Eczema
Introduction
Have you ever had an itch that just wouldn't stop, no matter how much you scratched it? Did the itchy area become a red, inflamed, scaly rash? If so, you may have had an outbreak of eczema ('ek-ze-ma'). Eczema is commonly known as "the rash that itches and the itch that rashes."
What is it?
Eczema, also known as atopic dermatitis (or inflammation of the skin), is a chronic skin condition commonly characterized by dry, red, swollen, patches of skin that itch relentlessly. For many individuals who have eczema, frequent scratching of the affected area only makes the condition more bothersome and uncomfortable. Repeated scratching also may cause the skin to become red or swollen, which can then cause the area to crack, ooze clear liquid, and become crusty. Eczema occurs most often in the folds of the elbows or behind the knees, but it can appear anywhere on the surface of the body. In children, eczema often occurs on the scalp and face as well. An eczema outbreak can last from a few days to a few weeks or more. And whereas some individuals experience a single outbreak, many experience frequent flare-ups, usually as a result of exposure to one or more triggers or irritants.
The itching and scratching caused by eczema can lead to breaks or cracks in the skin. Often, bacteria can infect the open skin wounds and cause an infection. These skin infections, also called cellulitis, can cause the skin to appear red and swollen and may be warm to the touch. These skin infections can spread to other areas of the body, therefore, it is important to contact a doctor if cellulitis is suspected.
There are eight types of eczema, usually distinguished by either cause or appearance. Learn more about the types of eczema by clicking on the links below.
Neurodermatitis (Lichen simplex)
Neurodermatitis (Lichen simplex) is a form of dermatitis that presents as scaly patches of skin on the head, lower legs, wrists, or forearms caused by a localized itch (such as an insect bite) that becomes intensely irritated when scratched. It normally occurs in adults aged between 30 to 50 years old and is seen more commonly in women than in men. Tightly worn clothing and dry skin can irritate an individual's nerves and cause this to occur. This type of dermatitis also seems to recur even after effective treatment with the initial breakout.
Dyshidrotic Eczema
Dyshidrotic eczema is an irritation of the skin on the palms of hands, sides of the fingers, and soles of the feet characterized by clear, deep blisters that itch and burn and can occur in both men and women. Its onset occurs usually before the age of 40. It is usually seasonal and may be triggered by contact to some type of allergen. People experiencing some type of emotional stress may be more likely to develop flare-ups.
Atopic Eczema
Atopic eczema (or atopic dermatitis) is the most common form of the illness, accounting for nearly 70 percent of all cases. This form of eczema causes the skin to become dry, red, itchy, scaly, and swollen. It often runs in families and is frequently associated with asthma and hay fever. Individuals of all ages and both males and females can be affected. However, atopic eczema appears to occur more frequently in infants and young adults. In infants and young adults, the outbreaks frequently occur on the forearms or the back of the legs behind the knee joint. In adults, the disease is usually confined to the hands. Typically, when an outbreak of atopic eczema occurs, it initiates the "itch and scratch cycle": an itch causes more scratching and more scratching causes more itching. Eventually, this cycle may lead to breaking of the skin and oozing and crusting of the affected area.
Allergic Contact Eczema
Allergic contact eczema occurs when the skin comes into contact with an allergen, either directly or indirectly, and the individual's immune system reacts to dispel it. Generally, repeated exposure to the allergen is necessary for the individual to develop an immune reaction. Examples of allergens that may cause allergic contact eczema include clothing (or the button and zippers on them), jewelry, perfume, hand and bathing soaps, household cleaners, laundry detergents, rubber gloves, and poison ivy or oak-agents that can also cause irritant contact eczema. Some people appear to be genetically predisposed to develop allergic contact eczema. Others may have triggers that cause the allergic reactions to flare up. Some triggers that have been found are UV light (sunlight, tanning beds) and perspiration. This type of eczema is characterized by local inflammation of the skin with itching, pain, redness, swelling, and formation of small blisters. If allergic contact eczema is expected, a patch test can be done to identify the cause. Strips of tape containing approximately 25 to 150 types of allergens are placed on the person?s back for 2 days and if a small red spot is present on the skin then the substance is a possible allergen to the person. The individual is then checked after another 2 days to look for delayed reactions.
Irritant Contact Eczema
Irritant contact eczema is very similar to allergic contact eczema. It occurs when the skin comes into contact with agents that are irritating, such as glues, solvents, paint or paint thinners, pesticides, fertilizers, oils, greases, gasoline, and bleaching agents. The severity of the outbreak often depends on how long the skin is exposed to the irritant. The most common symptoms associated with this form of eczema are dryness, redness, itching, inflammation, blistering, weeping, and burning at the site of contact. Individual symptoms depend on the nature of the reaction. For example, if the affected site has been in recent contact with an irritant or has been scratched or picked, it may weep and become inflamed. By contrast, if time has elapsed since the contact with the irritant, the affected area may appear dry, crusty, flaky, or leathery.
Seborrheic Eczema
Seborrheic eczema (or seborrheic dermatitis) typically occurs on the scalp, but it may also originate on the eyebrows, eyelids, nose, ears, face, groin, or buttocks. It generally appears in infancy and may materialize again in adulthood. In infants, this form of eczema is commonly known as "cradle cap". Seborrheic eczema differs from atopic and contact dermatitis in appearance, and is distinguished by dry or greasy scaly, itchy, inflamed areas of skin. The affected area may be greasy due to abnormal secretion and discharge of sebum, a fatty material produced by the sebaceous glands of the skin. Researchers think the cause of this form of eczema may be a yeast, Pityrosporum ovale, which lives in the sebum and causes irritation to the skin. This form of eczema is usually more prevalent and severe in men as compared to women.
Nummular Eczema
An uncommon form of dermatitis, nummular eczema is characterized by small circles or oval lesions on the affected area(s) that are generally dry, scaly, red, and swollen. This form of eczema appears to be more common among elderly men and is usually more prevalent during the winter months.
Stasis Eczema
Stasis eczema is a form of dermatitis that commonly affects individuals who are 50 years of age and older. It develops as a result of poor circulation in the feet and ankles, which can cause excess fluid accumulation and, in turn, the skin becomes dry, red, scaly, itchy, and irritated, which is characteristic of stasis eczema. Repeated picking and scratching of the affected area can cause it to ooze, crust, or become thickened. Individuals who have heart failure or varicose veins or who have had recent trauma may be at greater risk for developing stasis eczema.
What causes it?
Medical researchers believe that eczema may be an abnormal response of the immune system to various environmental or emotional triggers. When the body comes into contact with one or more of these triggers, the immune system senses the trigger and reacts to dispel it. The immune system's reaction is thought to be the cause of the symptoms that are associated with eczema outbreaks.
Triggers for eczema can include skin irritants, such as chemicals, emotional stress, allergies, for example, to food and airborne allergens; and extreme changes in temperature. Paint thinners and pesticides, alcohol-containing products, astringents, and fragrances are chemicals that can trigger eczema in some individuals. Although paint thinners and pesticides can be avoided fairly easily, it is harder to avoid alcohol, astringents, and fragrances, which are ingredients in most cosmetics and household cleaners. If you believe any of these types of products contribute to your eczema, it is a good idea to check the ingredient list on the label before purchasing one of these products.
Heightened emotional states, for example, feelings of extreme anxiety, anger, or aggression, can also trigger eczema outbreaks. Understanding and trying to avoid situations that lead to these stresses may be beneficial in preventing eczema outbreaks. Approaches to avoiding stress include getting plenty of sleep, exercising regularly, and avoiding alcohol or illegal drugs.
Certain foods, for example, milk, eggs, soy, or peanuts, trigger eczema outbreaks for some individuals. Reading the ingredient list before purchasing food products that you suspect may contain ingredients you are allergic to is a wise step to take.
Airborne allergens such as pollens, mold spores, and animal dander as well as extreme changes in temperature can also lead to an outbreak of eczema for some individuals. During the heat of summer, remaining indoors where air conditioning is available is a good preventive measure. In the winter months, using a humidifier to add moisture to the air inside your home may help prevent dry skin, thus preventing an eczema outbreak.
Who has it?
It is estimated that 15 million people in the United States have some form of eczema. Eczema often begins in infancy and childhood but it can occur at any age. Somewhere between 10 to 20 percent of all infants have eczema. About 50% of people who develop eczema as a child will have it for life, but eczema usually becomes less severe with age. Nearly 5 out of 1000 adults experience eczema in their lifetime. Stasis eczema is more common among individuals who are 50 years of age and older.
What are the risk factors?
The risks associated with developing eczema are similar to the triggers of the disease. Risk factors for eczema include the following:
- Family history of eczema
- Family history of asthma or hay fever/allergic rhinitis
- Physical trauma to the skin, such as cuts, burns, or insect bites
- Emotional stress
- Extreme temperature
- Low humidity urban areas
- Poor circulation of the lower extremities
What are the symptoms?
Symptoms, which depend on the type of eczema and its severity, can include the following:
- Dry, itchy skin especially on the face, behind the ears, inside the elbows, and behind the knees
- Red, inflamed skin that itches or burns
- Scaly or crusted skin resulting from excessive scratching
- Blisters that itch, burn, or ooze
- Thick, callused skin resulting from excessive scratching
How is it treated?
Although there is no cure for eczema, many available treatments can ease or eliminate the symptoms associated with the illness. Both topical and oral medications have the ability to reduce existing rashes and prevent future flare-ups or outbreaks, which is the goal of treatment. For severe cases of eczema, topical and oral medications may be used together.
Because there are several types of eczema and the disease affects everyone differently, you should consult your doctor to determine the treatment option that is best for you.
The following are some treatment options for eczema:
Moisturizers are recommended for all types of eczema because they promote rehydration of dry, cracked areas. Such products include Aquaphor, Eucerin, Moisturel, mineral oil and baby oil. It is recommended that the selected moisturizer be applied liberally to the affected area. Products containing alcohol may result in burning of the affected area, so it is best to choose the product with the smallest amount of alcohol. If you need assistance choosing a product, talk to your doctor or pharmacist.
Topical steroids are often used in addition to moisturizers if eczema symptoms do not improve and the affected area becomes severely irritated and swollen. The topical steroid selected often varies from very low potency to high potency, depending on the severity of the disease. Your doctor is the best person to determine whether a topical steroid is appropriate for your eczema and, if appropriate, its potency.
Topical immunosuppressants such as tacrolimus (Protopic) and pimecrolimus (Elidel) have been shown to be extremely effective in the treatment of eczema. By controlling how the immune system reacts to potential irritants or triggers, immunosuppressants are able to clear the affected area and provide relief from itching. However, until further studies have been conducted to identify any potential long-term effects, they should be considered a treatment of last resort.
Antihistamines taken by mouth are often used to reduce the itching associated with eczema. Newer antihistamines, such as loratadine (Claritin, Alavert) and fexofenadine (Allegra), do not appear to be as effective in controlling itching as older antihistamines [for example, hydroxyzine (Atarax), diphenhydramine (Benadryl)]. However, the older antihistamines cause more drowsiness. Topical antihistamines such as Benadryl (diphenhydramine) are usually not recommended because they contain additives that may exacerbate the condition.
Oral steroids are generally reserved for eczema that is resistant to all other treatments because this class of drugs is much more likely to cause side effects.
Phototherapy (ultraviolet A or B light therapy) may be used when all other avenues of topical and oral treatments have been exhausted. Phototherapy works by controlling cells in the skin that allow skin cell development. By controlling the rate at which skin cells develop, it is possible to control the scaling and sloughing of skin that is associated with eczema.
Oral antibiotics may be used for skin infections that arise at the site of an eczema flare-up. Skin infections are indicated if white or yellow pus oozes from the affected site. Topical antibiotics can also be used when the skin is broken to help prevent infection and to treat mild infections. Consult your doctor if you think your outbreak calls for an antibiotic.
To learn more about how each type of eczema is treated, click on the links below.
Treatment of Neurodermatitis (Lichen simplex)
Treatment with potent topical corticosteroids are usually the first-line treatment for this type of eczema to reduce the inflammation and itching. Other options include moisturizers to decrease dryness, oral antihistamines to help reduce itching, wrapping of the affected skin to prevent scratching and to increase potency of the medication, corticosteroid injections for serious cases, and possibly phototherapy for people with larger areas of this type of eczema. Topical antibiotics can be used when the skin is broken to help prevent infection or to treat mild infection. Oral antibiotics are used if an infection presents itself. Topical keratolytics (such as urea) are sometimes used to help thin thickened skin.
Treatment of Dyshidrotic Eczema
Corticosteroid creams and ointments plus cold compresses are important treatments for this type of eczema. Using plastic wrappings over corticosteroids may increase the corticosteroid?s effectiveness. Topical immunosuppressants (like tacrolimus or pimecrolimus) can also be used to reduce inflammation. Severe attacks may require the use of an oral or intramuscular (injected into a muscle) corticosteroid or an oral immunosuppressive medication (such as methotrexate, cyclosporine, or mycophenolate mofetil). Oral antihistamines may be used to help reduce itching. Antibiotics may be necessary if an infection is present. In addition, large blisters may need to be drained by a dermatologist to relieve the pain.
Treatment of Atopic Eczema
Topical treatments, which have minimal side effects, are usually the first-line agents used to treat atopic eczema. Creams, ointments, lotions, bath oils, and emollients can produce relief by hydrating the affected area. These should be applied frequently and in large quantities to be effective (every 4 hours or at least 3 to 4 times per day). For severe cases, low-dose topical corticosteroids may be used to assist the healing process by controlling inflammation. Topical steroids should only be used a few days per week for acute inflammation and after application the person should wait at least 30 minutes before applying creams or emollients. Corticosteroids are usually not used for less severe cases of eczema because of their side effects. Topical immunosuppressants such as tacrolimus or pimecrolimus, can also be used to decrease inflammation. These are more expensive and have about the same efficacy as topical steroids and are usually used after original therapy fails. In some cases, oral antihistamines and/or cold compresses applied directly to the skin may be used to control persistent itching associated with the outbreak. If the area becomes infected, antibiotics are used. Phototherapy can also be used to relieve moderate to severe cases after other treatments have failed. In children, atopic eczema may resolve without treatment, but adults usually end up needing some type of treatment.
Treatment of Allergic or Irritant Contact Eczema
Management of contact eczema is usually based on identifying, removing, and avoiding the offending agent. Mild to moderate contact eczema, characterized by red, raised, flaky rashes that may or may not ooze on scratching, is usually treated with lotions, creams, or ointments. High-dose topical steroids or topical immunosuppressants, typically a cream or an ointment, are used most frequently to aid healing of severe eczema (red and inflamed areas of skin that usually ooze or bleed with or without scratching). In severe cases that persist or spread to genitalia, oral corticosteroids may be used. In both moderate and severe cases, oral antihistamines may be used to control itching. Phototherapy can also be used to relieve severe cases after other treatments have failed.
Treatment of Seborrheic Eczema
Seborrheic eczema, which is limited to the scalp, is typically treated with dandruff shampoos and/or low-dose topical corticosteroids to control inflammation and speed healing. These dandruff shampoos can be used on other places other than the scalp as directed by a dermatologist. But, topical corticosteroids and antifungals can be used as well. Phototherapy can also be used to relieve severe cases after other treatments have failed.
Infants with eczema limited to the scalp usually can be controlled by using baby shampoo and carefully brushing away the scales; topical corticosteroids or antifungals can also be used. When it involves areas other than the scalp a low-dose topical corticosteroid or antifungal medication is used for infants.
Treatment of Nummular Eczema
The treatment of this form of the disease is similar to treatment of atopic eczema. First, the patient is advised to avoid the offending agent or trigger. Creams, ointments, lotions, bath oils, and emollients should be used to help hydrate dry, flaky areas. These work best if applied after a lukewarm bath or shower. Low-dose topical corticosteroids are used to control the inflammation associated with the rash and promote healing. In some cases, oral antihistamines may be used to control persistent itching and anxiety associated with the rash. Antibiotics may be used if the area becomes infected and weepy. Oral corticosteroids, which can have extensive side effects, are typically recommended only for severe cases of eczema. Also in severe cases, phototherapy and bed rest in a cool, moist environment may be helpful. Humidifiers can be used to add moisture to the air.
Treatment of Stasis Eczema
The treatment of this condition is initiated by correcting the condition that causes fluid accumulation in the lower parts of the body, which includes wearing elastic support hose, taking diuretics ("water pills"), or even undergoing varicose vein surgery. Individuals may also use wet dressings to soften the thickened, but fragile, skin and to prevent infection. Elevation of the legs above the heart can improve circulation in the legs and decrease swelling. Application of a topical steroid can help reduce inflammation and oral or topical antibiotics can help treat an infection if present.
Helping Yourself
Individuals with eczema generally should try to avoid potential irritants and triggers and use moisturizers year-round to hydrate the skin. Other ways you can limit or avoid eczema outbreaks include the following:
- Avoid scratching or picking at the affected area, which could aggravate your condition or even cause new lesions to form.
- Limit exposure to the sun and the use of sunscreen, both of which can contribute to eczema outbreaks.
- Avoid stressful situations as much as possible.
- When selecting clothing, choose clothing made of softer fabrics like cotton rather than stiff fibers like wool. In addition, avoid tight, occlusive clothing like leather. By allowing the skin to "breathe" less sweat will accumulate.
- Avoid soaking in the bathtub, and use lukewarm water when bathing. Use moisturizing soaps for bathing and apply moisturizing creams or lotions immediately afterward.
- Clean furniture and wash bedding regularly to get rid of dust mites and pet dander, both of which are associated with eczema.
- Choose dye-free, fragrance-free skin products which are more appropriate for sensitive skin.
What is on the horizon?
Research in the past few decades has increased our understanding of eczema, but much is still unknown about this skin disorder. Researchers continue to investigate the role that the immune system, genetics, and environmental factors play in the development of eczema. New oral, topical, and phototherapy treatment options are continually being studied to determine their effectiveness in relieving the symptoms and frequency of eczema. As researchers gain additional knowledge about the causes of eczema, even more effective treatments will be developed for the various forms of eczema.
A new treatment product for eczema may be on the horizon. The pharmaceutical company, CutiCeuticals, Inc., recently received a United States patent for a new product called CutiCort Spray. CutiCort Spray is a 0.05% clobetasol-containing aerosol spray engineered for the treatment of psoriasis, eczema, and other inflammatory skin conditions. Although the product appears to be safe in previous clinical trials, more safety and efficacy data is needed for FDA (U.S Food and Drug Administration) approval.
The popular wrinkle treatment injection, botulinum toxin type A (also known as "botox"), has recently been shown to have some benefit in people with dyshidrotic hand eczema. The benefit is thought to be because the injection relaxes the muscles and/or inhibits the nerve impulses in the area. A very small study found that people with dyshidrotic eczema that was not able to be treated with regular therapy had good results when treated with botulinum toxin and it seemed to work really well in those that had excessive hand sweating or worsening during the summer. These results look promising but time will tell if this might become an option for treatment-resistant dyshidrotic eczema.
References
American Acadamy of Dermatology, Eczema/Atopic Dermatitis, Available at URL: http://www.aad.org/public/publications/pamphlets/skin_eczema.html. Accessed April 2, 2008.
Canadian Centre for Occupational Health and Safety home page. Allergic Contact Dermatitis. Available at URL: http://www.ccohs.ca/oshanswers/diseases/allergic_derm.html. Accessed May 25, 2006, April 5, 2007, and April 2, 2008.
Canadian Centre for Occupational Health and Safety home page. Irritant Contact Dermatitis. Available at URL: http://www.ccohs.ca/oshanswers/diseases/dermatitis.html. Accessed May 25, 2006, April 5, 2007, and April 2, 2008.
Consumer Information Center. Atopic Dermatitis-Definition. Available at URL: http://www.pueblo.gsa.gov/cic_text/health/atopic-dermatitis/defining.html. Accessed June 15, 2005, April 5, 2007, April 2, 2008.
EczemaNet home page. Eczema. Available at URL: http://www.skincarephysicians.com/eczemanet/index.html. Accessed May 25, 2006, April 5, 2007, and April 2, 2008.
Cheigh,NH. Dermatologic Drug Reactions, Self-Treatable Skin Disorders, and Skin Cancer. In: Pharmacotherapy A Pathophysiologic Approach. 6th ed. Dipiro JT, Talbert RL eds. Stamford, CT;Appleton and Lange: 2005: 1745.
i-Dermatitis.com home page. Dermatitis. Available at URL: http://www.i-dermatitis.com. Accessed June 15, 2005, April 5, 2007, April 2, 2008.
MayoClinic.com. Dermatitis. Available at URL: http://www.mayoclinic.com/invoke.cfm?id=DS00339. Accessed May 25, 2006, April 5, 2007, and April 2, 2008.
Medical News Today. New psoriasis and eczema treatment receives US patent [press release] February 1, 2005. Available at URL: http://www.medicalnewstoday.com/medicalnews.php?newsid=19486. Accessed May 25, 2006, April 5, 2007, and April 2, 2008.
The Merck Manual of Medical Information-Home Edition: Dermatitis. Available at URL: http://www.merck.com/mmhe/sec18/ch203/ch203c.html#sec18-ch203-ch203c-68. Accessed April 5, 2007 and April 2, 2008.
National Eczema Society home page. Eczema: Frequently Asked Questions. Available at URL: http://www.eczema.org. Accessed May 25, 2006, April 5, 2007, and April 2, 2008.
National Institute of Arthritis and Musculoskeletal and Skin Diseases home page. Atopic Dermatitis. Available at URL: http://www.niams.nih.gov. Accessed October 5, 2003, and April 2, 2008.
Swartling C, Naver H, Lindberg M, Anveden I. Treatment of dyshidrotic hand dermatitis with intradermal botulinum toxin. Journal of the American Academy of Dermatology. 2002 Nov;47(5):667-71.
Swerlick RA, Lawley TJ. Eczema, psoriasis, cutaneous infections, acne, and other common skin disorders. Harrison's Principles of Internal Medicine. 14th ed. Fauci AS, Kasper DL, Hauser SL, eds. St. Louis: McGraw-Hill;1998:298-300.
U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases. Atopic Dermatitis: A type of eczema. URL: http://www.pueblo.gsa.gov/cic_text/health/atopic-dermatitis/atopic.pdf. Accessed April 5, 2007 and April 2, 2008.
DermNet NZ. Lichen simplex. URL: http://dermnetnz.org/dermatitis/lichen-simplex.html. Accessed April 5, 2007 and April 2, 2008.
Health-cares. What is dyshidrotic eczema? URL: http://skin-care.health-cares.net/dyshidrotic-eczema.php. Accessed April 5, 2007 and April 2, 2008.
Hogan D. eMedicine. Lichen simplex chronicus. Last updated June 12,2006. URL:http://emedicine.com/derm/topic236.htm. Accessed April 11, 2007 and April 2, 2008.
Eczema Health Condition Last Updated: April 2008
Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It is not intended to diagnose a health condition, but it can be used as a guide to help you decide if you should seek professional treatment or to help you learn more about your condition once it has been diagnosed.