- The skin usually feels dry.
- Some areas of the skin become red and inflamed. The most common
areas affected are next to skin creases such as the front of the elbows
and wrists, backs of knees, and around the neck. However, any areas of
skin may be affected. The face is commonly affected in babies.
- Inflamed skin is itchy. If you scratch a lot it may cause patches of skin to become thickened.
- Sometimes the inflamed areas of skin become blistered and weepy.
- Sometimes inflamed areas of skin become infected.
As a rule, inflamed areas of skin tend to 'flare-up' from time
to time, and then tend to settle down. The severity and duration of
'flare-ups' varies from person to person, and from time to time in the
same person.
- In mild cases, a flare-up may cause just one or
two small, mild patches of inflammation. Often these are behind the
knees, or in front of elbows or wrists. Flare-ups may occur only 'now
and then'.
- In severe cases the flare-ups can last several weeks or more, and cover many areas of skin. This can cause great distress.
- Many people with atopic eczema are somewhere in between these extremes.
Who has atopic eczema?
Most cases first
develop in children under the age of five years. It is unusual to first
develop atopic eczema after the age of 20. About 1 in 6 schoolchildren
have some degree of atopic eczema. However, in about 2 in 3 cases, by
the mid teenage years, the flare-ups of eczema have either gone
completely, or are much less of a problem. However, there is no way of
predicting which children will still be affected as adults.
About 1 in 20 adults have atopic eczema.
What causes atopic eczema?
The
cause is not known. The lipid (oily) barrier of the skin tends to be
reduced in people with atopic eczema. This leads to an increase in
water loss and a tendency towards dry skin. Also, some cells of the
immune system release chemicals under the skin surface which can cause
some inflammation. But it is not known why these things occurs. Genetic
(hereditary) factors play a part. Atopic eczema occurs in about 8 in 10
children where both parents have the condition, and in about 6 in 10
children where one parent has the condition. The precise genetic cause
is not clear (which genes are responsible, what effects they have on
the skin, etc).
Atopic eczema has become more common in recent
years. There are various theories for this. Factors which may play a
role include: changes in climate, pollution, allergies to house dust
mite or pollens, diet, infections, or other 'early-life factors'.
However, there is no proven single cause. There may be a combination of
factors in someone who is genetically prone to eczema which causes the
drying effect of the skin and the immune system to react and cause
inflammation in the skin.
What is the usual treatment for atopic eczema?
The usual treatment consists of three parts:
- Avoid irritants to the skin and other 'triggers' wherever possible.
- Emollients (moisturisers) - use every day to help prevent inflammation developing.
- Topical steroids (steroid creams and ointments) - mainly used when inflammation flares-up.
Treatment part 1 - avoid irritants and 'triggers' where possible
Many
people with eczema have flare-ups of from time to time for no apparent
reason. However, some flare-ups may be caused (triggered) or made worse
by irritants to the skin, or other factors. It is commonly advised to:
- Avoid
soaps, bubble baths, etc, when you wash. They can dry out the skin and
make it more prone to irritation. Instead, use a soap substitute plus a
bath/shower emollient (see below).
- Try as much as possible not to scratch the eczema. To help with
this, keep nails short and use anti-scratch mittens in babies. If you
need to relieve an itch, rub with fingers rather than scratch with
nails.
- Wear cotton clothes next to skin rather than
irritating fabrics such as wool. However, it is probably the smoothness
of the material rather than the type of the material which helps. Some
smooth man-made fabrics are probably just as good as cotton.
- Avoid getting too hot or too cold as extremes of temperature can irritate the skin.
- After you wash clothes with detergent, rinse them well. Some
'biological' detergents are said by some people to be irritating. But
there is little proof that commonly used detergents that are used in
the normal way make eczema worse.
House dust mite may be a trigger in some cases
House
dust mite is a tiny insect that occurs in every home. You cannot see it
without a microscope. It mainly lives in bedrooms and mattresses as
part of the dust. Many people with eczema are allergic to house dust
mite. If you are allergic, you have to greatly reduce the numbers of
house dust mite for any chance that symptoms may improve.
However,
it is impossible to clear house dust mite completely from a home, and
it is hard work to greatly reduce their number to a level which may be
of benefit. It involves regular cleaning and vacuuming with particular
attention to your bedroom, mattress, and bedclothes.
Therefore,
in general, it is not usually advised to do anything about house dust
mite. Especially if your eczema is mild to moderate, and can be managed
by the usual treatments of emollients and short courses of topical
steroids. However, if you have moderate or severe eczema which is
difficult to control with the usual treatments, you may wish to
consider reducing the number of house dust mites from your home.
Another leaflet gives more details on how to reduce house dust mites.
Food sensitivity may be a trigger in some cases
Less
than 1 in 10 children with atopic eczema have a food sensitivity
(allergy) which can make symptoms worse. In general, it is young
children with severe eczema who may have a food sensitivity as a
trigger factor. The most common foods which trigger eczema symptoms in
some people include: cow's milk, eggs, soya, wheat, fish, and nuts.
If
you suspect a food is making your child's symptoms worse, then see a
doctor. You may be asked to keep a diary over 4-6 weeks. The diary aims
to record any symptoms and all foods and drink taken. It may help to
identify one or more suspect foods. In some cases, if a 'trigger food'
is identified, a diet without this food may be advised if the eczema is
severe and difficult to control by other means. But this should only be
done under the supervision of a dietician and only helps in a small
proportion of cases.
Other triggers
Other possible factors which
may trigger symptoms, or make symptoms worse, include: stress and
'habit scratching', pollens, moulds, dander from pets, pregnancy, and
hormone changes before a period in women. However, some of these may
not be avoidable.
See separate leaflet in this series called 'Eczema - Triggers and Irritants' for more details.
Treatment part 2 - emollients (moisturisers)
People
with eczema have a tendency for their skin to become dry. Dry skin
tends to 'flare-up' and become inflamed into patches of eczema.
Emollients are lotions, creams, ointments and bath/shower additives
which prevent the skin from becoming dry. They 'oil' the skin, keep it
supple and moist, and help to protect the skin from irritants. This
helps to prevent itch and helps to prevent or reduce the number of
eczema flare-ups.
The regular use of emollients is the most
important part of the day-to-day treatment for eczema. Your doctor,
nurse or pharmacist can advise on the various types and brands
available, and the ones which may suit you best.
You should
apply emollients as often as you need. This may be twice a day, or
several times a day if your skin becomes very dry. Some points about
emollients include:
- As a rule, thicker, greasy ointments
work better and for longer than thinner creams, but they are messier to
use. Some people don't mind using thick ointments, but some people
prefer creams (but apply them more often.)
- Apply liberally to all areas of skin. You cannot overdose or
overuse emollients. They are not active drugs and do not get absorbed
through the skin.
- Use emollients every day. A common mistake is to stop using
emollients when the skin appears good. Patches of inflammation, which
may have been prevented, may then quickly flare-up again.
- Various emollient preparations come as bath additives and shower
gels. These may be considered in people with extensive areas of dry
skin. However, there is some debate as to how well these work. If you
do use them they should be used in addition to, not instead of, creams
ointments or lotions that you rub onto the skin.
Many people with eczema use a range of different emollients.
For example, a typical routine for an 'average' person with eczema
might be:
- When you have a bath or shower, consider adding an
emollient oil to the bathwater or as you shower. This will give your
skin a general background 'oiling'.
- Use a thick emollient ointment as a soap substitute for cleaning. You can also rub this into particularly dry areas of skin.
- After a bath or shower it is best to dry by patting with a towel rather than by rubbing.
- Then apply an emollient cream or ointment to any remaining dry areas of skin.
- Between baths or showers, use an emollient cream, ointment or lotion as often as necessary.
- Use an emollient ointment at bedtime.
Note: emollients used for eczema tend to be 'bland' and
non-perfumed. Occasionally, some people become sensitised to an
ingredient in an emollient. This can make the skin worse rather than
better. If you suspect this, see your doctor for advice. There are many
different types of emollients with various ingredients. A switch to a
different type will usually sort this uncommon problem.
Warning:
bath additive emollients will coat the bath and make it greasy and
slippery. It is best to use a mat and/or grab rails to reduce the risk
of slipping. Warn anybody else who may use the bath that it will be
slippery.
See separate leaflet called 'Emollients (Moisturisers) for Eczema' for more details.
Treatment part 3 - topical steroids (steroid creams and ointments)
Topical
steroids work by reducing inflammation in the skin. (Steroid drugs that
reduce inflammation are sometimes called corticosteroids. They are very
different to the anabolic steroids which are used by some body-builders
and athletes.) Topical steroids are grouped into four categories
depending on their strength - mild, moderately potent, potent, and very
potent. There are various brands and types in each category. For
example, hydrocortisone cream 1% is a commonly used steroid cream and
is classed as a mild topical steroid. The greater the strength
(potency), the more effect it has on reducing inflammation, but the
greater the risk of side-effects with continued use.
Creams are
usually best to treat moist or weeping areas of skin. Ointments are
usually best to treat areas of skin which are dry or thickened. Lotions
may be useful to treat hairy areas such as the scalp.
As a rule,
a course of topical steroid is used when one or more patches of eczema
flare up. You should use topical steroids until the flare-up has
completely gone, and then stop it. In many cases, a course of treatment
for 7-14 days is enough to clear a flare-up of eczema. In some cases, a
longer course is needed. Many people with eczema require a course of
topical steroids every 'now and then' to clear a flare-up. The
frequency of flare-ups, and the number of times a course of topical
steroids is needed varies greatly from person to person.
It is
common practice to use the lowest strength topical steroid which clears
the flare-up. If there is no improvement after 3-7 days then a stronger
topical steroid is usually then prescribed. For severe flare-ups a
stronger topical steroid may be prescribed from the outset. Sometimes
two or more preparations of different strengths are used at the same
time. For example, a mild steroid for the face, and a stronger steroid
for patches of eczema on the thicker skin of the arms or legs.
Short bursts of high strength steroid as an alternative
For
adults, a short course (usually three days) of a strong topical steroid
may be an option to treat a mild to moderate flare-up of eczema. A
strong topical steroid often works quicker than a mild one. (This is in
contrast to the traditional method of using the lowest strength
wherever possible. However, studies have shown that using a high
strength for a short period can be more convenient and is thought to be
safe.)
Short duration treatment to prevent flare ups (weekend therapy)
Some
people have frequent flare ups of eczema. For example, a flare-up may
subside well with topical steroid therapy. But then, within a few
weeks, a flare-up returns. In this situation, one option that might
help is to apply steroid cream on the usual sites of flare-ups for two
days every week. This is often called 'weekend therapy'. This aims to
prevent a flare-up from occurring. In the long run, it can mean that
the total amount of topical steroid used is less than if each flare-up
was treated as and when it occurred. You may wish to discuss this
option with your doctor.
How do I apply topical steroids?
Topical
steroids are usually applied once a day (sometimes twice a day - your
doctor will advise). Rub a small amount thinly and evenly just onto
areas of skin which are inflamed. (This is different to emollients
which should be applied liberally all over.)
To work out how
much you should use each dose: squeeze out some cream or ointment from
the tube onto the end of an adult finger - from the tip of the finger
to the first crease. This is called a 'fingertip unit'. One fingertip
unit is enough to treat an area of skin twice the size of the flat of
an adult's hand with the fingers together. Gently rub the cream or
ointment into the skin until it has disappeared. Then wash your hands
(unless your hands are the treated area).
Note: don't forget to use emollients as well when you are using a course of topical steroids.
What about side-effects of topical steroids?
Short
courses of topical steroids (less than four weeks) are usually safe and
usually cause no problems. Problems may develop if topical steroids are
used for long periods, or if short courses of strong topical steroids
are repeated often. The concern is mainly if strong topical steroids
are used long-term. Side-effects from mild topical steroids are
uncommon.
- Thinning of the skin is the most common possible
problem. If skin thinning occurs it often reverses when the topical
steroid is stopped.
- With long-term use of topical steroid the skin may develop
permanent striae (like 'stretch' marks), bruising, discolouration, or
thin spidery blood vessels (telangiectasia).
- Topical steroids may trigger or worsen other skin disorders such as acne, rosacea and perioral dermatitis.
- Some topical steroid gets through the skin and into the
bloodstream. The amount is usually small and usually causes no problems
unless strong topical steroids are used regularly on large areas of the
skin. The main concern is with children who need frequent courses of
strong topical steroids. The steroid can have an effect on growth.
Therefore, children who need repeated courses of strong topical
steroids should have their growth monitored.
See separate leaflet called 'Topical Steroids for Eczema' for more details.
Using emollients and topical steroids together
Most
people with eczema will be prescribed emollients to use every day and a
topical steroid to use when eczema flares up. When using the two
treatments, apply the emollient first. Wait 10-15 minutes after
applying an emollient before applying a topical steroid. That is, the
emollient should be allowed to absorb before a topical steroid is
applied (the skin should be moist or slightly tacky, but not slippery,
when applying the steroid).
Infected eczema patches
Sometimes, one or
more patches of eczema get infected during a flare-up. Characteristics
of infected eczema include 'weeping' blisters, infected skin lumps
(pustules), crusts, failure to respond to normal treatment, and rapidly
worsening eczema. If the infection becomes more severe you may also
develop a fever (temperature) and generally feel unwell. If infected
eczema develops then a course of an antibiotic tablet or liquid
medicine will usually clear the infection. This is used in addition to
usual eczema topical treatments. Sometimes, a topical antibiotic is
used if the infection is confined to a small area.
Once the
infection is cleared it is best to throw away all your usual creams,
ointments and lotions and get fresh new supplies. This is to reduce the
risk of applying creams etc that may have become contaminated with
bacteria (germs). Also, if you seem to get recurring bouts of infected
eczema, you may be advised to use a topical antiseptic such as
chlorhexidine on a regular basis. This is in addition to your usual
treatments. The aim is to keep the number of bacteria on your skin to a
minimum.
What if treatment does not work?
See your
doctor if a flare-up of eczema is getting worse or not clearing despite
the usual treatments with emollients and topical steroids. Things which
may be considered include:
- Should the strength of the topical steroid be increased?
- Are emollients being used often enough to keep the skin supple and moist?
- Has the inflamed skin become infected and needs an antibiotic?
- Allergy. Occasionally, some people become sensitised ('allergic')
to an ingredient in a cream (such as a preservative which is included
with the steroid or emollient). This can make the skin inflammation
worse rather than better.
You may be referred to a skin specialist if a flare-up does not improve with the usual treatments.
Other treatments
-
Tacrolimus ointment and pimecrolimus cream
are treatments introduced in 2002. They work by suppressing some cells
involved in causing inflammation. (They are 'topical
immunomodulators'.) They are not steroids. They seem to work well to
reduce the skin inflammation of eczema. At present they are licensed
for use in people aged two years and over who have eczema which is not
controlled very well with usual treatments. The long-term safety of
these new products is still being evaluated.
-
Steroid tablets are sometimes prescribed for a short time if eczema becomes severe and topical treatments are not helping much.
-
Eczema with blisters may need special soaks to dry up the weepy blisters.
-
Hospital treatment is sometimes needed for severe cases.
Treatments which are sometimes used include: 'wet wraps', tar and/or
steroid occlusion bandages, light therapy, and immunosuppressive
medication.
-
Tar shampoos are useful to lift scale from affected scalps.
-
Antihistamine tablets are sometimes tried to help ease itch.
They do not have a great effect on reducing itch, but some types of
antihistamines can make you drowsy. A dose at bedtime may help children
who are troubled with itch to get to sleep.
Alternative remedies
Alternative remedies
such as herbal medicines are sometimes tried by some people. There is
little proof that any alternative treatment helps. But, turning to
these remedies is understandable if conventional treatments fail to
control severe eczema. However, beware of extravagant claims of success
which cost large amounts of money.
Also, remember that all
treatments that claim to work well may also have side effects,
including so-called natural remedies. For example, some Chinese herbal
medicines have been associated with life-threatening side effects.
Disclaimer: This article is for information only and should not
be used for the diagnosis or treatment of medical conditions. EMIS and
PiP have used all reasonable care in compiling the information but make
no warranty as to its accuracy. Consult a doctor or other health care
professional for diagnosis and treatment of medical conditions.
© EMIS and PiP 2008 Reviewed: 18 Aug 2008
