Eczema

Eczema, often used interchangeably with the term atopic dermatitis, is a chronic inflammatory skin condition. It is characterised by itchy, red, dry, and cracked skin, which can significantly impact a person's quality of life. Though there is currently no cure for eczema, various treatments and self-care strategies can effectively manage its symptoms and reduce flare-ups. 

This guide discusses its causes, symptoms, diagnosis, treatment options, and provides practical advice for those living with this condition. 

Eczema is a condition that makes your skin red and itchy. It's a long-term (chronic) condition that tends to flare up periodically. The term "eczema" is actually a broad term encompassing several types of skin inflammation. Atopic dermatitis is the most common and often what people mean when they say "eczema." The word "atopic" refers to a tendency towards allergic conditions, such as asthma and hay fever, which are often seen alongside eczema.

At its core, eczema is thought to be caused by a combination of genetic and environmental factors. People with eczema often have an overactive immune system that reacts to irritants and allergens, leading to inflammation of the skin. 

The skin barrier, which normally protects the body from the outside world, is also often impaired in individuals with eczema, making the skin more susceptible to dryness and irritation. This defective barrier allows moisture to escape and irritants to get in, triggering the characteristic symptoms of eczema.

Eczema is a widespread condition affecting individuals of all ages, ethnicities, and socioeconomic backgrounds.

Worldwide Prevalence: Globally, the prevalence of atopic dermatitis varies significantly between populations and age groups. Many children outgrow the condition, but for others, it can persist into adulthood. 

Prevalence in India: In India, the prevalence of eczema is also significant, although specific large-scale epidemiological studies are still emerging. It has a higher prevalence in urban areas and among children. 

While atopic dermatitis is the most common type, there are several other forms of eczema, each with its own distinct characteristics and triggers:

Contact Dermatitis: This type occurs when the skin comes into direct contact with an irritant (like soaps, detergents, or chemicals) or an allergen (like nickel or poison ivy). It usually manifests as a localised rash at the site of contact.

Dyshidrotic Eczema (Pompholyx): This type is characterised by small, intensely itchy blisters on the palms of the hands, soles of the feet, and sides of the fingers and toes. The exact cause is unknown but may be linked to stress, allergies, or fungal infections.

Nummular Eczema (Discoid Eczema): This presents as coin-shaped patches of itchy, scaly skin. The cause is not fully understood but it can be triggered by dry skin or skin injury.

Seborrhoeic Dermatitis: This type mainly affects the scalp, face, chest, and back, causing scaly, greasy patches and redness. It's believed to be related to a yeast (Malassezia) that lives on the skin and the body's immune response. Dandruff is a mild form of seborrhoeic dermatitis of the scalp.

Stasis Dermatitis: This occurs on the lower legs in people with poor circulation. It can cause swelling, redness, itching, and skin changes.

Hand Eczema: This is a broad term referring to eczema that affects the hands. It can be caused by irritants, allergens, or can be a form of atopic dermatitis or dyshidrotic eczema.

The exact causes of eczema are not fully understood, but it's believed to be a complex interplay of genetic and environmental factors. Key contributing factors include:

Genetics: A family history of eczema, asthma, or hay fever significantly increases the risk of developing eczema. Specific genes involved in skin barrier function and immune regulation are thought to play a role. For instance, mutations in the gene responsible for filaggrin, a protein crucial for maintaining the skin's protective barrier, are commonly found in people with eczema.

Immune System Dysfunction: In people with eczema, the immune system overreacts to common irritants and allergens. This overactive response leads to inflammation in the skin, causing the characteristic redness and itching.

Skin Barrier Dysfunction: The skin barrier in individuals with eczema is often impaired. This means it's less effective at retaining moisture and protecting against irritants, allergens, and bacteria. This dryness makes the skin more susceptible to flare-ups.

Environmental Triggers: Various environmental factors can trigger or worsen eczema symptoms. These can include:

• Irritants: Soaps, detergents, fragrances, certain fabrics (like wool and synthetic fibres), and chemicals can irritate sensitive skin.
• Allergens: Airborne allergens like pollen, dust mites, pet dander, and mould can trigger eczema in some individuals. Food allergies, such as to milk, eggs, peanuts, soy, and wheat, can also play a role in some cases, particularly in young children.
• Climate: Extreme temperatures and humidity levels can exacerbate eczema. Dry winter air can dry out the skin, while high humidity and heat can cause sweating, which can also be irritating.
• Stress: Emotional stress can trigger or worsen eczema flare-ups in some people.
• Hormonal Changes: Fluctuations in hormone levels, such as during menstruation or pregnancy, can sometimes affect eczema symptoms.
• Infections: Bacterial (e.g., Staphylococcus aureus), viral (e.g., herpes simplex), and fungal infections can worsen eczema.

It's important to identify individual triggers to effectively manage eczema and prevent flare-ups.

The symptoms of eczema can vary significantly from person to person and depending on the type and severity of the condition. However, common symptoms include:

• Intense Itching (Pruritus): This is often the most bothersome symptom and can be severe, leading to scratching that further damages the skin. The itch may be worse at night.
• Dry, Scaly Skin: The affected skin often feels dry, rough, and flaky. This is due to the impaired skin barrier's inability to retain moisture.
• Red or Brown Patches: Inflamed areas of skin can appear red in lighter skin tones and brownish in darker skin tones. These patches can vary in size and location.
• Thickened, Leathery Skin (Lichenification): Chronic scratching can cause the skin to become thick and leathery over time.
• Small, Raised Bumps That May Leak Fluid and Crust Over: During flare-ups, small blisters may form that can weep fluid and then crust over.
• Swelling: The affected skin may become swollen, especially during severe flare-ups.
• Cracked Skin: Dry skin can crack, leading to pain and increasing the risk of infection.
• Sleep Disturbances: The intense itching can make it difficult to sleep, leading to fatigue and impacting overall well-being.

The location of eczema rashes can also vary with age. In infants, eczema often appears on the face, scalp, cheeks, chin, chest, back, arms, and legs. In children and adults, it commonly affects the creases of the elbows and knees, wrists, ankles, neck, and upper chest.

There is no specific blood test to diagnose eczema. Diagnosis is primarily based on a thorough clinical examination by a doctor, usually a dermatologist. The doctor will consider:

• Medical History: They will ask about the patient's personal and family history of eczema, allergies (like hay fever and asthma), and other relevant medical conditions.
• Physical Examination: The doctor will carefully examine the affected skin, noting the appearance, location, and distribution of the rash. They will also look for characteristic signs of eczema, such as dryness, scaling, and lichenification.
• Symptom History: The doctor will inquire about the patient's symptoms, particularly the onset, duration, severity of itching, and any factors that seem to trigger or worsen the condition.

In some cases, the doctor may recommend patch testing to identify specific allergens that might be contributing to contact dermatitis. This involves applying small amounts of various substances to the skin and observing for allergic reactions. Skin biopsies are rarely needed but may be performed to rule out other skin conditions if the diagnosis is uncertain.

The primary goals of eczema treatment are to relieve itching and inflammation, heal the skin, prevent flare-ups, and manage any secondary infections. Treatment strategies often involve a combination of approaches:

Emollients (Moisturisers): Regular and liberal use of emollients is the cornerstone of eczema management. Emollients help to hydrate the skin, restore the skin barrier, and reduce dryness and itching. Different types of emollients are available, including creams, ointments, lotions, and sprays. Ointments are generally the most effective for very dry skin. It's crucial to apply emollients frequently throughout the day, especially after washing or bathing.

Topical Corticosteroids (Steroid Creams and Ointments): These are anti-inflammatory medications that are applied directly to the affected skin. They help to reduce redness, swelling, and itching during flare-ups. Topical corticosteroids come in various strengths, and the doctor will prescribe the appropriate potency based on the severity and location of the eczema. They should be used as directed by the doctor, and prolonged use of high-potency steroids can have side effects. (Brand available: Betnovate C, Quadriderm RF, Surfaz SN)

Topical Calcineurin Inhibitors (TCIs): These are non-steroidal anti-inflammatory creams and ointments, such as tacrolimus and pimecrolimus. They work by suppressing the immune system's response in the skin. TCIs are often used on sensitive areas like the face and neck or for long-term management to reduce the need for topical corticosteroids.

Oral Antihistamines: These medications can help to relieve itching, particularly night-time itching, which can improve sleep quality. However, they do not treat the underlying inflammation of eczema. Sedating antihistamines may be more effective for itch relief but can cause drowsiness. (Brand available: Atarax) 

Systemic Medications: For severe eczema that doesn't respond to topical treatments, systemic medications taken by mouth or injection may be necessary. These can include:

• Oral Corticosteroids: These are potent anti-inflammatory drugs that can provide rapid relief during severe flare-ups. However, they have potential long-term side effects and are usually used for short periods.
• Immunosuppressants: Medications like cyclosporine, azathioprine, and methotrexate suppress the overactive immune system. They are used for more severe, persistent eczema under specialist supervision.
• Biologics: Newer injectable medications, such as dupilumab, target specific proteins involved in the inflammatory process of eczema. They are used for moderate to severe atopic dermatitis that has not responded well to other treatments.

Phototherapy (Light Therapy): This involves exposing the skin to specific wavelengths of ultraviolet (UV) light under medical supervision. It can help to reduce inflammation and itching in some people with moderate to severe eczema.

Wet Wrap Therapy: This involves applying a topical medication and then covering the affected skin with a damp layer of gauze or fabric followed by a dry layer. It can help to hydrate the skin and enhance the effectiveness of topical treatments.

Treatment of Infections: If the eczema becomes infected (bacterial or viral), appropriate antibiotics or antiviral medications will be prescribed.

Some people with eczema explore alternative therapies to manage their symptoms. It's important to discuss these with a doctor before trying them, as their effectiveness and safety can vary. Some commonly explored alternative therapies include:

• Nutritional Supplements: Some supplements, such as vitamin D, evening primrose oil, and probiotics, are sometimes used, but scientific evidence supporting their effectiveness for eczema is generally limited or inconclusive.
• Balneotherapy (Therapeutic Baths): Soaking in baths with added ingredients like colloidal oatmeal, Epsom salts, or diluted bleach (under medical guidance) may help to soothe the skin and reduce inflammation.

It's crucial to be cautious about unproven or unregulated alternative therapies and to prioritise treatments with established safety and efficacy.

Several factors can increase the risk of developing eczema:

• Family History: Having a family member (parent, sibling) with eczema, asthma, or hay fever is a significant risk factor.
• Personal History of Allergies: Individuals with other allergic conditions are more likely to develop eczema.
• Environmental Factors: Exposure to certain irritants and allergens can increase the risk in susceptible individuals.
• Climate: Living in dry or cold climates can exacerbate skin dryness and increase the risk of eczema.

Eczema can lead to several complications:

• Secondary Skin Infections: Broken skin due to scratching can become infected with bacteria (e.g., impetigo), viruses (e.g., herpes simplex, causing eczema herpeticum), or fungi.
• Sleep Disturbances: Severe itching can interfere with sleep, leading to fatigue, irritability, and difficulty concentrating.
• Neurodermatitis (Lichen Simplex Chronicus): Chronic scratching and rubbing can lead to thickened, leathery patches of itchy skin.
• Emotional Distress: The visible nature of eczema, persistent itching, and impact on daily life can lead to anxiety, depression, and low self-esteem.
• Allergic Contact Dermatitis: Individuals with eczema may be more prone to developing allergic reactions to substances that come into contact with their skin.
• Asthma and Hay Fever: There is a strong association between eczema and the development of asthma and hay fever.

Living with eczema can be challenging, but adopting certain strategies can help manage the condition and improve quality of life:

• Establish a Consistent Skincare Routine: Stick to a regular regimen of gentle cleansing and frequent moisturising.
• Learn Your Triggers: Keep a diary to track flare-ups and potential triggers.
• Manage Stress Effectively: Find healthy ways to cope with stress.
• Prioritise Sleep: Aim for adequate sleep to support overall health and reduce stress.
• Wear Comfortable Clothing: Choose soft, breathable fabrics.
• Avoid Overheating: Excessive sweating can irritate eczema.
• Communicate with Your Doctor: Maintain regular contact with your dermatologist to discuss treatment options and address any concerns.

“Eczema is just dry skin.”

While dry skin is a symptom, eczema is a complex inflammatory condition involving the immune system and skin barrier dysfunction. 

“Eczema will go away on its own.”

While some children may outgrow eczema, it can be a chronic condition that persists into adulthood for many. Management is usually required.

“Topical steroids are dangerous.” 

When used correctly under a doctor's supervision, topical corticosteroids are a safe and effective treatment for eczema flare-ups. Concerns about side effects often arise from misuse or prolonged use of high-potency steroids without medical guidance.

It's important to see a doctor if you experience any of the following:

• Symptoms of eczema for the first time.
• Eczema symptoms that are severe or widespread.
• Eczema that is not improving with over-the-counter treatments.
• Signs of skin infection, such as increased redness, warmth, pain, pus, or fever.
• Significant sleep disturbances due to itching.
• Eczema that is significantly impacting your daily life or emotional well-being.
• Sudden worsening of your eczema symptoms.

• What type of eczema do I have?
• What are the treatment options for my eczema?
• How should I use the prescribed medications?
• What are the potential side effects of the treatments?
• How often should I apply emollients? What type do you recommend?
• What are my potential triggers? How can I identify and avoid them?
• Are there any lifestyle changes that might help manage my eczema?
• When should I use topical corticosteroids or other prescription treatments?

• Encourage Self-Care: Support them in maintaining their skincare routine and adopting stress-management techniques.
• Avoid Minimising Their Condition: Don't dismiss their symptoms or suggest simple "cures."
• Accompany Them to Appointments: Offer to go with them to doctor's appointments for support.
• Celebrate Small Victories: Acknowledge and appreciate their efforts in managing their eczema.

Eczema is a common yet complex skin condition that can significantly impact the lives of those affected. While there is no cure, a combination of consistent skincare, appropriate medical treatments, identification and avoidance of triggers, and supportive lifestyle adjustments can help individuals with eczema find relief and improve their quality of life.