Atopic Eczema

Atopic eczema is a complex condition. It happens because of poor skin barrier function and an overactive immune system. A combination of these two factors gives abnormal reaction patterns to a variety of things such as contact with soaps, detergents, and any other chemicals applied to the skin, exposure to allergens, and infection with certain bacteria and viruses.

A tendency to atopic conditions often runs in families (see below) and is part of your genes. An alteration in a gene that is important in maintaining a healthy skin barrier has been closely linked to the development of eczema. This condition makes the skin of patients with eczema much more susceptible to infection and allows irritating substances/particles to enter the skin, causing itching and inflammation. AE cannot be caught from somebody else.

Yes. Atopic eczema tends to run in families. If one or both parents have eczema, it is more likely that their children will develop it too.  AE affects both males and females equally.

The main symptom is itch. Scratching in response to irritation may cause many changes to the skin. The itch can be severe enough to interfere with sleep, causing tiredness and irritability. Typically AE goes through phases of being severe, then less severe, and then gets worse again.

How does atopic eczema look like?

Atopic eczema can affect any part of the skin, including the face, but the areas that are most commonly affected are the creases in the joints at the elbows and knees, as well as the wrists and neck (called a flexural pattern).

Other common appearances of AE include coin-sized areas of inflammation on the limbs (a discoid pattern).

Numerous small bumps that coincide with the hair follicles (a follicular pattern).

Affected skin is usually red and dry, and scratch marks (accompanied by bleeding) are common. When AE is very active, it may become moist and weep fluid (during a ‘flare-up’), and small water blisters may develop, especially on the hands and feet.

In areas that are repeatedly scratched, the skin may thicken (a process known as lichenification), and this may cause the skin to itch more.

Sometimes affected areas of the skin may become darker or lighter in color than the surrounding, unaffected skin. 

The features of AE are usually easily recognized by health visitors, practice nurses, and doctors when they assess the skin.

Many factors in the person’s environment can worsen AE; these include heat, dust, woolen clothing, pets, and irritants such as soaps, detergents, and other chemicals. 

• Being unwell, for example, having a common cold can cause a flare-up.
• Infections with bacteria or viruses can worsen AE. Bacterial infection (usually with a bacteria called Staphylococcus) makes the affected skin yellow, crusty and inflamed, and may need specific treatment. An infection with the cold sore virus (herpes simplex) can cause a sudden painful widespread (and occasionally dangerous) flare-up of AE, with weeping small sores.
• Dryness of the skin.
• Teething in babies. 
• In some, food allergens may rarely cause a flare-up. 
• Stress

No, it cannot be cured, but there are many ways of controlling it. As they grow older, most children will improve. However, many of these people continue to have dry skin and so need to avoid irritants such as soaps, detergents, and bubble baths.

AE may be troublesome for people in specific jobs that involve contact with irritant materials, such as catering, hairdressing, cleaning, or healthcare work. In later life, AE can present as hand dermatitis, and as a result, exposure to irritants and allergens must be avoided both at home and at work.

Regular use of medical moisturizers can help restore the skin’s barrier in children who might otherwise develop AE.   For some patients who flare-up frequently, intermittent use of a topical steroid or calcineurin inhibitors (see below) may reduce the number of outbreaks.

Yes. You can lead a full life, including sports, swimming, and travel. You may need to make minor changes such as keeping moisturizer with you at school, work, or when away from home. How can atopic eczema be treated? ‘Topical’ means ‘applied to the skin surface.’

Most eczema treatments are topical, although, for more severe eczema, some people need to take ‘oral’ medication (by mouth) as well. ‘Complete emollient therapy’ is the mainstay of treatment for all patients with eczema as the most crucial part of their treatment – this means regular application of a moisturizer (also known as an emollient) and washing with a moisturizer instead of soap (known as a soap substitute).

These should be applied several times every day to help the outer layer of your skin function better as a barrier to your environment. The drier your skin, the more frequently you should apply a moisturizer. Different options are available, varying in their degree of greasiness, and it is essential that you choose one you like to use.

The best one to use is the greasiest one to apply. Moisturizers containing an antiseptic may be useful if repeated infections are a problem. Aqueous cream was initially developed as a soap substitute. It is often used as a moisturizer but can irritate the skin and make your AE worse. For this reason, it is recommended that aqueous cream is not used as a moisturizer.

These creams will usually improve the redness and itching of AE when it is active. They come in different strengths, and your doctor will advise you on which type of cream needs to be used, where, and for how long.

Use a fingertip unit (squeeze steroid from the tube to cover the length of your index fingertip) to cover an area of the size of the front and back of your hand. Use appropriately topical steroids as these are very effective and safe to use. If used inappropriately (too strong or for too long and on the wrong body site), topical steroids may cause side effects, including thinning of the skin.

However, insufficient treatment with topical steroids is generally considered by doctors to be more of a problem than overuse. Weaker topical steroids are usually prescribed for use on the face, breasts, genitals, eyelids, and armpits because the skin is much thinner on these sites. Stronger steroids can be used at other sites, especially thicker areas such as hands and feet. It is recommended that you do not purchase ‘natural’ herbal creams, as they can cause irritation and allergic reactions.

Some so-called ‘natural’ creams have been shown to contain potent steroids. Other herbal creams have been shown to contain high levels of harmful bacteria, including MRSA, which may cause skin infections and septicemia.

If your AE becomes wet, weepy, and crusted, it may be infected, and a course of antibiotics may be needed. Antiseptics, when applied to the skin alone or as part of a moisturizing preparation, can help stop the infection. Incorrect use of antiseptics can, however, irritate the skin and make AE worse. Antiseptics should not be used continuously because this can result in excessive drying of the skin.

Calcineurin inhibitors, tacrolimus ointment, and pimecrolimus cream may be used when AE is not responding to topical steroids, or on skin sites that are more susceptible to the side effects of steroids, such as the face, eyelids and armpits and groin.

The most common side effect is stinging after applying it, but this usually disappears after a few applications. They are associated with an increased risk of skin infections and should not be used to infected (weeping, crusted) skin.

A maintenance regimen using intermittent calcineurin inhibitors (see below) is useful in patients who have frequent flare-ups of AE.

Antihistamine tablets can be helpful in some patients. Antihistamines that make people sleepy can be useful when used at night. They do not affect the inflammation of AE and are mainly useful as a result of their sedating effects, reducing sleep disruption.

Bandaging (dressings): Cotton bandages and cotton or silk vests/leggings worn on top of creams can help keep creams from rubbing off and stop scratching. Sometimes these may be applied as ‘Wet wraps, ’ which can be useful for short periods.

Wet wraps can upset babies/young children because they can become too cold. For some patients, the use of medicated paste bandages may be helpful, as they are soothing and provide a physical barrier to scratching. It is essential to be taught how to use the dressings correctly. Your doctor or nurse will advise you regarding the suitability of the various bandages and dressings available.

• Airborne allergens from cats, dogs, pollen, grass, or the house dust mite, can cause flares of AE in some patients. 
• Food allergies. In infants and young children where the AE is severe, intensely itchy, and challenging to control, food allergens may be aggravating the skin. Dietary avoidance should only be undertaken with medical advice.
• Latex (rubber) allergy is more common in atopic people. The symptoms may consist only of itching of the skin after contact with rubber products.
• Contact allergy to creams and ointments used to treat atopic eczema can rarely occur. Let your doctor know if your treatments seem to be making your skin worse (see Patient Information Leaflet on Contact Dermatitis). Ultraviolet light: Some people with chronic eczema benefit from ultraviolet light treatment, which is usually given in a specialist hospital department (see Patient Information Leaflet on Phototherapy). This treatment is not usually recommended for children.

People with severe or widespread atopic eczema not responding to topical treatments may need oral treatments (taken by mouth). The oral treatment works by dampening down the immune system and are given under the close supervision of a health care professional.

Options include:

• Oral steroids (prednisolone)
• Azathioprine 
• Ciclosporin 
• Methotrexate 
• Mycophenolate mofetil 

• Moisturize your skin as often as possible, ideally at least two times each day. The most greasy, non-perfumed moisturizer tolerated is best. This step is the most crucial part of your skincare. Smoothen it on in the direction of hair growth. Do not put your fingers back and forth into the pot of moisturizer, as it may become contaminated and be a source of infection. It is best to remove an adequate amount to cover the skin with a spoon or spatula and put this on a saucer or piece of kitchen roll. 
• Wash skin with a moisturizer instead of soap (known as a soap substitute), and avoid soap, bubble baths, shower gels, and detergents.
• Wear non-powdered non-rubber gloves (e.g., vinyl gloves) to protect your hands and avoid contact with irritants, such as when doing housework. 
• Rinse well after swimming and apply plenty of your moisturizer after drying. Make sure that the shower at the swimming pool contains fresh water and not the chlorinated water.
• Wear comfortable clothes made of materials such as cotton and avoid wearing wool next to your skin. 
• Try to resist the temptation to scratch. It may relieve your itch briefly, but it will make your skin itchier in the long term. Smoothen a moisturizer onto itchy skin.
• Avoid close contact with anyone who has an active cold sore as patients with eczema are at risk of getting a widespread cold sore infection. 
• Do not keep pets to which there is an apparent allergy.
• Keep cool. Overheating can make eczema itch more. 
• Treat eczema early – the more severe it becomes, the more difficult it is to control.
• Wash clothes with non-biological washing powder and use a double rinse cycle to remove detergent residues from the clothing.