Eczema
Eczema
or often referred to as atopic dermatitis (from Greek ἔκζεμα ēkzema, "to boil
over") is a form of dermatitis, or inflammation of the epidermis (the outer
layer of the skin).
The
term eczema is broadly applied to a range of persistent skin conditions. These
include dryness and recurring skin rashes that are characterized by one or more
of these symptoms: redness, skin edema (swelling), itching and dryness,
crusting, flaking, blistering, cracking, oozing, or bleeding. Areas of temporary
skin discoloration may appear and are sometimes due to healed injuries.
Scratching open a healing lesion may result in scarring and may enlarge the
rash.
The
word eczema comes from Greek, meaning "to boil over". Dermatitis comes from the
Greek word for skin – and both terms refer to the same skin condition. In some
languages, dermatitis and eczema are synonymous, while in other languages
dermatitis implies an acute condition and "eczema" a chronic one. The two
conditions are often classified
together.
More severe
eczema
A patch of
eczema that has been scratched
The term eczema refers to a set of clinical
characteristics. Classification of the underlying diseases has been haphazard
and unsystematic, with many synonyms used to describe the same condition. A type
of eczema may be described by location (e.g., hand eczema), by specific
appearance (eczema craquele or discoid), or by possible cause (varicose eczema).
Further adding to the confusion, many sources use the term eczema for the most
common type of eczema (atopic dermatitis)
interchangeably.
The European
Academy of Allergology and Clinical Immunology (EAACI) published a position
paper in 2001 which simplifies the nomenclature of allergy-related diseases
including atopic and allergic contact eczemas. Non-allergic eczemas are not
affected by this proposal.
The
classifications below is ordered by incidence
frequency.
Common
Atopic eczema (aka infantile e., flexural e., atopic
dermatitis) is an allergic disease believed to have a hereditary component and
often runs in families whose members also have asthma. Itchy rash is
particularly noticeable on head and scalp, neck, inside of elbows, behind knees,
and buttocks. Experts[who?] are urging doctors to be more vigilant in weeding
out cases that are, in actuality, irritant contact dermatitis. It is very common
in developed countries, and rising. (L20)
Contact dermatitis is of two
types: allergic (resulting from a delayed reaction to some allergen, such as
poison ivy or nickel), and irritant (resulting from direct reaction to a
detergent, such as sodium lauryl sulfate, for example). Some substances act both
as allergen and irritant (wet cement, for example). Other substances cause a
problem after sunlight exposure, bringing on phototoxic dermatitis. About three
quarters of cases of contact eczema are of the irritant type, which is the most
common occupational skin disease. Contact eczema is curable, provided the
offending substance can be avoided and its traces removed from one's
environment. (L23; L24; L56.1; L56.0)
Xerotic eczema (aka asteatotic e., e.
craquele or craquelatum, winter itch, pruritus hiemalis) is dry skin that
becomes so serious it turns into eczema. It worsens in dry winter weather, and
limbs and trunk are most often affected. The itchy, tender skin resembles a dry,
cracked, river bed. This disorder is very common among the older population.
Ichthyosis is a related disorder. (L30.8A; L85.0)
Seborrhoeic dermatitis or
Seborrheic dermatitis ("cradle cap" in infants) is a condition sometimes
classified as a form of eczema that is closely related to dandruff. It causes
dry or greasy peeling of the scalp, eyebrows, and face, and sometimes trunk. The
condition is harmless except in severe cases of cradle cap. In newborns it
causes a thick, yellow crusty scalp rash called cradle cap, which seems related
to lack of biotin and is often curable. (L21; L21.0)
Less
common
Dyshidrosis (aka dyshidrotic e., pompholyx, vesicular palmoplantar
dermatitis, housewife's eczema) only occurs on palms, soles, and sides of
fingers and toes. Tiny opaque bumps called vesicles, thickening, and cracks are
accompanied by itching, which gets worse at night. A common type of hand eczema,
it worsens in warm weather. (L30.1)
Discoid eczema (aka nummular e.,
exudative e., microbial e.) is characterized by round spots of oozing or dry
rash, with clear boundaries, often on lower legs. It is usually worse in winter.
Cause is unknown, and the condition tends to come and go. (L30.0)
Venous
eczema (aka gravitational e., stasis dermatitis, varicose e.) occurs in people
with impaired circulation, varicose veins and edema, and is particularly common
in the ankle area of people over 50. There is redness, scaling, darkening of the
skin and itching. The disorder predisposes to leg ulcers. (I83.1)
Dermatitis
herpetiformis (aka Duhring's Disease) causes intensely itchy and typically
symmetrical rash on arms, thighs, knees, and back. It is directly related to
celiac disease, can often be put into remission with appropriate diet, and tends
to get worse at night. (L13.0)
Neurodermatitis (aka lichen simplex
chronicus, localized scratch dermatitis) is an itchy area of thickened,
pigmented eczema patch that results from habitual rubbing and scratching.
Usually there is only one spot. Often curable through behavior modification and
anti-inflammatory medication. Prurigo nodularis is a related disorder showing
multiple lumps. (L28.0; L28.1)
Autoeczematization (aka id reaction,
autosensitization) is an eczematous reaction to an infection with parasites,
fungi, bacteria or viruses. It is completely curable with the clearance of the
original infection that caused it. The appearance varies depending on the cause.
It always occurs some distance away from the original infection.
(L30.2)
There are also eczemas overlaid by viral infections (e. herpeticum,
e. vaccinatum), and eczemas resulting from underlying disease (e.g. lymphoma).
Eczemas originating from ingestion of medications, foods, and chemicals, have
not yet been clearly systematized. Other rare eczematous disorders exist in
addition to those listed here.
Cause
Complex
eczema treated with a combination of antifungal and corticosteroid creams
concurrently.
The cause of eczema is unknown but is presumed to be a
combination of genetic and environmental factors.
The hygiene
hypothesis postulates that the cause of asthma, eczema, and other allergic
diseases is an unusually clean environment. It is supported by epidemiologic
studies for asthma. The hypothesis states that exposure to bacteria and other
immune system modulators is important during development, and missing out on
this exposure increases risk for asthma and allergy.
While it has
been suggested that eczema may sometimes be an allergic reaction to the
excrement from house dust mites, with up to 5% of people showing antibodies to
the mites, the overall role this plays awaits further
corroboration.
Researchers
have compared the prevalence of eczema in people who also suffer from celiac
disease to eczema prevalence in control subjects, and have found that eczema
occurs about three times more frequently in celiac disease patients and about
two times more frequently in relatives of celiac patients, potentially
indicating a genetic link between the two conditions.
The failure
of the body to metabolize linoleic acid into y-linoleic acid (GLA) may be a
cause of eczema, and administration of GLAs has been demonstrated to alleviate
symptoms. Eczema may be in some cases caused by an inherited abnormality of
essential fatty accid metabolism.
Diagnosis
Diagnosis of
eczema is based mostly on history and physical examination. However, in
uncertain cases, skin biopsy may be useful.
Prevention
Those with
eczema should not get the smallpox vaccination due to risk of developing eczema
vaccinatum, a potentially severe and sometimes fatal
complication.
Treatment
There is no
known cure for eczema; therefore, treatments aim to control the symptoms by
reducing inflammation and relieving itching.
Medications
Corticosteroids
Corticosteroids are highly effective in controlling or
suppressing symptoms in most cases. For mild-moderate eczema a weak steroid may
be used (e.g. hydrocortisone), while in more severe cases a higher-potency
steroid (e.g. clobetasol propionate) may be used. In severe cases, oral or
injectable corticosteroids may be used. While these usually bring about rapid
improvements, they have greater side effects.
Side
effects
Lower arm of
a 47-year-old female showing skin damage due to topical steroid
use
Prolonged use of topical corticosteroids is thought to increase the risk
of side effects, the most common of which is the skin becoming thin and fragile
(atrophy). Because of this, if used on the face or other delicate skin, only a
low-strength steroid should be used. Additionally, high-strength steroids used
over large areas, or under occlusion, may be significantly absorbed into the
body, causing hypothalamic-pituitary-adrenal axis suppression (HPA axis
suppression). Finally by their immunosuppressive action they can, if used
without antibiotics or antifungal drugs, lead to some skin infections (fungal or
bacterial). Care must be taken to avoid the eyes, as topical corticosteroids
applied to the eye can cause glaucoma or cataracts.
Because of
the risks associated with this type of drug, a steroid of an appropriate
strength should be sparingly applied only to control an episode of eczema. Once
the desired response has been achieved, it should be discontinued and replaced
with emollients as maintenance therapy. Corticosteroids are generally considered
safe to use in the short- to medium-term for controlling eczema, with no
significant side effects differing from treatment with non-steroidal
ointment.
Some recent
research claims that topically applied corticosteroids did not significantly
increase the risk of skin thinning, stretch marks or HPA axis suppression (and
where such suppression did occur, it was mild and reversible where the
corticosteroids were used for limited periods of time). Further, skin conditions
are often under-treated because of fears of side effects. This has led some
researchers to suggest that the usual dosage instructions should be changed from
"Use sparingly" to "Apply enough to cover affected areas", and that specific
dosage directions using "fingertip units" or FTUs be provided, along with photos
to illustrate FTUs. However, caution must always be used as long-term use,
prolonged widespread coverage, or use with occlusion, can create side effects
that are permanent and resistant to treatment.
Topical
immunosuppressants
Tacrolimus
0.1%
Topical immunosuppressants like pimecrolimus (Elidel and Douglan) and
tacrolimus (Protopic) were developed after topical corticosteroids had come into
widespread use. These newer agents effectively suppress the immune system in the
affected area, and appear to yield better results in some populations. The U.S.
Food and Drug Administration has issued a public health advisory about the
possible risk of lymph node or skin cancer from use of these products, but many
professional medical organizations disagree with the FDA's findings;
The
postulation is that the immune system may help remove some pre-cancerous
abnormal cells which is prevented by these drugs. However, any chronic
inflammatory condition such as eczema, by the very nature of increased
metabolism and cell replication, has a tiny associated risk of cancer (see
Bowen's disease).
Current practice by UK dermatologists is not to consider
this a significant real concern and they are increasingly recommending the use
of these new drugs. The dramatic improvement on the condition can significantly
improve the quality of life of sufferers (and families kept awake by the
distress of affected children). The major debate, in the UK, has been about the
cost of such newer treatments and, given only finite NHS resources, when they
are most appropriate to use.
In addition to cancer risk, there are other
potential side effects with this class of drugs. Adverse reactions including
severe flushing, headaches, flu-like syndrome, photosensitive reactivity and
possible drug interactions with a variety of medications, alcohol and
grapefruit.
Systemic
immunosuppressants
When eczema
is severe and does not respond to other forms of treatment, immunosuppressant
drugs are sometimes prescribed. These dampen the immune system and can result in
dramatic improvements to the patient's eczema. However, immunosuppressants can
cause side effects on the body. As such, patients must undergo regular blood
tests and be closely monitored by a doctor. In the UK, the most commonly used
immunosuppressants for eczema are ciclosporin, azathioprine and methotrexate.
These drugs were generally designed for other medical conditions but have been
found to be effective against eczema.
Itch
relief
Anti-itch
drugs, often antihistamine, and dermasil may reduce the itch during a flare up
of eczema, and the reduced scratching in turn reduces damage and irritation to
the skin (the "itch cycle").[citation needed] However, in some cases,
significant benefit may be due to the sedative side effects of these drugs,
rather than their specific antihistamine effect. Thus sedating antihistamines
such as promethazine (Phenergan) or diphenhydramine (Benadryl) may be more
effective at preventing night time scratching than the newer, nonsedating
antihistamines.
Capsaicin
applied to the skin acts as a counter irritant (see gate control theory of nerve
signal transmission).
Hydrocortisone applied to the skin aids in temporary itch
relief.
Temporary
yet significant and fast-acting relief can be found by cooling the skin via
water (swimming, cool water bath or wet washcloth), air (direct output of an air
conditioning vent), or careful use of an ice pack (wrapped in soft smooth cloth,
e.g., pillow case, to protect skin from damage).
Moisturizers
Eczema can
be exacerbated by dryness of the skin. Moisturizing is one of the most important
self-care treatments for eczema. Keeping the affected area moistened can promote
skin healing and relief of symptoms. Soaps and detergents should not be used on
affected skin because they can strip natural skin oils and lead to excessive
dryness.
Moistening
agents are called emollients. In general, it is best to match thicker ointments
to the driest, flakiest skin. Light emollients may not have any effect on
severely dry skin. Moisturizing gloves (gloves which keep emollients in contact
with skin on the hands) can be worn while sleeping. Generally, twice-daily
applications of emollients work best. Ointments, with less water content, stay
on the skin longer and need fewer applications, but they can be greasy and
inconvenient. Steroids may also be mixed in with
ointments.
For unbroken
skin, direct application of waterproof tape with or without an emollient or
prescription ointment can improve moisture levels and skin integrity which
allows the skin to heal. This treatment regimen can also help prevent the skin
from cracking, as well as put a stop to the itch cycle. The end result is
reduced lichenification (the roughening of skin from repeated scratching).
Taping works best on skin away from joints.
There is a
disagreement whether baths are desirable or a necessary evil. For example, the
Mayo Clinic advises against daily baths to avoid skin drying. On the other hand,
the American Academy of Dermatology claims "it is a common misconception that
bathing dries the skin and should be kept to a bare minimum" and recommends
bathing to hydrate skin. They even suggest up to 3 short baths a day for people
with severe eczema. According to them, a moisturizer should be applied within 3
minutes to trap the moisture from bath in the skin.
Anecdotal
evidence suggested that soft water could have therapeutic effects for people
with eczema currently using hard water.
However, a
trial involving 336 children with eczema showed no objective difference in
outcomes between the children whose homes were fitted with a water softener and
those without.
Ceramides,
which are the major lipid constituent of the stratum corneum, have been used in
the treatment of eczema. They are often one of the ingredients of modern
moisturizers. These lipids were also successfully produced synthetically in the
laboratory.
However,
detergents are so ubiquitous in modern environments in items like tissues, and
so persistent on surfaces, "safe" soaps are necessary to remove them from the
skin in order to control eczema. Although most eczema recommendations use the
terms "detergents" and "soaps" interchangeably, and tell eczema sufferers to
avoid both, detergents and soaps are not the same and are not equally
problematic to eczema sufferers. Detergents, which differ from soap in that they
commonly have a sulfate polar group, increase the permeability of skin membranes
in a way that soaps and water alone do not. Sodium lauryl sulfate, the most
common household detergent, has been shown to amplify the allergenicity of other
substances ("increase antigen penetration").
Unfortunately there is no one agreed-upon best kind of skin
cleanser for eczema sufferers. Different clinical tests, sponsored by different
personal product companies, unsurprisingly tout various brands as the most
skin-friendly based on specific properties of various products and different
underlying assumptions as to what really determines skin friendliness. The terms
"hypoallergenic" and "doctor tested" are not regulated, and no research has been
done showing that products labeled "hypoallergenic" are in fact less problematic
than any others. It may be best to avoid soaps and detergent cleansers
altogether, except for the armpits, groin and perianal areas, and use cheap
bland emollients in the bath or shower.
or often referred to as atopic dermatitis (from Greek ἔκζεμα ēkzema, "to boil
over") is a form of dermatitis, or inflammation of the epidermis (the outer
layer of the skin).
The
term eczema is broadly applied to a range of persistent skin conditions. These
include dryness and recurring skin rashes that are characterized by one or more
of these symptoms: redness, skin edema (swelling), itching and dryness,
crusting, flaking, blistering, cracking, oozing, or bleeding. Areas of temporary
skin discoloration may appear and are sometimes due to healed injuries.
Scratching open a healing lesion may result in scarring and may enlarge the
rash.
The
word eczema comes from Greek, meaning "to boil over". Dermatitis comes from the
Greek word for skin – and both terms refer to the same skin condition. In some
languages, dermatitis and eczema are synonymous, while in other languages
dermatitis implies an acute condition and "eczema" a chronic one. The two
conditions are often classified
together.
More severe
eczema
A patch of
eczema that has been scratched
The term eczema refers to a set of clinical
characteristics. Classification of the underlying diseases has been haphazard
and unsystematic, with many synonyms used to describe the same condition. A type
of eczema may be described by location (e.g., hand eczema), by specific
appearance (eczema craquele or discoid), or by possible cause (varicose eczema).
Further adding to the confusion, many sources use the term eczema for the most
common type of eczema (atopic dermatitis)
interchangeably.
The European
Academy of Allergology and Clinical Immunology (EAACI) published a position
paper in 2001 which simplifies the nomenclature of allergy-related diseases
including atopic and allergic contact eczemas. Non-allergic eczemas are not
affected by this proposal.
The
classifications below is ordered by incidence
frequency.
Common
Atopic eczema (aka infantile e., flexural e., atopic
dermatitis) is an allergic disease believed to have a hereditary component and
often runs in families whose members also have asthma. Itchy rash is
particularly noticeable on head and scalp, neck, inside of elbows, behind knees,
and buttocks. Experts[who?] are urging doctors to be more vigilant in weeding
out cases that are, in actuality, irritant contact dermatitis. It is very common
in developed countries, and rising. (L20)
Contact dermatitis is of two
types: allergic (resulting from a delayed reaction to some allergen, such as
poison ivy or nickel), and irritant (resulting from direct reaction to a
detergent, such as sodium lauryl sulfate, for example). Some substances act both
as allergen and irritant (wet cement, for example). Other substances cause a
problem after sunlight exposure, bringing on phototoxic dermatitis. About three
quarters of cases of contact eczema are of the irritant type, which is the most
common occupational skin disease. Contact eczema is curable, provided the
offending substance can be avoided and its traces removed from one's
environment. (L23; L24; L56.1; L56.0)
Xerotic eczema (aka asteatotic e., e.
craquele or craquelatum, winter itch, pruritus hiemalis) is dry skin that
becomes so serious it turns into eczema. It worsens in dry winter weather, and
limbs and trunk are most often affected. The itchy, tender skin resembles a dry,
cracked, river bed. This disorder is very common among the older population.
Ichthyosis is a related disorder. (L30.8A; L85.0)
Seborrhoeic dermatitis or
Seborrheic dermatitis ("cradle cap" in infants) is a condition sometimes
classified as a form of eczema that is closely related to dandruff. It causes
dry or greasy peeling of the scalp, eyebrows, and face, and sometimes trunk. The
condition is harmless except in severe cases of cradle cap. In newborns it
causes a thick, yellow crusty scalp rash called cradle cap, which seems related
to lack of biotin and is often curable. (L21; L21.0)
Less
common
Dyshidrosis (aka dyshidrotic e., pompholyx, vesicular palmoplantar
dermatitis, housewife's eczema) only occurs on palms, soles, and sides of
fingers and toes. Tiny opaque bumps called vesicles, thickening, and cracks are
accompanied by itching, which gets worse at night. A common type of hand eczema,
it worsens in warm weather. (L30.1)
Discoid eczema (aka nummular e.,
exudative e., microbial e.) is characterized by round spots of oozing or dry
rash, with clear boundaries, often on lower legs. It is usually worse in winter.
Cause is unknown, and the condition tends to come and go. (L30.0)
Venous
eczema (aka gravitational e., stasis dermatitis, varicose e.) occurs in people
with impaired circulation, varicose veins and edema, and is particularly common
in the ankle area of people over 50. There is redness, scaling, darkening of the
skin and itching. The disorder predisposes to leg ulcers. (I83.1)
Dermatitis
herpetiformis (aka Duhring's Disease) causes intensely itchy and typically
symmetrical rash on arms, thighs, knees, and back. It is directly related to
celiac disease, can often be put into remission with appropriate diet, and tends
to get worse at night. (L13.0)
Neurodermatitis (aka lichen simplex
chronicus, localized scratch dermatitis) is an itchy area of thickened,
pigmented eczema patch that results from habitual rubbing and scratching.
Usually there is only one spot. Often curable through behavior modification and
anti-inflammatory medication. Prurigo nodularis is a related disorder showing
multiple lumps. (L28.0; L28.1)
Autoeczematization (aka id reaction,
autosensitization) is an eczematous reaction to an infection with parasites,
fungi, bacteria or viruses. It is completely curable with the clearance of the
original infection that caused it. The appearance varies depending on the cause.
It always occurs some distance away from the original infection.
(L30.2)
There are also eczemas overlaid by viral infections (e. herpeticum,
e. vaccinatum), and eczemas resulting from underlying disease (e.g. lymphoma).
Eczemas originating from ingestion of medications, foods, and chemicals, have
not yet been clearly systematized. Other rare eczematous disorders exist in
addition to those listed here.
Cause
Complex
eczema treated with a combination of antifungal and corticosteroid creams
concurrently.
The cause of eczema is unknown but is presumed to be a
combination of genetic and environmental factors.
The hygiene
hypothesis postulates that the cause of asthma, eczema, and other allergic
diseases is an unusually clean environment. It is supported by epidemiologic
studies for asthma. The hypothesis states that exposure to bacteria and other
immune system modulators is important during development, and missing out on
this exposure increases risk for asthma and allergy.
While it has
been suggested that eczema may sometimes be an allergic reaction to the
excrement from house dust mites, with up to 5% of people showing antibodies to
the mites, the overall role this plays awaits further
corroboration.
Researchers
have compared the prevalence of eczema in people who also suffer from celiac
disease to eczema prevalence in control subjects, and have found that eczema
occurs about three times more frequently in celiac disease patients and about
two times more frequently in relatives of celiac patients, potentially
indicating a genetic link between the two conditions.
The failure
of the body to metabolize linoleic acid into y-linoleic acid (GLA) may be a
cause of eczema, and administration of GLAs has been demonstrated to alleviate
symptoms. Eczema may be in some cases caused by an inherited abnormality of
essential fatty accid metabolism.
Diagnosis
Diagnosis of
eczema is based mostly on history and physical examination. However, in
uncertain cases, skin biopsy may be useful.
Prevention
Those with
eczema should not get the smallpox vaccination due to risk of developing eczema
vaccinatum, a potentially severe and sometimes fatal
complication.
Treatment
There is no
known cure for eczema; therefore, treatments aim to control the symptoms by
reducing inflammation and relieving itching.
Medications
Corticosteroids
Corticosteroids are highly effective in controlling or
suppressing symptoms in most cases. For mild-moderate eczema a weak steroid may
be used (e.g. hydrocortisone), while in more severe cases a higher-potency
steroid (e.g. clobetasol propionate) may be used. In severe cases, oral or
injectable corticosteroids may be used. While these usually bring about rapid
improvements, they have greater side effects.
Side
effects
Lower arm of
a 47-year-old female showing skin damage due to topical steroid
use
Prolonged use of topical corticosteroids is thought to increase the risk
of side effects, the most common of which is the skin becoming thin and fragile
(atrophy). Because of this, if used on the face or other delicate skin, only a
low-strength steroid should be used. Additionally, high-strength steroids used
over large areas, or under occlusion, may be significantly absorbed into the
body, causing hypothalamic-pituitary-adrenal axis suppression (HPA axis
suppression). Finally by their immunosuppressive action they can, if used
without antibiotics or antifungal drugs, lead to some skin infections (fungal or
bacterial). Care must be taken to avoid the eyes, as topical corticosteroids
applied to the eye can cause glaucoma or cataracts.
Because of
the risks associated with this type of drug, a steroid of an appropriate
strength should be sparingly applied only to control an episode of eczema. Once
the desired response has been achieved, it should be discontinued and replaced
with emollients as maintenance therapy. Corticosteroids are generally considered
safe to use in the short- to medium-term for controlling eczema, with no
significant side effects differing from treatment with non-steroidal
ointment.
Some recent
research claims that topically applied corticosteroids did not significantly
increase the risk of skin thinning, stretch marks or HPA axis suppression (and
where such suppression did occur, it was mild and reversible where the
corticosteroids were used for limited periods of time). Further, skin conditions
are often under-treated because of fears of side effects. This has led some
researchers to suggest that the usual dosage instructions should be changed from
"Use sparingly" to "Apply enough to cover affected areas", and that specific
dosage directions using "fingertip units" or FTUs be provided, along with photos
to illustrate FTUs. However, caution must always be used as long-term use,
prolonged widespread coverage, or use with occlusion, can create side effects
that are permanent and resistant to treatment.
Topical
immunosuppressants
Tacrolimus
0.1%
Topical immunosuppressants like pimecrolimus (Elidel and Douglan) and
tacrolimus (Protopic) were developed after topical corticosteroids had come into
widespread use. These newer agents effectively suppress the immune system in the
affected area, and appear to yield better results in some populations. The U.S.
Food and Drug Administration has issued a public health advisory about the
possible risk of lymph node or skin cancer from use of these products, but many
professional medical organizations disagree with the FDA's findings;
The
postulation is that the immune system may help remove some pre-cancerous
abnormal cells which is prevented by these drugs. However, any chronic
inflammatory condition such as eczema, by the very nature of increased
metabolism and cell replication, has a tiny associated risk of cancer (see
Bowen's disease).
Current practice by UK dermatologists is not to consider
this a significant real concern and they are increasingly recommending the use
of these new drugs. The dramatic improvement on the condition can significantly
improve the quality of life of sufferers (and families kept awake by the
distress of affected children). The major debate, in the UK, has been about the
cost of such newer treatments and, given only finite NHS resources, when they
are most appropriate to use.
In addition to cancer risk, there are other
potential side effects with this class of drugs. Adverse reactions including
severe flushing, headaches, flu-like syndrome, photosensitive reactivity and
possible drug interactions with a variety of medications, alcohol and
grapefruit.
Systemic
immunosuppressants
When eczema
is severe and does not respond to other forms of treatment, immunosuppressant
drugs are sometimes prescribed. These dampen the immune system and can result in
dramatic improvements to the patient's eczema. However, immunosuppressants can
cause side effects on the body. As such, patients must undergo regular blood
tests and be closely monitored by a doctor. In the UK, the most commonly used
immunosuppressants for eczema are ciclosporin, azathioprine and methotrexate.
These drugs were generally designed for other medical conditions but have been
found to be effective against eczema.
Itch
relief
Anti-itch
drugs, often antihistamine, and dermasil may reduce the itch during a flare up
of eczema, and the reduced scratching in turn reduces damage and irritation to
the skin (the "itch cycle").[citation needed] However, in some cases,
significant benefit may be due to the sedative side effects of these drugs,
rather than their specific antihistamine effect. Thus sedating antihistamines
such as promethazine (Phenergan) or diphenhydramine (Benadryl) may be more
effective at preventing night time scratching than the newer, nonsedating
antihistamines.
Capsaicin
applied to the skin acts as a counter irritant (see gate control theory of nerve
signal transmission).
Hydrocortisone applied to the skin aids in temporary itch
relief.
Temporary
yet significant and fast-acting relief can be found by cooling the skin via
water (swimming, cool water bath or wet washcloth), air (direct output of an air
conditioning vent), or careful use of an ice pack (wrapped in soft smooth cloth,
e.g., pillow case, to protect skin from damage).
Moisturizers
Eczema can
be exacerbated by dryness of the skin. Moisturizing is one of the most important
self-care treatments for eczema. Keeping the affected area moistened can promote
skin healing and relief of symptoms. Soaps and detergents should not be used on
affected skin because they can strip natural skin oils and lead to excessive
dryness.
Moistening
agents are called emollients. In general, it is best to match thicker ointments
to the driest, flakiest skin. Light emollients may not have any effect on
severely dry skin. Moisturizing gloves (gloves which keep emollients in contact
with skin on the hands) can be worn while sleeping. Generally, twice-daily
applications of emollients work best. Ointments, with less water content, stay
on the skin longer and need fewer applications, but they can be greasy and
inconvenient. Steroids may also be mixed in with
ointments.
For unbroken
skin, direct application of waterproof tape with or without an emollient or
prescription ointment can improve moisture levels and skin integrity which
allows the skin to heal. This treatment regimen can also help prevent the skin
from cracking, as well as put a stop to the itch cycle. The end result is
reduced lichenification (the roughening of skin from repeated scratching).
Taping works best on skin away from joints.
There is a
disagreement whether baths are desirable or a necessary evil. For example, the
Mayo Clinic advises against daily baths to avoid skin drying. On the other hand,
the American Academy of Dermatology claims "it is a common misconception that
bathing dries the skin and should be kept to a bare minimum" and recommends
bathing to hydrate skin. They even suggest up to 3 short baths a day for people
with severe eczema. According to them, a moisturizer should be applied within 3
minutes to trap the moisture from bath in the skin.
Anecdotal
evidence suggested that soft water could have therapeutic effects for people
with eczema currently using hard water.
However, a
trial involving 336 children with eczema showed no objective difference in
outcomes between the children whose homes were fitted with a water softener and
those without.
Ceramides,
which are the major lipid constituent of the stratum corneum, have been used in
the treatment of eczema. They are often one of the ingredients of modern
moisturizers. These lipids were also successfully produced synthetically in the
laboratory.
However,
detergents are so ubiquitous in modern environments in items like tissues, and
so persistent on surfaces, "safe" soaps are necessary to remove them from the
skin in order to control eczema. Although most eczema recommendations use the
terms "detergents" and "soaps" interchangeably, and tell eczema sufferers to
avoid both, detergents and soaps are not the same and are not equally
problematic to eczema sufferers. Detergents, which differ from soap in that they
commonly have a sulfate polar group, increase the permeability of skin membranes
in a way that soaps and water alone do not. Sodium lauryl sulfate, the most
common household detergent, has been shown to amplify the allergenicity of other
substances ("increase antigen penetration").
Unfortunately there is no one agreed-upon best kind of skin
cleanser for eczema sufferers. Different clinical tests, sponsored by different
personal product companies, unsurprisingly tout various brands as the most
skin-friendly based on specific properties of various products and different
underlying assumptions as to what really determines skin friendliness. The terms
"hypoallergenic" and "doctor tested" are not regulated, and no research has been
done showing that products labeled "hypoallergenic" are in fact less problematic
than any others. It may be best to avoid soaps and detergent cleansers
altogether, except for the armpits, groin and perianal areas, and use cheap
bland emollients in the bath or shower.
