. It affects about 10% of infants and close to 15% of the U.S. population overall. The condition usually improves in childhood or sometime before age 25. In teens and young adults, eczema most commonly affects the elbows, knee folds, ankles, and wrists. It generally improves by puberty and eventually localizes to the hands.

About 60% of people with eczema have skin problems throughout life. About 80% of people with eczema have family members with similar skin problems.

What You Can Expect

Atopic eczema is a chronic disease that flares and subsides periodically. The overwhelming majority -- 90% -- of patients see the disease spontaneously clear itself before the onset of puberty. Throughout the course of the illness, it can be managed with conscientious treatment.

Established Causes

No specific causes have been established for eczema.

Theoretical Causes

The cause of eczema is theoretically believed to be genetically determined. It may be related to an overactivity of the immune system.

Risk Factors

Risk factors to this skin disease include:

  • Emotional stress
  • Exposure to excessive hot or cold climates
  • Exposure to cigarette smoke
  • Skin infections
  • Irritant due to chemicals or clothing
  • Use of immunosuppressives
  • Family history
  • Hay fever and asthma

Symptoms and Diagnosis

The most common problem is itching of the skin. Other signs and symptoms include:

  • Dry skin
  • Skin lesions with a specific morphology and distribution
  • Facial erythema (abnormal redness of the skin)

Conditions That May Be Mistaken for Eczema

Some conditions that may be confused with eczema are:

How Eczema Is Diagnosed

Diagnosis is mostly based on a clinical assessment of the rash, as well as on the medical history of the family. Based on these two assessments, a skin biopsy is rarely needed.

Goals of Treatment

Atopic eczema cannot be cured, but it can be treated effectively. Before the onset of puberty, 90% of patients experience spontaneously healing of the disease.

Mild cases of atopic eczema can be treated quite easily with over-the-counter creams, ointments, antihistamines, and bath preparations. More serious cases require persistent, diligent treatment to keep symptoms under control and may require oral corticosteroids and antibiotics.

The goal of treatment is to relieve itching, inflammation, and other discomforts, to return skin to its normal appearance, and to restore the barrier function of the skin.

Treatment Overview

Most treatments designed to treat atopic eczema are rooted in moisturizing the skin, while soothing the skin and controlling itching. These therapies include therapeutic baths.

In addition, mild corticosteroid creams or ointments, even an antihistamine at bedtime, may control itching. Severe atopic eczema may be treated with prescription corticosteroid tablets. For adults, ultraviolet light treatments plus oral doses of psoralen -- a drug that intensifies the effects of ultraviolet light -- may help.

There are also general measures that will make living with atopic eczema easier:

  • Avoid stress. Stress can exacerbate or cause a flare-up.
  • Take lukewarm baths or showers -- avoid very hot water, and keep them short.
  • Wash new clothes before wearing them. Rinse laundry twice.
  • Wear cotton-lined rubber gloves when cleaning.
  • Bathe every other day, and use super-fatted soaps.
  • Use hypoallergenic, total-body moisturizers, bath oil, etc.
  • Avoid strenuous exercise and sweating. Sweating will only worsen your condition.
  • Avoid substances that may exacerbate a flare-up (wool, detergents, perfumes, perfumed soaps, etc.).
  • Brief exposure to the sun (but not sunburn) may be helpful.
  • Humidify your house.

Drug Therapy

Drugs most commonly prescribed

Drugs of choice involve the use of medications including:

  • Topical corticosteroids of varying strength
  • Oral antihistamines to relieve itching
  • Oatmeal lotions and baths
  • Barrier creams

Second choices

If alternatives are needed, systemic steroids, like prednisone, may be taken over short periods of time. Usually, these cases are severe. For stubborn eczema, intralesional steroids may be administered.

Appropriate Health Setting

The appropriate healthcare is outpatient from a family physician, pediatrician, dermatologist, or internist, and self-care after diagnosis.

Possible Complications

Possible complications arising from eczema include:

  • Skin infections
  • Greater risk of later developing cataracts
  • Atrophy of face and skin folds due to corticosteroid use
  • Systemic absorption of steroids with cushingoid condition
  • Irritation due to contact with substances such as wool (lanolin), nickel compounds, etc.

Activity and Diet Recommendations

Those with outbreaks of atopic eczema should avoid any activity that causes sweating or overheating. Avoid stressful activities, which can exacerbate the outbreak.

When eczema carries into adulthood, it is usually unrelated to food allergies. Some studies show, however, that children with atopic eczema can have sensitivities to certain foods. Identify the foods that spark a reaction, and avoid them. Some foods cause allergic reactions more frequently than others do: milk, dairy products, eggs, shellfish, wheat, soy, peanuts, tomatoes, and citrus fruits.

Considerations for Children and Adolescents

Children with very severe atopic eczema should not be vaccinated against smallpox. Such vaccinations can cause eczema herpeticum, a serious illness requiring hospitalization. Check with your doctor about the appropriate timing of vaccinations.

Atopic eczema is generally a disease of childhood. Take special care that children's fingernails are clipped short and their hands are kept clean. Scratching with dirty fingernails can cause serious secondary infections.

Diet

Many studies show that eczema often results from food sensitivities. For example, Dutch researchers placed children and adults with severe eczema on an elimination diet, which involves cutting out specific foods and then reintroducing them to see what happens. The majority of the subjects improved after this diet pinpointed problem foods. The foods most likely to cause eczema were eggs, milk, peanuts, fish, wheat, and soybeans. [1]

Supplements

  • Fish oil contains the omega-3 fatty acids found in cold-water fish.
  • Evening primrose oil also contains omega-3 fatty acids. A British study showed that compared with a placebo treatment, evening primrose oil provided significant relief of eczema. [2], but other studies do not confirm these results.

Herbs

  • Chamomile has anti-inflammatory action. Commission E, the German expert panel that judges the safety and effectiveness of medicinal herbs for Germany's counterpart of the Food and Drug Administration, endorses chamomile compresses for eczema and other inflammatory skin conditions.
  • Chinese herbs may help relieve eczema. British researchers gave a Chinese herb formula to 10 people with eczema. Two months later, their skin was significantly clearer. [3] Consult a practitioner of Chinese herbalism for specific advice. Chinese herbs can be very risky for children. Beware: the products you buy are not monitored for quality control or approved ingredients by the U.S. Food and Drug Administration (FDA).

Relaxation

Stress may contribute to eczema. Incorporate a stress-management regimen into your life that includes relaxing therapies like meditation, biofeedback, yoga, or deep breathing.

Hydrotherapy

An oatmeal bath helps relieve itching. Grind oatmeal fine in a coffee grinder and add a handful or two to a warm bath. Or use Aveeno powder, which is also fine-ground oatmeal.

Preventing Eczema

  • Identify and avoid all allergens that irritate your skin
  • Wash new clothes before wearing them and rinse laundry twice
  • Avoid stress

Self-Care Measures

  • Try not to scratch. It aggravates the inflammation and can cause a secondary bacterial infection.
  • Showering dries skin. Take quick showers, avoiding overly hot water, and apply moisturizing lotion immediately afterwards and throughout the day when you feel itchy.
  • Use mild soap.
  • Avoid skin irritants, which include harsh soaps, detergents, solvents, fragrances, fumes, paints, and any fabrics to which you are sensitive.
  • Treat your allergies -- they often play a role in eczema.
  • Alcohol dries skin. Don't use personal-care products that contain it.
  • A dry environment contributes to dermatitis. Install a humidifier to help add moisture to the air.
  • Wash new clothes before wearing them to remove potential irritants.

Websites & Organizations

American Dermatologic Society of Allergy and Immunology
Mayo Clinic
Rochester, MN 55905
Phone: 507-284-2555

Dermatology Foundation
1653 Maple Avenue
Evanston, IL 60201
Phone: 312-328-2256

Health World Online

The National Eczema Society
163 Eversholt Street
London NW1 1BU

National Jewish Medical and Research Center
1400 Jackson St.
Denver, CO 80206
Phone: 303-388-4461 or 800-222-LUNG (5864)

The Society for Investigative Dermatology
Suite 340
820 West Superior Avenue
Cleveland, OH 44113-1800
Phone: 216-579-9300
Fax: 216-579-9333
Email: SID@SIDNET.org

Society for Pediatric Dermatology
5422 North Bernard
Chicago, IL 60625
Phone: 773-583-9780
Fax: 773-583-9765

Women's Dermatologic Society
930 North Meacham Road
Schaumberg, IL 60173
Phone: 847-330-9830
Fax: 847-330-1090
Email: kward@aad.org

Sources for This Article

Books

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Bennett, J. Claude and Plum, Fred. Cecil Textbook of Medicine, eds. Philadelphia: W. B. Saunders, 1996.

Fauci, Anthony J., et. al. Harrison's Principles of Internal Medicine, eds. New York: McGraw-Hill, 1998.

Hardman, Joel G. and Limbird, Lee E. Goodman and Gilman's The Pharmacological Basis of Therapeutics eds. New York: McGraw-Hill, 1996.

Hurst, J. Willis. Medicine for the Practicing Physician eds. Stamford, CT: Appleton & Lange 1996.

Murray, Michael T. Encyclopedia of Natural Medicine. Prima, 1998.

Noble, John. Primary Care Medicine ed. St. Louis: Mosby, 1996.

Physicians' Desk Reference. Montvale, NJ: Medical Economics Co., 1998.

Rakel, Robert E. Conn's Current Therapy eds. Philadelphia: W.B. Saunders, 1998.

Taylor, Robert B. Family Medicine: Principles and Practice. New York: Springer-Verlag, 1998.

Tierney, L.M., McPhee, S.J., and Papadakis, M.A. Current Medical Diagnosis and Treatment eds. Stamford, CT: Appleton & Lange, 1998.


Articles

Carlsen, KH, Halvorsen, R, Pettersen, M, Carlsen, KC. "Inflammation Markers and Symptom Activity in Children with Bronchial Asthma. Influence of Atopy and Eczema." Pediatr Allergy Immunol. 8(3):112-20. Aug 1997.

Chandra, RK. "Five-year Follow-up of High-risk Infants with Family History of Allergy who were Exclusively Breast-fed or Fed Partial Whey Hydrolysate, Soy, and Conventional Cow's Milk Formulas." J Pediatr Gastroenterol Nutr. 24(4):380-8. Apr 1997.

Davis, MD, McEvoy, MT, el-Azhary, RA. "Topical Psoralen-Ultraviolet A Therapy for Palmoplantar Dermatoses: Experience with 35 Consecutive Patients." Mayo Clin Proc. 73(5):407-11. May 1998.

Fleming, C, Parry, E, Forsyth, A, Kemmett, D. "Patch Testing in Discoid Eczema." Contact Dermatitis. 36(5):261-4. May 1997.

Goulden, V, Wilkinson, SM. "Patch Testing for Compositae Allergy." Br J Dermatol. 138(6):1018-21. Jun 1998.

Grimbacher, B, Peters, T, Peter, HH. "Lactose-intolerance May Induce Severe Chronic Eczema." Int Arch Allergy Immunol. 113(4):516-8. Aug 1997.

Jarvikallio, A, Naukkarinen, A, Harvima, IT, Aalto, ML, Horsmanheimo, M. "Quantitative Analysis of Tryptase- and Chymase-containing Mast Cells in Atopic Dermatitis and Nummular Eczema." Br J Dermatol. 136(6):871-7. Jun 1997.

Schafer, T, Dirschedl, P, Kunz, B, Ring, J, Uberla, K. "Maternal Smoking During Pregnancy and Lactation Increases the Risk for Atopic Eczema in the Offspring." J Am Acad Dermatol. 36(4):550-6. Apr 1997.

Schmeller, W. "Community Health Workers Reduce Skin Diseases in East African Children." Int J Dermatol. 37(5):370-7. May 1998.

Weisshaar, E, Forster, C, Dotzer, M, Heyer, G. "Experimentally Induced Pruritus and Cutaneous Reactions with Topical Antihistamine and Local Analgesics in Atopic Eczema." Skin Pharmacol. 10(4):183-90. 1997.

De Maat-Bleeker, F. et al. "Food Allergy in Adults with Atopic Dermatitis," Highlights in Food Allergy, 32:157, 1996.

Morse, PF et al. "Meta-Analysis of Placebo-Controlled Studies of the Efficacy of Epogram in Treatment of Atopic eczema," Br. J. Dermatol, 121:75, 1989.

Xu, XJ et al. "Modulation by Chinese Herbal Therapy of Immune Mechanisms in the Skin of Patients with Atopic Eczema," Br. J. Dermatol., 136:54, 1997.


 

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