Eczema

Editor-In-Chief: Lixia Ellis, M.D., Beth Israel Deaconess Medical Center, Boston

For patient information click here

Overview
Eczema is a form of dermatitis, or inflammation of the upper layers of the skin.

The term "eczema" is broadly applied to a range of persistent skin conditions. These include dryness and recurring skin rashes characterized by one or more of these symptoms: redness, skin edema, itching and dryness, crusting, flaking, blistering, cracking, oozing, or bleeding. Areas of temporary skin discoloration are sometimes due to healed lesions, although scarring is rare.

Types
ICD-10 codes are provided where available. 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 and the term for the most common type of eczema (atopic eczema) 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 classification below is clustered by incidence frequency.

Types of common eczemas

 * Atopic eczema (aka infantile e., flexural e., atopic dermatitis) is believed to have a hereditary component, and often runs in families whose members also have hay fever and asthma. Itchy rash is particularly noticeable on face and scalp, neck, inside of elbows, behind knees, and buttocks. Experts 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 solvent, for example). Some substances act both as allergen and irritant (e.g. wet cement). 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. (L85.3; L85.0)


 * Seborrhoeic dermatitis (aka cradle cap in infants, dandruff) causes dry or greasy scaling of the scalp and eyebrows. Scaly pimples and red patches sometimes appear in various adjacent places. 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 eczemas

 * 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 and can often be put into remission with appropriate diet. (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.

Diagnosis
Eczema diagnosis is generally based on the appearance of inflamed, itchy skin in eczema sensitive areas such as face, chest and other skin crease areas. For evaluation of the eczema, a scoring system can be used (for example, SCORAD, a scoring system for atopic dermatitis).

Given the many possible reasons for eczema flare-ups, a doctor is likely to ascertain a number of other things before making a judgment:


 * An insight to family history
 * Dietary habits
 * Lifestyle habits
 * Allergic tendencies
 * Any prescribed drug intake
 * Any chemical or material exposure at home or workplace

To determine whether an eczema flare is the result of an allergen, a doctor may test the blood for the levels of antibodies and the numbers of certain types of cells. In eczema, the blood may show a raised IgE or an eosinophilia.

The blood can also be sent for a specific test called Radioallergosorbent Test (RAST) or a Paper Radioimmunosorbent Test (PRIST). In the test, blood is mixed separately with many different allergens and the antibody levels measured. High levels of antibodies in the blood signify an allergy to that substance.

Another test for eczema is skin patch testing. The suspected irritant is applied to the skin and held in place with an adhesive patch. Another patch with nothing is also applied as a control. After 24 to 48 hours, the patch is removed. If the skin under the suspect patch is red and swollen, the patch test result is considered positive and suggests that the person is probably allergic to the suspected irritant.

Occasionally, the diagnosis may also involve a skin biopsy which is a procedure that removes a small piece of the affected skin that is sent for microscopic examination in a pathology laboratory.

Blood tests and biopsies are not always necessary for eczema diagnosis. However, doctors will at times require them if the symptoms are unusual, severe or in order to identify particular triggers.

Moisturizing
Eczema can be exacerbated by dryness of the skin. Moisturizing is one of the most important self-care treatments for sufferers of eczema. Keeping the affected area moistened can promote skin healing and relief of symptoms. Soaps and harsh detergent should not be used on affected skin because they can strip natural skin oils and lead to excessive dryness. Instead, the use of moisturizing body wash, or an emollient like aqueous cream, will maintain natural skin oils and may reduce some of the need to moisturize the skin. Another option is to try bathing using colloidal oatmeal bath treatments. In addition to avoiding soap, other products that may dry the skin (such as powders or perfume) should also be avoided.

Moistening agents are called 'emollients'. In general, it is best to match thicker ointments to the driest, flakiest skin. Light emollients like aqueous cream may not have any effect on severely dry skin.

Some common European emollients for the relief of eczema include Oilatum, Balneum, Medi Oil, Diprobase, bath oils and aqueous cream. Sebexol, Epaderm ointment and Eucerin lotion or cream may also be helpful with itching. Lotions or creams may be applied directly to the skin after bathing to lock in moisture. 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. While creams are easy to apply, they are quickly absorbed into the skin, and therefore need frequent reapplication. Ointments, with less water content, stay on the skin for longer and need fewer applications, but they can be greasy and inconvenient.

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 putting a stop to the itch cycle. The end result is reduced lichenification (the roughening of skin from repeated scratching). Exfoliated skin under the tape loosens the contact after 3 days and the lesion can then be cleaned and aired for one day. The skin may appear dappled in areas not affected by eczema. Repeat the tape coverage for another 4 days and discontinue. Treat the same area promptly when the itch returns and cover it with tape once for 3 days. Taping works best on skin away from joints.

An alternative treatment which was fashionable in the Victorian and Edwardian eras was the topical application of sulfur. Recently sulfur has regained some popularity as a homeopathic alternative to steroids and coal tar. However, there is currently no scientific evidence for the claim that sulfur treatment relieves eczema. Of course, if used in homeopathic doses, no actual sulphur atoms would be present.

Eczema and skin cleansers
The first and primary recommendation is that people suffering from eczema shouldn't use detergents of any kind on their skin unless absolutely necessary. Eczema sufferers can reduce pruritus by using cleansers only when water is not sufficient to remove dirt from skin.

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, often made from petrochemicals, 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.

Dermatological recommendations in choosing a soap generally include:
 * Avoid harsh detergents or drying soaps
 * Choose a soap that has an oil or fat base; a "superfatted" goat milk soap is best
 * Use an unscented soap
 * Patch test your soap choice, by using it only on a small area until you are sure of its results
 * Use a non-soap based cleanser

Instructions for using soap:
 * Use soap sparingly
 * Avoid using washcloths, sponges, or loofahs, or anything that will abrade the skin
 * Use soap only on areas where it is necessary
 * Soap up only at the very end of your bath
 * Use a fragrance-free barrier-type moisturizer such as vaseline or aquaphor before drying off
 * Use care when selecting lotion, soap, or perfumes to avoid suspected allergens; ask your doctor for recommendations
 * Never rub your skin dry, or else your skin's oil/moisture will be on the towel and not your body; pat dry instead

Itch relief
Anti-itch drugs, often antihistamine, may reduce the itch during a flare up of eczema, and the reduced scratching in turn reduces damage & irritation to the skin (the Itch cycle).

Capsaicin applied to the skin acts as a counter irritant (see Gate control theory of nerve signal transmission). Other agents that act on nerve transmissions, like menthol, also have been found to mitigate the body's itch signals, providing some relief. Recent research suggests Naloxone hydrochloride and dibucaine suppress the itch cycle in atopic-dermatitis model mice as well.

Corticosteroids
Dermatitis is often treated by doctors with prescribed glucocorticoid (a corticosteroid steroid) ointments, creams or lotions. For mild-moderate eczema a weak steroid may be used (e.g. hydrocortisone or desonide), whilst more severe cases require a higher-potency steroid (e.g. clobetasol propionate). Medium-potency Corticosteroids such as clobetasone butyrate (Eumovate) or Betamethasone Valerate (Betnovate) are also available, generally medical practioners will prescribe the less potent ones first before trying the more potent ones. In the UK, Hydrocortisone and Eumovate can be purchased 'over the counter' from a pharmacy without a prescription whilst the more potent ones are prescription-only. Corticosteroids do not cure eczema, but are highly effective in controlling or suppressing symptoms in most cases.

Corticosteroids must be used sparingly to avoid possible side effects, the most common of which is that their prolonged use can cause the skin to thin and become 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.

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.

Oral cortisosteroids such as prednisolone may also be prescribed in severe cases; while these usually bring about rapid improvements, they should not be taken for any length of time and the eczema often returns to its previous level of severity once the medication is stopped.

Immunomodulators
Topical immunomodulators like pimecrolimus (Elidel and Douglan) and tacrolimus (Protopic) were developed after corticosteroid treatments, effectively suppressing the immune system in the affected area, and appear to yield better results in some populations. The US 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, photosensitive reactivity and possible drug interaction in patients who consume even small amounts of alcohol.

Antibiotics
When the normal protective barrier of the skin is distrupted (dry and cracked), it allows easy entry for bacteria. Scratching by the patient both introduces infection and spreads it from one area to another. Any skin infection further irritates the skin and a rapid deterioration in the condition may ensue; the appropriate antibiotic should be given.

Light therapy
Light therapy using ultraviolet light can help control eczema. UVA is mostly used, but UVB and Narrow Band UVB are also used. Ultraviolet light exposure carries its own risks, particularly eventual skin cancer from exposure.

When light therapy alone is found to be ineffective, the treatment is performed with the application (or ingestion) of a substance called psoralen. This PUVA (Psoralen + UVA) combination therapy is termed photo-chemotherapy. Psoralens make the skin more sensitive to UV light, thus allowing lower doses of UVA to be used. However, the increased sensitivity to UV light also puts the patient at greater risk for skin cancer.

Immunosuppresants
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, immunosuppresants 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.

Diet and nutrition
Recent studies provide hints that food allergy may trigger atopic dermatitis. For these people, identifying the allergens could lead to an avoidance diet to help minimize symptoms, although this approach is still in an experimental stage.

Dietary elements that have been reported to trigger eczema include dairy products and coffee (both caffeinated and decaffeinated), soybean products, eggs, nuts, wheat and maize (sweet corn), though food allergies may vary from person to person.

Alternative therapies
Non-conventional medical approaches include traditional herbal medicine and others. Patients should inform their doctor/allergist/dermatologist if they are pursuing one of these treatment routes. Patients can also wear clothing designed specifically to manage the itching, scratching and peeling associated with eczema. Sulfur has been used for many years as a treatment in the alleviation of eczema, although this could be suppressive. Many patients find that swimming in the ocean will relieve symptoms and clear up the red patchy scales. Oatmeal is a common kitchen remedy to relieve itching, and can be applied topically as a cream or, as a colloid, in the bath. Add 2tbl to a square of muslin and fasten securely with elastic band. Submerge in the bath and when the organic porridge oats are saturated, squeeze. The bath water becomes opaque with a soothing scent of oats.

Pseudoceramides
On August 27, 2007, scientists led by Jeung-Hoon Lee created in the laboratory synthetic lipids called pseudoceramides which are involved in skin cell growth and could be used in treating skin diseases such as atopic dermatitis, a form of eczema characterized by red, flaky and very itchy skin; psoriasis, a disease that causes red scaly patches on the skin; and glucocorticoid-induced epidermal atrophy, in which the skin shrinks due to skin cell loss.

Herbal Medicine
Historical sources - notably traditional Chinese medicine and Western herbalism - suggest a wide variety of treatments, each of which may vary from individual to individual as to efficacy or harm. Toxicity may be present in some. Some of these remedies are for topical use.
 * Potentilla chinensis
 * Aebia clematidis
 * Clematis armandii
 * Rehmannia glutinosa
 * Paeonia lactiflora (Chinese Peony)
 * Lophatherum gracile
 * Dictamnus dasycarpus
 * Tribulus terrestris
 * Glycyrrhiza uralensis
 * Glycyrrhiza glabra (Licorice)
 * Schizonepeta tenuifolia (Neem)
 * Schizonepeta tennuifolia
 * Azadirachta indica
 * Evening primrose oil
 * Tea tree oil
 * Burdock
 * Rooibos
 * Linseed oil
 * Calamine
 * Oatmeal
 * Cod liver oil
 * Neem oil
 * Aloe propolis cream
 * Raw goat's milk
 * Grapefruit seed extract (GSE)
 * Hemp cream
 * Guto Kola

Behavioural approach
In the 1980's, a Swedish dermatologist (Dr Peter Noren) developed a behavioural approach to the treatment of long term atopic eczema. This approach has been further developed by a dermatologist (Dr Richard Staughton) and psychiatrist (Christopher Bridgett) at the Chelsea and Westminster Hospital in London.

Patients undergo a 6 week monitored programme involving scratch habit reversal and self awareness of scratching levels. For long term eczema sufferers, scratching can become habitual. Sometimes scratching becomes a reflex (scratching without conscious awareness), and not always from the feeling of itchiness itself. The habit reversal programme is done in conjunction with the standard applied emollient/corticosteroid treatments so that the skin can heal. It also reduces future scratching, as well as reduces the likelihood of further flareups. The behavioural approach can give an eczema sufferer some control over the degree of severity of eczema.

Research
Other than direct treatments of the symptoms, no cure is presently known for most types of dermatitis; even cortisone treatments and immunomodulation may often have only minor effects on what may be a complex problem. As the condition is often related to family history of allergies (and thus heredity), it is probable that gene therapy or genetic engineering might help.

Damage from the enzymatic activity of allergens is usually prevented by the body's own protease inhibitors, such as, LEKTI, produced from the gene SPINK5. Mutations in this gene are known to cause Netherton’s syndrome, which is a congenital erythroderma. These patients nearly always develop atopic disease, including hay fever, food allergy, urticaria and asthma. Such evidence supports the hypothesis that skin damage from allergens may be the cause of eczema, and may provide a venue for further treatment.

Another study identified a gene that the researchers believe to be the cause of inherited eczema and some related disorders. The gene produces the protein filaggrin, the lack of which causes dry skin and impaired skin barrier function.

A recent study indicated that two specific chemicals found in the blood are connected to the itching sensations associated with eczema. The chemicals are Brain-derived neurotrophic factor (BDNF) and Substance P.

Psychological effects
Eczema often comes and goes in cycles, meaning that at some times of the year sufferers are able to feel normal, while at other times they will distance themselves from social contact. Sufferers with visible marks generally feel fine (physically) and can act normally, but when it is mentioned, they may become withdrawn and self-conscious. Since it is a condition made worse by scratching, a sufferer with highly visible sores aggravated by scratching often feels as if everyone is looking at the marks and that they are self-induced. Although scratching does give a sense of relief, it is usually a temporary solution and can lead to problems with constant scratching. Sufferers often shy away from scratching in public, but the solution is to scratch in privacy. In some cases, sufferers may hide visible patches of Eczema under articles of clothing, such as gloves or hats. These solutions may mask the visible signs, but can worsen the condition due to agitation by rubbing or sweating. In cases of children with eczema, visible scars or scratch marks can lead to suspicion of home abuse or self-mutilation, which causes possible peer rejection and may add to a general level of stress.

Vulnerability to live vaccinia virus
In June, 2007, Science magazine reported that an American soldier who had been vaccinated for smallpox-- the vaccine that contains live vaccinia virus-- had transmitted vaccinia virus to his two-year-old son. The soldier and his son both had a history of eczema. The son rapidly came down with a rare side effect, eczema vaccinatum, which had been seen during the 1960s when children were routinely vaccinated against smallpox. The child developed a severe full-body pustular rash, his abdomen filled with fluid, and his kidneys nearly failed. Intense consultation with experts from the Centers for Disease Control and Prevention and a donation of an experimental antiviral drug by SIGA Technologies saved the child's life. Those with a family history of eczema are advised not to accept the smallpox vaccination, or any other that contains live vaccinia virus.

Research
Other than direct treatments of the symptoms, no cure is presently known for most types of dermatitis; even cortisone treatments and immunomodulation may often have only minor effects on what may be a complex problem. As the condition is often related to family history of allergies (and thus heredity), it is probable that gene therapy or genetic engineering might help.

Damage from the enzymatic activity of allergens is usually prevented by the body's own protease inhibitors, such as, LEKTI, produced from the gene SPINK5. Mutations in this gene are known to cause Netherton’s syndrome, which is a congenital erythroderma. These patients nearly always develop atopic disease, including hay fever, food allergy, urticaria and asthma. Such evidence supports the hypothesis that skin damage from allergens may be the cause of eczema, and may provide a venue for further treatment.