Eczema (Atopic Dermatitis)

Also Listed As: Atopic Dermatitis; Dermatitis, Atopic; Skin Disorders, Eczema

Eczema, also called atopic dermatitis, is a chronic, inflammatory skin disorder. Its main features are blisters that dry to become scaly, itchy rashes. The skin becomes dry and itchy because too much moisture is lost from its upper layer. This leaves the skin without protection, making it easy for bacteria and viruses to penetrate. The disease occurs episodically; in other words, there may be periods when symptoms are severe (flares) and times when there are no symptoms at all (remission). Eczema is not contagious, but nevertheless it is very common — estimates are that more than 15 million people in the United States have eczema. People with eczema often have a personal or family history of allergic conditions like asthma or hay fever. There is no cure, but treatments can reduce symptoms and help prevent outbreaks.

Signs and Symptoms

Symptoms of eczema occur repeatedly. The most common signs of eczema are:

• Dry, extremely itchy skin
• Blisters with oozing and crusting
• Redness of the skin around the blisters
• Raw areas of the skin from scratching which may even lead to bleeding
• Dry, leathery areas with more or less pigment than their normal skin tone (called lichenification)

Eczema in children under 2 years old generally begins on the cheeks, elbows, or knees. In adults, it tends to be located on the inside surfaces of the knees and elbows.

Causes

The cause of eczema is thought to be a combination of hereditary (genetic) and environmental factors. This means that factors such as allergies can cause eczema in susceptible people. Exposure to certain irritants and allergens (see Lifestyle section for further definition of these substances) in the environment can worsen symptoms as can dryness of the skin, exposure to water, temperature changes, and stress.

Risk Factors

• Young age — infants and young children are most affected by eczema (about 65% of cases occur before age one, and approximately 90% occur before age 5)
• Skin exposure to harsh conditions
• Living in a climate with low humidity
• Personal and/or family history of allergies to plants, chemicals, or food
• Deficiencies of certain vitamins and minerals (for example, zinc)
• Stress can make eczema worse

Irritants that may worsen eczema include:

• Wool or synthetic fibers
• Certain soaps and detergents as well as perfumes and some cosmetics
• Dust or sand
• Cigarette smoke

Diagnosis

Your doctor will most likely base a diagnosis on both the appearance of the skin and on personal and family history. For adults, he or she may ask about stress in your life, your diet, drugs you are taking, soaps and detergents you use, and chemicals or materials you may be exposed to at work, to find the cause of your rash. A skin lesion biopsy (removal of a small piece of skin for examination in a laboratory) may be performed, but is not always required to make the diagnosis.

Preventive Care

Control of stress, nervousness, anxiety, and depression may help prevent flares of eczema. Mind/body techniques that have shown some success include cognitive-behavioral therapy, autogenic training, and these two techniques combined with learning about eczema.

Dietary restrictions that may help avoid flare ups include eggs, fish, peanuts, and soy. This is very individual and should be discussed with your health care provider. A doctor, dietitian, or naturopath, for example, can help you make these dietary changes and determine if the lack of these foods in your diet is reducing the incidence and severity of your eczema.

Although somewhat controversial, some studies have shown that children who are exclusively breast-fed for at least 4 months are less likely to get eczema.This is particularly true when the nursing mother has avoided cow's milk in her own diet.

Similarly, recent studies suggest that babies whose mothers used probiotics during pregnancy and while breastfeeding were less likely to have eczema up to 2 years of age. (See Nutrition and Dietary Supplements section for definition and more information on probiotics.)

Preliminary studies suggest that pretreatment of skin with creams containing omega fatty acids can reduce the severity of eczema or prevent eczema entirely.

Treatment Approach

The goals when treating eczema are to heal the skin, reduce symptoms, prevent skin damage, and prevent flares. Treatment may vary depending on age, symptoms, and general health. Developing skin care routines, identifying factors that trigger flares, and avoiding these triggers is a large part of any treatment plan.

Lifestyle

• Avoid anything that aggravates the symptoms, such as allergens (substances to which the immune system overreacts) and irritants to the skin. Common allergens include pollen, dust mites, and animal dander. Common skin irritants include wool, synthetic fibers, soaps and detergents, perfumes, cosmetics, lanolin, certain chemicals such as chlorine and solvents (including mineral oil), cigarette smoke, dust, and sand.
• Avoid scratching or rubbing affected areas
• Protect skin from rough clothing and irritants
• Be aware of emotional stress and try stress-reducing techniques
• Keep your environment cool, with stable temperature and humidity

Dry skin often makes the condition worse. Remember to:

• Avoid hot baths or showers; lukewarm water is best
• Wash or bathe as quickly as possible to lessen water contact.
• Use a mild soap or a nonsoap cleanser, or less soapthan usual.
• Moisturize. After bathing, it is important to trap the moisture in theskin by applyinglubricating cream on theskin while it isdamp (within 3 minutes of bathing).

Parents can help their children by:

• Providing distractions to prevent them from scratching
• Keeping fingernails short to reduce chances of infection from scratching
• Being aware that there may well be social and emotional stress associated with visible skin lesions; additional support and encouragement may be needed

Medications

• Mild anti-itch lotions or topical corticosteroids-low potency coticosteroids and over-the-counter lotions may soothe less severe or healing areas, or dry scaly lesions
• Chronic thickened areas may be treated with ointments or creams that contain tar compounds, corticosteroids (medium to very high potency), and ingredients that lubricate or soften the skin.
• Systemic corticosteroids may be prescribed to reduce inflammation in some severe cases. In very rare instances, medications that suppress the immune system (called immunosuppressants such as cyclosporine) may be considered in adults with extremely severe eczema who do not respond to oral steroids.
• Antihistamines may be recommended for nighttime use to prevent nighttime scratching. These medications may cause drowsiness.
• New treatments-the latest treatment for eczema is a new class of skin medications called topical immunomodulators (TIMs). These medications are steroid-free. The most common are tacrolimus and ascomycin. Studies have shown as high as an 80% success rate using these new medications.

Surgery and Other Procedures

Phototherapy and Photochemotherapy
Treatment with ultraviolet light waves may effectively treat mild to moderate cases of eczema in children over age 12 and adults. If phototherapy is ineffective alone, it may be combined with a drug called psoralen. It is then called photochemotherapy.

Nutrition and Dietary Supplements

Paying attention (even keeping a diary) to what you (or your child) eat and the effect it has on your skin (or your child's) may help you (or your child) avoid foods that provoke flares of eczema. Potentially provoking foods include peanuts, milk, soy, fish, and eggs. Foods high in saturated fats (like meat and full fat dairy) and trans-fatty acids (such as fried foods and hydrogenated oils) may stimulate inflammation as might sugar and highly processed foods. On the other hand, fresh fruits (particularly dark berries) and vegetables, whole grains, and foods rich in omega-3 fatty acids (such as nuts, flax, seeds, and cold-water fish) may reduce inflammation in those without sensitivities to these foods.

Supplements to consider and discuss with your healthcare provider include:

Gamma-linolenic acid (GLA)
GLA is an omega-6 essential fatty acid. Studies are mixed, but there is some evidence that the metabolism of essential fatty acids is abnormal in people with eczema, resulting in low levels of GLA. Several early studies suggested that GLA derived from evening primrose oil (EPO) is beneficial for relieving symptoms associated with this skin condition such as itching, redness, and scaling. However, more recent studies have not had the same positive results. Whether or not GLA or EPO supplements work for eczema may be very individual. Interestingly, preliminary studies show that pretreatment of skin with fatty acid-rich creams can reduce the severity of eczema or prevent eczema entirely.

Probiotics
Probiotics, or "good" bacteria, inhabit the intestines and protect against the proliferation of "bad" organisms that can cause disease. Studies suggest that gut bacteria in babies at high risk for allergic disorders may be different from that of other babies. Two well-designed studies of mother-infant pairs showed that babies of mothers who took probiotics while pregnant and breastfeeding were less likely to have eczema in the first two years of life. The most commonly used probiotics are Lactobacillus species.

Sulfur
Sulfur is found abundantly in keratin, a protein that strengthens hair, nails, and skin. Sulfur baths, and other forms of sulfur applied directly to the skin, seem to benefit eczema. Use of sulfur as a supplement is not currently recommended for children.

Zinc
Eczema is one of the symptoms of zinc deficiency, but there is no indication that oral supplementation with zinc helps treat eczema.

Others


Although evidence is limited or conflicting, the following may also be useful for eczema:

• Selenium
• Vitamin C

Herbs

Herbs, like drugs, may produce side effects or interact with other medications. They should, therefore, be used with caution and only under the guidance of a professionally trained and qualified herbalist.

Evening Primrose (Oenothera biennis) Oil
Evening primrose seed oil (EPO) is used primarily to relieve the itchiness associated with certain skin conditions, including eczema. Results of studies regarding EPO for eczema are mixed. Similar to GLA (see Nutrition and Dietary Supplements section), an omega-6 fatty acid that is derived from EPO, whether EPO relieves the symptoms of eczema may be very individual. Talk to your healthcare provider to decide if it is safe and worthwhile for you to try EPO for your eczema.

Lavender (Lavandula angustifolia)
Known mainly for its relaxing effects to aid with anxiety and insomnia, some herbal specialists prescribe oral lavender for skin conditions like eczema. In one study of topical lavender, however, children with eczema who received massage with or without lavender oil applied to the skin both did well. In other words, the improvement in the rash was related to the massage – whether lavender oil was used or not seemed to make no difference. To the extent that eczema is worsened by stress, it is possible that lavender adds some benefit by helping you relax.

Others
Herbs that have been used traditionally to treat eczema are listed below. A naturopathic doctor or other herbal specialist might recommend one or more of these remedies after evaluating you and your eczema.

• Burdock root (Arctium lappa) – applied topically for skin inflammations
• German chamomile (Matricaria recutita) – may reduce inflammation and speed wound healing
• Goldenrod (Solidago virgaurea) – applied topically for wound healing; has anti-inflammatory properties
• Red clover (Trifolium pratense) – has anti-inflammatory properties and has been used as an ointment for this skin condition
• Roman chamomile (Chamaemelum nobile) – may ease discomfort associated with eczema
• Stinging nettle (Urtica dioica)

Homeopathy
Although very few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of eczema based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type. A constitutional type is defined as a person's physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual. Any remedy that causes aggravation of symptoms should be discontinued right away.

• Calendula - applied to the skin, particularly if the affected area is inflamed; this remedy soothes but does not cure the skin condition
• Sulphur - for redness, burning, itching, and hot skin that tends to worsen with washing and scratching
• Urtica urens - for large, red rashes (particularly those related to allergies) that itch and burn intensely
• Rhus toxicodendron - used as a remedy for inflamed skin resulting from direct contact with an irritating substance; some homeopaths use it to treat eczema

Massage and Physical Therapy

One study evaluating essential oils for treating children with eczema concluded that massage with and without essential oils was effective in improving the dry, scaly skin lesions. Children with this scaly, itchy skin problem seem to experience less redness, scaling, and other symptoms if receiving massage between flares. Massage should not be used when this skin condition is actively inflamed. The essential oils most often chosen by the mothers in the study were: sweet marjoram, frankincense, German chamomile, myrrh, thyme, benzoin, spike lavender, and Litsea cubeba.

Exercise
In one study it was found that regular group sporting activities improved symptoms in those who participated for 3 weeks. The therapeutic effect of exercise may be related to the positive impact it has on the emotions. Sports should be avoided during the worst stages of an outbreak.

Climatotherapy
Climatotherapy is the use of sunlight and water (such as the ocean) as therapy. The Dead Sea in Israel is known for its healing properties, and many people with eczema go there to sit in the sun and swim in the water. Studies suggest that this is a successful treatment for eczema. One study looked at the experience of more than 1,500 people with eczema and found that 95% of skin was cleared in people who had previous stays at the Dead Sea and stays longer than 4 weeks.

Mind/Body Medicine

Flares of eczema are associated with anxiety and stress. Several studies have shown that relaxation techniques to reduce stress and anxiety can successfully decrease the number of occurrences and relieve symptoms of eczema. Biofeedback seems to be a particularly useful technique.

Other Considerations

Starting an infant on solid foods conservatively and gradually may help prevent the food sensitivities that can cause eczema. Those who are allergic to ragweed, chrysanthemums, asters, echinacea, or feverfew should avoid chamomile because it is in the same plant family.

Pregnancy

Avoid the use of burdock and sulfur during pregnancy.

Warnings and Precautions

Although Chinese herbal treatments for eczema have been gaining popularity in both the United States and the United Kingdom, caution must be exercised when considering such remedies for this skin condition. Many of the Chinese herbal creams available in these two countries have been tested and high amounts of steroid medications have been discovered. This is worrisome and potentially dangerous because the amount of the medication in such creams is not standardized or regulated. In a few rare instances, the use of oral Chinese herbs (like a tea) for eczema has led to kidney damage.

Prognosis and Complications

Although there may be complications of eczema such as bacterial infections of the skin and permanent scar formation, eczema is usually just an annoyance that is easily controlled with treatment and by avoiding irritants. Call for an appointment with your healthcare provider if it does not respond to treatment or if signs of infection (such as fever, redness, pain) occur. Children with eczema, after a certain period of time, often go into remission (period when there are no symptoms) for the rest of their lives, although skin may remain sensitive and dry.

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